Every finding on record at NHC Healthcare, Desloge

Based on interview and record review, the facility failed to notify a resident's Responsible Party (RP) after a change in condition when one resident (Resident #43) out of 16 sampled residents had behavioral issues and was transferred to the hospital for evaluation. The facility census was 64. Review of the facility's Change in Patient Status Policy, dated March 2024, showed: - The patient or patient's representative is encouraged to be involved in all decision-making regarding changes in plan of care; - The charge nurse on duty is notified of any changes in condition, the patient will be assessed, the physician, physician extender and patient's representative will be notified; - The patient may not be transferred to hospital without first notifying the patient's representative unless to delay would be harmful to the patient; - If unable to contact family, the patient will be transferred per doctors orders, and efforts to reach patient's representative will be continued and documented. 1. Review of Resident #43's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument required to be completed by the facility staff), dated 02/14/24, showed: - admitted on [DATE]; - Diagnoses of dementia (thinking and social symptoms that interfere with daily functioning), schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), depression and anxiety; - Moderately impaired cognition. Review of the resident's progress notes showed: - On 04/10/25 at 2:45 A.M., resident was transported via ambulance to the hospital for behavioral issues; - No documentation that the resident's responsible party was notified of change in condition and need for evaluation. Review of an undated document provided by the Social Services Director (SSD) showed: - Resident was supposed to have been transferred from the hospital to the facility on [DATE]; - Resident instructed the transportation driver to drive him/her to the RP's address; - The RP instructed the driver to return the resident to the facility. During an interview on 04/11/25 at 11:47 A.M., the resident's RP said on 04/10/25 the facility sent the resident to the hospital without notifying the RP. The RP said he/she had no idea the resident had gone to the hospital until the resident showed up at the RP's house in a taxi. The RP told the taxi driver to return the resident to the facility. Later, the RP was informed that the resident had been sent to the hospital due to behaviors. During an interview on 04/24/25 at 1:12 P.M., the SSD said the transfer/discharge to the RP had been placed in the mail the very next day at approximately 9:30 A.M. During a phone interview on 05/06/25 at 9:39 A.M., Registered Nurse (RN) T said when he/she came on shift, staff had given report of resident being aggressive, unable to be calmed, and sent to hospital. He/She had asked if the RP had been notified and was told that they would try to contact. During an interview on 04/24/25 at 1:39 P.M., the Administrator said she would have hoped that the staff would have called the RP after sending the resident to the hospital. Complaints MO00252597 and MO00252619

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reason for transfer for two residents (Resident #5 and #31) out of 16 sampled residents. The facility census was 64. Review of the facility's Patient Care Policies, titled, Transfer/Discharge, revised 3/2024, showed: - A patient may be transferred or discharged to another healthcare institution or discharged home upon the written order of the attending physician; - Sufficient information will be provided to the patient to assure continuity of care, regardless of destination of the patient or the reason for the transfer. 1. Review of Resident #5's medical record showed: - Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers. 2. Review of Resident #31's medical record showed: - Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer/discharge to a hospital at the time of the transfer. During an interview on 04/24/25 at 12:57 P.M., the Administrator said the bed hold/transfers are sent with the resident to the hospital and a copy is mailed to resident's responsible party either the next day or following business day. During an interview on 04/24/25 at 6:05 P.M., the Administrator said she would expect written notification of transfer to be sent to the resident, and/or resident representative, and to the Ombudsman for thirty day and emergency discharges.

Based on interview and record review, the facility failed to inform the resident and/or the resident representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #5, #31, and #65) out of 16 sampled residents. The facility census was 64. Review of the facility's Social Work Services Manual titled, Bed hold/Bed Reservation Policy, last revised 11/2016, showed: - Patient's bed hold rights provided to the patient/patient representative during the admission process in the admission and Financial Agreement; - In the event of the patient's transfer from the center, the social services department is responsible for contacting the patient/legal representative to discuss the center's bed hold policy and to ascertain the plans of the patient to reserve the bed; - Patient's bed will be held until call placed to ascertain the plans of the patient/patient representative to reserve the bed; - The patient/patient representative's intent is to be documented in the Social Service progress noted and communicated to the Business Office by the Social Worker. 1. Review of Resident #5's medical record showed: - Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfers. 2. Review of Resident #31's medical record showed: - Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. 3. Review of Resident #65's medical record showed: - Resident was transferred to the hospital on [DATE], resident passed away at the hospital; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. During an interview on 04/24/25 at 4:35 P.M., the Director of Nursing (DON) said that a bed hold was not given to resident #65 at the time of transfer to the hospital. During an interview on 04/24/25 at 6:05 P.M., the Administrator said she would expect bed holds to be completed and given to the resident and/or resident representative upon transfer.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by facility staff) for two residents (Resident #27 and #62) out of 16 sampled residents. The facility census was 64. The facility did not provide a policy regarding MDS coding for accuracy. The facility follows the RAI (Resident Assessment Instrument) manual. 1. Review of Resident #27's medical record showed: - Diagnoses of unspecified dementia with agitation (a group of symptoms that negatively affect memory, thinking, and social abilities to interfere with daily functioning), aggression, psychotic disturbances with psychosis (mental condition characterized by a loss of contact with reality, often involving symptoms like delusions, hallucinations and disorganized thinking), schizophrenia with psychosis (a disorder that affects a person's ability to think feel and behave clearly), cognitive communication deficit (communication difficulty caused by impairments in cognitive functions like attention, memory, and reasoning, rather than language or speech problems), benign prostatic hyperplasia (BPH-a condition where the prostate gland, enlarges without forming cancer) with lower urinary tract symptoms, retention of urine, urinary tract infection (UTI-a common infection that can affect any part of the urinary tract, including the bladder, kidneys or urethra), chronic kidney disease (CKD-long term condition where the kidneys gradually lose their ability to filter waste products from the blood) stage 3, and muscle weakness; - Review of the resident's progress notes, dated 12/14/24, showed the resident returned to the facility from the hospital where he/she had been treated for a UTI and blood fungal infection while hospitalized ; - Review of the resident's quarterly MDS, dated [DATE], showed Section I, not coded for UTI; - The facility failed to accurately code the MDS assessment on 12/16/24 regarding an active diagnosis of UTI. 2. Review of Resident #62's medical record showed: - Diagnoses of Alzheimer's (a progressive disease that destroys memory and other important mental functions), anxiety (intense, excessive, and persistent worry and fear about everyday situations), dysphagia (difficulty swallowing), and hallucinations (a perception of having seen, heard, touched, tasted or smelled something that wasn't actually there); - Review of the resident's admission MDS, dated [DATE], showed: - Section J 1400, coded no for a prognosis of less than six months; should be coded yes since the resident is receiving hospice services; - Section O 00110 K.1 coded yes for hospice services; - The facility failed to accurately code the MDS assessment regarding prognosis. During an interview on 04/24/25 at 6:05 P.M., the Administrator said she would expect the MDS to be coded accurately and to reflect the condition of the resident. During an interview on 05/02/25 at 10:47 A.M., the Director of Nursing (DON) said that Registered Nurse (RN) Q is completing the MDS assessments. The facility staff does the observations and gives the information to RN Q. The MDS assessments are done on entry, admission, quarterly, annually, significant change, discharge and 5 day assessment, if needed. He/She said the MDS should reflect the resident's current diagnoses and condition at the time the assessment is done. 49754

Based on interview and record review, the facility failed to update and revise care plans with specific resident centered interventions to meet individual needs for three residents (Resident #15, #55, and #62) out of 16 sampled residents. The facility census was 64. Review of the facility's policy, Patient Care Policies, revised 03/2024, showed: - Patients are assessed initially and at regular intervals using a Federal/State specified, standardized, comprehensive resident assessment instrument to identify functional capacity and health status, Care Area Assessments (CAAs) document the additional assessment and review performed and serve as the basis for planning individual patient care; - The patient care plan process involves the entire inter-disciplinary team, including the patient and/or representative, including the patient's health care surrogate and/or the designated decision-maker who could be next of kin, legal guardian, Power of Attorney (P.O.A), surrogate or proxy; - Will include the attending physician in the development of the patient's plan of care by incorporating the physician's plan of care (orders) into the care plan; - Decision making/planning is based on identified needs/problems and builds on patient strengths while taking into account the patient's preferences; - The care plan serves as a guide for care decisions and is made available for use by all patient care personnel. 1. Review of Resident #15's medical record showed: - admitted [DATE]; - Diagnoses of Alzheimer's (a progressive disease that destroys memory and other important mental functions), dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), Parkinson's (a disorder of the central nervous system that affects movement, often including tremors), PTSD (Post-traumatic stress disorder-a mental health condition that's caused by an extremely stressful or terrifying event), cognitive communication defect, and suicidal ideations (diagnosis date of 12/08/21, and a diagnosis removal date of 10/02/23). Review of Resident #15's care plan, revised 02/01/25, showed: - Problem start date of 02/03/25, Goal target date of 05/02/25, diagnosis (dx) of suicidal ideations related to PTSD and depression; - The facility failed to remove the diagnosis of suicidal ideations from the care plan. 2. Review of Resident #55's medical record showed: - admitted [DATE]; - Diagnoses of dementia, PTSD, fracture (broken bone) of the fifth metacarpal (bone connecting the wrist to the little finger/pinky) on left hand and muscle weakness; - PTSD assessment, dated 03/13/25, showed a negative screening for PTSD; - POS with an order, dated 02/04/25, for escitalopram (medication that treats depression), 20 milligrams (mg), once daily. Review of the resident's care plan, last revised 02/01/25, showed: - Resident received an antidepressant medication related to behaviors for PTSD; - Monitor for effectiveness; - Monitor and report signs of sedation, hypotension or anticholineric symptoms (decreased saliva, slow digestion or dilated pupils); - Care Plan did not address history of PTSD or triggers. During an interview on 04/24/25 at 10:07 A.M., the Director of Nursing (DON) said the facility had a lot of veterans, so the triggers would probably be loud noises and sudden movements and should be on the care plan. During an interview on 04/24/25 at 10:30 A.M., the DON said after reviewing the resident's chart, there was a history of PTSD due to an assault, however, the resident did not trigger at the facility. The care plan should have been updated to reflect the resident's current status. 3. Review of Resident #62's medical record showed: - admitted [DATE]; - Diagnoses of Alzheimer's, anxiety (intense, excessive, and persistent worry and fear about everyday situations), dysphagia, and hallucinations (a perception of having seen, heard, touched, tasted or smelled something that wasn't actually there); - POS showed no current order for ABHR cream (a cream containing lorazepam, Diphenhydramine, haloperidol, and metoclopramide). Order start date, 01/04/25 and stop date 04/21/25. Review of the resident's care plan, revised 03/07/25, showed: - Problem start date of 03/07/25, Goal target date of 06/06/25, Administer medications ABHR cream as ordered and monitor for side effects; - The facility failed to remove use of ABHR cream from the care plan. During an interview on 04/24/25 at 2:15 P.M., the Director of Nursing (DON) said he/she had been doing care plans before taking the position as DON. Care plans are updated quarterly and as needed. The current Minimum Data Set (MDS - a federally mandated assessment completed by the facility) staff has only been in that position for a week, and we currently have a regional staff member assisting with care plans. During an interview on 04/24/25 at 6:05 P.M., the Administrator said she would expect care plans to be updated and revised to reflect the resident's current condition. 46460 49754

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This deficient practice affected three residents (Resident #10, #27 and #31) out of 16 sampled residents and one resident (Resident #34) outside the sample and had the potential to affect all residents. The facility census was 64. Review of the facility's Medication Storage policy, revised 02/25/25, showed: - Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier; - Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are removed from inventory and disposed of according to procedures for medication disposal; - Certain medications or package types, such as multiple dose injectable vials or testing solution strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency, in such case, the nurse may determine the expiration date based on opening, storage or usage as manufacturer specifies; - The nurse will document the date opened on label; - In the event a container has been opened and there is absence of an opened date, the expiration date will be calculated from the dispense date on the pharmacy label where available; - No expired medications will be given to a resident; - All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Review of the package insert on lantus.com, v2.0-08/2022, showed: - After the first use of the Lantus Solostar pen, keep at room temperature, below 86 degrees Fahrenheit (F), don't refrigerate; - After 28 days, throw your opened Lantus pen away-even if it still has insulin in it. Review of insulin aspart storage and disposal instructions on medlineplus.gov, revised 08/15/2023, showed: - Opened vials of insulin, cartridges and pens can be stored at room temperature for up to 28 days; - Discard after 28 days. Review of the storage instructions for Basaglar insulin on pi.lilly.com showed: - In-use pens, store the pen you are currently using at room temperature; up to 86 degrees (F), and away from heat and light; - Throw away the pen you are using after 28 days, even if it still has insulin left in it. Observation on 04/21/25 at 3:37 P.M. of the C Hall Nurse Cart showed: - Resident #10's Lantus insulin, open with no opened date; - Resident #27's Basaglar insulin, opened 03/11/25 and expiration date of 04/09/25. Insulin Aspart opened 03/17/25 and expiration date of 04/15/25; - Resident #31's Insulin Aspart, open with no opened date; - Resident #34's Lantus insulin, open with no opened date; During an interview on 04/21/25 at 3:45 P.M., Registered Nurse (RN) P said Resident #27 gets his/her insulin from this Basaglar pen because it is his/her scheduled long acting insulin, and hasn't gotten the Insulin Aspart in about a month. During an interview on 04/24/25 at 6:05 P.M., the Administrator said she would expect insulin pens to have the date they were opened on them and to be disposed of when expired.

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents and staff. The facility census was 64. Review of the facility's Refrigerated Food Storage Guide, last revised [DATE], showed: - Food items shall be rotated, using First In, First Out (FIFO), in order to ensure product quality; - Foods should be covered and dated with a use by date; - Foods such as cottage cheese, cheese, cream cheese, sour cream and yogurt should be refrigerated immediately. Review of the facility's Equipment Cleaning Schedule, last revised [DATE], showed: - Clean spills, and splashes as soon as possible, daily, after use and weekly; - Clean and sanitize shelves and racks as soon as possible, daily, after use and weekly; - Sweep, mop, brush or squeegee floors and mats, after each meal and daily; - Clean, sanitize equipment parts, surfaces, and work tables after each use or between each product change. Review of the facility's Safety and Sanitation Best Practice Guidelines, last revised [DATE], showed: - All partners handling food products or contacting equipment used for food preparation should wash hands and forearms with soap and warm water, using proper procedures; - The basic practice of hand washing is the single most important action that can be taken to prevent the spread of disease; - Hands should be washed before starting to work, after break time, using rest room, touching face, hair or body, after eating, drinking, smoking, sneezing, coughing or touching money; - Hands should be washed before putting on gloves and after removing gloves; - Sanitizing gel may only be used as an added measure after washing hands to minimize bacteria, but not in place of hand washing. Observation on [DATE] at 9:50 A.M. of the kitchen showed: - An uncovered tray of apple crisp dessert on a shelf under the microwave; - Three trays with individual bowls of chocolate chip cheesecakes, covered and sitting on shelves outside of the refrigerator; - One 104 ounce (oz), unopened, dented can of mandarin oranges on the shelf; - Five opened, undated bags of pork flavored gravy mix, each in an individual plastic bag and all in one large plastic resealable bag; - 10 pounds (lbs) of opened, undated, uncooked spaghetti noodles in a large plastic resealable bag; - Another 10 lb bag, half full of uncooked spaghetti noodles, in an unsealed plastic resealable bag; - A 3 lb 1.8 oz bag of stuffing, undated; - Two large plastic resealable bags of frozen hash brown wedges, undated, in freezer; - One large plastic resealable bag of frozen tater tots, undated, in freezer; - One package of eight graham cracker pie crusts, opened and sitting on a shelf in the storage area; - A 7.5 quart container, half full of chocolate chips, not labeled or dated; - Two packages of dry pudding mix, expiration date of ,d+[DATE]; - One package of dry pudding mix, expiration date of ,d+[DATE]; - Nine packages of undated butterscotch instant pudding/pie filling mix, stored in a large, plastic tote with no lid and powdery debris and mouse droppings at the bottom. During an interview on [DATE] at 9:55 A.M., the Dietary Manager (DM) said the chocolate chip cheesecakes had been in the refrigerator, and still should have been, due to being served at lunch, but had been removed because there was no longer room in the refrigerator. Observation on [DATE] at 2:55 P.M. showed: - Three trays of uncovered cakes with icing on shelves in the preparation area; - One ice cream scoop with melted, tan liquid, on the counter; - Two trays of uncovered baked cookies on shelves under the microwave; - Debris and food particles on the floor; - A crumpled paper towel on the floor next to the trash can; - A mop head lay in the floor in front of the fryer; - Another mop head lay in the floor in front of the food warmer; - Steam table with one and one half inches of water in the bottom, with food particles floating in it; - Work counter in front of the steam table with particles of food and debris. Observation on [DATE] from 7:50 A.M. to 8:20 A.M. showed Dietary [NAME] L, Dietary [NAME] M, Dietary Partner N and Dietary Partner O plated and served food without gloves or using hand sanitizer. During an interview on [DATE] at 10:41 A.M., the DM said he/she would expect staff to keep the kitchen area clean, keep trays containing cookies to be covered, cheesecake to be stored in the refrigerator, dented cans to be sent back for a credit and not used, and everything dated once opened. He/She works closely with the Dietician who will make weekly visits. The DM said he/she realized there were things that needed addressed and is working to assure it happens. During an interview on [DATE] at 8:56 A.M., the DM said he/she had told staff before that they should wear gloves when plating and serving food. He/She does have new staff who are still learning. The sanitizer didn't get ordered because he/she was off last week. Staff should perform hand hygiene with glove changes, when they change tasks, stations, anytime they're touching anything, like their face or picking something up off the floor. During an interview on [DATE] at 6:05 P.M., the Administrator said he/she would expect the kitchen to be cleaned, open packages to be dated, dented and expired food cans to be discarded and food to be covered when sitting out. He/She would also expect kitchen staff to wear gloves when plating and serving food and perform hand hygiene and/or use hand sanitizer appropriately. He/She said staff should perform hand hygiene when hands were visible soiled, or when doing certain tasks such as handling raw meat.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during perineal care (peri care-cleaning the genitals and anal area of the body) for one resident (Resident #40) outside of the 16 sampled residents. The facility failed to implement enhanced barrier precautions (EBP) during wound care for one resident (Resident #28) out of 16 sampled residents. The facility census was 64. Review of the facility's Handwashing/Hand Hygiene Policy, last revised August 2015, showed: - The facility considers hand hygiene the primary means to prevent the spread of infections; - Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; - Use an alcohol-based hand rub or soap and water before and after coming on duty; - Before and after direct contact with residents; - Before and after preparing medications; - Before handling clean or soiled dressings, gauze or pads; - Before moving from contaminated body site to a clean body site; - After contact with Resident's intact skin; - After contact with blood or body fluids; - After handling used dressings or contaminated equipment and after removing gloves; - The use of gloves does not replace hand washing/hand hygiene. Review of the facility's policy, titled, Infection Control Manual Volume 1, -Enhanced Barrier Precautions (EBP), showed: - EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact activities. EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact patient care activities that provide opportunities for transfer of MDRO to staff hands and clothing; - EBP are indicated for patients with any of the following: infection or colonization with a Center for Disease Control (CDC)-targeted MDRO, wounds and/or indwelling medical devices even if the patient is not known to be infected or colonized with a MDRO; - Providers and partners must wear gloves and a gown for the following high-contact patient care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line (a thin flexible tubing inserted into a large vein, typically in the neck, chest or groin to provide long-term access to the bloodstream), urinary catheter (a thin flexible tube inserted into the bladder to drain urine), feeding tube (a soft, flexible plastic tube inserted into the stomach or small intestine to deliver liquid nutrition, medications, or fluids directly to the digestive tract), tracheostomy (a surgical procedure where an opening (a stoma) is created in the neck, directly into the trachea (windpipe), to establish a temporary or permanent airway), wound care: any opening requiring a dressing; generally, this includes chronic wounds, not shorter lasting wounds, such as skin tears/breaks covered with an adhesive bandage or similar dressing; other examples include, but are not limited to, pressure ulcers (localized damage to the skin and/or underlying tissue that occurs due to prolonged pressure or pressure combined with shear), diabetic foot ulcers (open sores or wounds on the feet of people with diabetes (a chronic metabolic disease characterized by elevated levels of sugar in the blood), usually on the bottom of the foot), unhealed surgical wounds, and venous stasis ulcers (a wound on the leg or ankle caused by abnormal or damaged veins). 1. Observation on 04/21/25 at 1:58 P.M. of Resident #40 showed: - Resident sat in his/her room in a wheelchair; - Certified Nurse Aide (CNA) D and CNA R transferred the resident from wheelchair to bed using a mechanical lift; - CNA D and CNA R donned gloves without washing hands; - CNA R performed peri care to the front peri area, removed gloves and did not wash hands; - CNA R donned gloves and performed peri care to the buttocks area; - CNA R removed gloves and left the room without washing/sanitizing his/her hands to get a clean lift sling; - CNA R re-entered the resident's room without performing hand hygiene and without a clean lift sling; - CNA R donned gloves, without washing/sanitizing his/her hands; - CNA D and CNA R transferred the resident from bed to wheelchair; - CNA R removed gloves and moved the mechanical lift out of the room; - CNA D bagged trash; - CNA R took trash to the dirty linen room; - CNA D and CNA R did not wash/sanitize hands after exiting the resident's room. During an interview on 04/21/25 at 4:15 P.M., CNA D and CNA R said they should sanitize, but try to wash their hands after every patient, after taking out the trash, and after transfers. They should also sanitize or wash hands with glove changes, and between dirty and clean tasks. 2. Review of Resident #28's medical record showed: - admitted on [DATE]; - Diagnoses of hemiplegia (paralysis of the muscles on one side of the body), history of cerebral infarction (stroke) and type II diabetes (a long term condition which the body has trouble controlling the blood sugar); - On 04/03/25, an order to cleanse area on right buttock with wound cleanser, pat dry, apply skin prep to peri-wound, cover with bordered gauze daily and as needed. Observation on 04/24/25 at 12:30 P.M. of Resident #28's wound care showed: - Bucket sticker on name plaque to notify staff to use EBP; - Licensed Practical Nurse (LPN) E gathered supplies from nurse treatment cart, including two small cups with moistened gauze in each cup, a dressing in a sealed package and a paper plate barrier; - LPN E and Registered Nurse (RN) K entered the resident's room and washed hands; - LPN E placed the plate on the bed containing the supplies, donned gloves, and did not don gown; - LPN E placed a plastic trash bag on the bed; - RN K washed hands and donned gloves; - LPN E picked up the plate containing the supplies and handed it to RN K; - LPN E assisted the resident to stand up from the recliner and hold onto the walker; - LPN E lowered the resident's pants and brief, removed old dressing from inner buttocks and placed the dressing in the trash bag, removed gloves and sanitized hands; - LPN E donned clean gloves; - RN K handed moistened gauze to LPN E; - LPN E used moistened gauze to cleanse inner buttocks wound, then placed soiled gauze in the trash bag; - LPN E removed gloves, sanitized hands and donned clean gloves; - RN K handed LPN E a clean piece of gauze; - LPN E patted wound dry with clean gauze and placed used gauze in the trash bag; - LPN E removed gloves, sanitized hands and donned clean gloves; - RN K opened skin prep package and handed prep to LPN E; - LPN E skin prepped the area around the wound, removed gloves, sanitized hands and donned clean gloves; - RN K opened dressing package and handed to LPN E; - LPN E placed dressing on inner buttocks wound; - RN K dated dressing: - LPN E and RN K assisted resident with pulling up brief and pants and to sit in recliner; - LPN E bagged up trash; - LPN E and RN K removed gloves; - LPN E washed his/her hands; - RN K moved walker to the side of the room, gathered trash bag and gave to LPN E; - RN K washed his/her hands; - LPN E carried trash to the soiled utility room and sanitized his/her hands. During an interview on 04/24/25 at 2:15 P.M., LPN E said he/she would wear EBP with residents who have indwelling catheters and major wounds, the residents with bucket stickers besides their name are on EBP precautions. LPN E provided an updated list of residents on EBP precautions, excluding Resident #28. During an interview on 04/24/25 at 6:05 P.M., the Administrator said she would expect staff to perform hand hygiene while performing peri care, before they start, from dirty to clean, if their hands are soiled and when they are done. She would also expect staff to wear appropriate personal protective equipment (PPE) for EBP. 46460

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #26) out of two sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility's census was 62. Review of the facility's policy titled, Pain Management, undated, showed: - Every patient is assessed for pain on admission, daily, as needed, and with all quarterly Minimum Data Set (MDS) (a federally mandated assessment completed by the facility) assessments; - Interventions for pain consist of pharmacological and non-pharmacological; - Medications will be given per physician orders, as needed orders will be assessed for effectiveness. Physicians will be notified if current medications or non-pharmacological interventions are not effective. 1. Review of Resident #26's medical record showed: - An admitted [DATE]; - Diagnoses of hypertensive heart disease (changes in the heart due to chronic elevated blood pressure) with heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (abnormal heart rhythm), atherosclerotic heart disease (the buildup of cholesterol, fats and other substances in and on the artery walls), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), pulmonary hypertension (a condition that affects the blood vessels in the lungs), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), mood disturbance, anxiety (persistent worry and fear about everyday situations), and pressure ulcer (damage to the skin and/or underlying tissue as a result of pressure). Review of the resident's significant change MDS, dated [DATE], showed: - Cognitive status mildly impaired; - Total dependence of two staff for lower body dressing, chair/bed to chair transfer, toilet transfer, and tub/shower transfer; - Unhealed Stage 3 (full thickness tissue loss and subcutaneous fat may be visible but bone, tendon or muscle are not exposed) pressure ulcer; - One Stage 3 pressure ulcer upon admission; - Pressure ulcer care; - Almost constant pain. Review of the resident's Physician's Order Sheet (POS), dated March 2024, showed: - An order to screen for pain every shift, dated 02/12/24; - An order for hydrocodone-acetaminophen (an opioid pain medication) 5-325 milligram (mg) tablet by mouth every four hours as needed for pain, dated 02/21/24; - An order to cleanse the area to the coccyx (tail bone) with wound cleanser, pat dry, cover the area with a foam dressing, change in the morning every other day and as needed, dated 02/26/24; - An order for hydrocodone-acetaminophen 5-325 mg tablet by mouth twice a day at 9 A.M., and 9 P.M., dated 03/28/24. Review of the resident's Medication Administration Record (MAR), dated March 2024, showed: - Hydrocodone-acetaminophen 5-325 mg tablet administered on 03/17/24; - Pain screens completed on 03/26/24 through 03/29/24 showed the resident had a pain score of zero (no pain), six out of eight opportunities and a score of two (mild pain), two out of the eight opportunities. Review of the resident's care plan, revised on 03/27/24, showed: - Resident at risk for pressure ulcer due to moisture and admitted with skin breakdown; - Pad bony prominences with foam wedges, rolled blankets or towels; - Pain/discomfort related to left humerus (the upper arm bone) fracture from 09/25/23; - Administer analgesic (pain medication), anticipate comfort needs, assist with positioning for comfort, observe nonverbal sign/symptom of discomfort, utilize non-medication interventions to relieve pain, and utilize pain scale to assess for pain. Observations of the resident showed: - On 03/26/24 at 10:36 A.M., 12:36 P.M., 1:36 P.M., and 2:46 P.M., the resident lay in bed on his/her back with no wedge; - On 03/27/24 at 8:37 A.M., the resident lay in bed on his/her back with no wedge; - On 03/27/24 at 1:17 P.M., the resident lay in bed on his/her back with no wedge. The resident's call light was on. Registered Nurse (RN) C entered the resident's room and turned the call light off. The resident asked RN C to please get him/her up. RN C told the resident he/she would be okay and would be back to complete his/her dressing change. RN C did not assess the resident's pain, offer any pain medication, nor offer any non-pharmalogical interventions to the resident; - On 03/27/24 at 2:14 P.M., Certified Nursing Assistant (CNA) J and RN C provided incontinent and wound care for the resident. RN C began the wound dressing change. During the dressing change, the resident moaned six times in pain and said, You're hurting me. I can't take this anymore. The resident was tearful during the dressing change and became nauseated. RN C did not assess the resident for pain nor was any pain medication offered prior to the dressing change. CNA J and RN C told the resident he/she was going to be okay and they were almost done with the treatment. RN C did not assess the resident's pain, offer any pain medication, nor offer any non-pharmalogical interventions to the resident after the wound treatment was completed; - On 03/27/24 at 4:50 P.M., the resident lay in bed on his/her back and complained he/she might throw up. CNA A went to get a bedpan. The resident was not assessed for pain, offered pain medication, nor provided with any non-pharmalogical interventions; - On 03/28/24 at 9:33 A.M., the resident asked staff to turn him/her, refused to eat breakfast, asked for his/her spouse, and said he/she was in pain and wanted to be turned. The resident lay on his/her back with no wedge and his/her feet hung off the side of the bed. The resident was not assessed for pain, offered pain medication, nor provided with any non-pharmalogical interventions; - On 03/28/24 at 1:40 P.M., the resident lay in bed on his/her back with a wedge under the left thigh area. CNA J assisted the resident with getting dressed. The resident said he/she was in pain and needed CNA J to help him/her. CNA J assisted the resident to get out of bed. The resident was not assessed for pain, offered pain medication, nor provided with any non-pharmalogical interventions. During an interview on 03/26/24 at 10:47 A.M., and 12:59 P.M., Resident #26 said he/she had a hole in his/her butt and it hurt. The wound had been there about a month and staff did not turn him/her most of the time during the day. Staff turned him/her maybe one time a day if he/she was lucky. The resident would like to get out of bed more often. During an interview on 03/27/24 at 3:57 P.M., Physical Therapist (PT) O said Resident #26 had been discharged from therapy on 03/26/24, due to noncompliance and not cooperating. The resident did not want to participate with PT, and was now on restorative therapy. The resident had always been noncompliant even before his/her wound developed. He/She did not know if the resident's pain contributed to his/her noncompliance. The resident often did not want to be in a wheelchair because of his/her pain. Observation on 03/28/24 at 2:10 P.M. - 3:10 P.M., showed the resident screaming, Please someone help me. Please I am hurting. Please come see me CNA J. CNA J told the resident he/she would be there in a minute but went to three other residents' rooms first. The resident was not assessed for pain, offered pain medication, nor provided with any non-pharmalogical interventions. During an interview on 03/28/24 at 4:33 P.M., CNA J said when a resident was in pain, he/she should notify the charge nurse and give the information about the resident's pain. Signs and symptoms of pain could be abnormal vital signs and grunting/moaning with movement. Non-pharmalogical things that could be done to help with pain was massage, apply lotion, rotate the resident in bed and keep the resident clean. During an interview on 03/28/24 at 4:48 P.M., Certified Medication Technician (CMT) N said he/she would consider giving a resident pain medication when they were screaming, acting anxious, fidgety, and grimacing. If the pain medication did not work, he/she would go to the main nurse to see if there was something else to give the resident. If the resident refused the pain medication, he/she would give them some time and try again. He/She would let the nurse know if they refused three times. Resident #26 didn't refuse pain medication. During an interview on 03/28/24 at 5:06 P.M., the Assistant Director of Nursing (ADON) said pain associated with pressure ulcers was assessed before a dressing change, prior to administering pain medication, and daily. Grimacing and verbal cues were all indicators of pain. The pain management regimen was reviewed as needed and by what the resident said or conveyed. If the pain management wasn't working, then staff faxed communication to the doctor. If a resident wasn't verbal about their pain, the staff looked for nonverbal signs. The CMT gave most pain medications to the residents. During an observation and interview on 03/29/24 at 10:41 A.M., Resident #26 was awake and alert. He/She lay in bed on his/her back and said he/she was in severe pain and hadn't received any pain medication. The resident wasn't sure what pain medication he/she had ordered. During an interview on 03/29/24 at 10:45 A.M., CMT N said Resident #26 said he/she was in pain. CMT N administered a pain pill on 03/29/24 at 9:00 A.M., to the resident. There was now a new order for the pain pill to be scheduled twice a day at 9:00 A.M., and 9:00 P.M. Due to miscommunication, the staff had been unaware of the resident's pain the last few days. During an interview on 03/29/24 at 1:49 P.M., RN C said the resident should be administered a pain pill when he/she reported or showed signs of pain. If there were observable signs of pain, staff should asses the resident's pain level, have the resident rate their pain, check the resident's physician orders, and give the resident the pain medication as ordered. He/She would not routinely assess or administer pain medication before a wound dressing, but it would depend on the wound.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #45) out of nine sampled residents exposed during care. The facility census was 62. Review of the facility's policy titled, Dignity, dated August 2009, showed: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #45's medical record showed: - admitted [DATE]; - Diagnoses of Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia (loss of memory, language, problem solving and other thinking abilities). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/16/24, showed: - Cognition severely impaired; - Always incontinent of bladder and bowel; - Dependent for toileting hygiene, and mobility. Observation of the resident on 03/28/24 at 2:26 P.M., showed: - The resident lay in bed; - Certified Nursing Assistant (CNA) A and CNA B entered the room to perform incontinent care; - The CNAs did not close the blind to the window; - The yard could be seen through the window with a person mowing; - CNA A left the room to obtain more wipes and the resident lay on his/her back with the genitalia area exposed. During an interview on 03/28/24 at 4:36 P.M., CNA A said prior to providing resident care, the door and window blinds/curtains should be closed and the privacy curtains should be drawn if needed. During an interview on 03/28/24 at 4:48 P.M., CNA B said the door, curtains and/or blinds should be closed. During an interview on 03/28/24 at 4:50 P.M., the Assistant Director of Nursing (ADON) said she would expect staff to be sure to close the door, pull the privacy curtain, and close the blinds if they were open.

Based on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200.00 Social Security (SSI) limit ($5,726.00) or when the resident's account was over the SSI limit. This affected two residents (Resident #2 and #8) reviewed who received Medicaid benefits. The census was 62. Review of the facility's policy titled, Bookkeeping Manual, dated, August 2007, showed: - Patient trust files and related information must be maintained and properly stored by the bookkeeping office for legal compliance and operational efficiency; - Patient trust file must include quarterly statement documentation that residents have been notified of their balance. 1. Review of the Resident Trust Statement for the period 01/31/24 through 03/31/24, showed Resident #2 had the following balances: Date Amount 01/31/24 $5,795.05 02/29/24 $7,217.68 03/31/24 $5,488.34 Review of the resident's fund documentation showed no resident fund notifications were provided to the resident and/or the representative. 2. Review of the Resident Trust Statement for the period 01/31/24 through 03/31/24, showed Resident #8 had the following balances: Date Amount 01/31/24 $5,053.21 02/29/24 $6,336.49 03/31/24 $5,643.45 Review of the resident's fund documentation showed no resident fund notifications were provided to the resident and/or the representative. During an interview on 03/29/24 at 1:30 P.M., the Business Office Manager (BOM) said he/she was responsible for identifying when the residents got close to the need of a spend down. A notification letter should be sent to the resident/resident's representative. He/She did not send a letter to Resident #2 or Resident #8. Some of the resident accounts had built up over the limit for a while and they were working to make corrections. During an interview on 03/31/24 at 5:00 P.M., the Administrator said she expects the residents' accounts to be kept below the limit and notification to be sent when they were close to their limit. During an interview on 04/02/24 at 3:30 P.M., the Regional Accountant said notice letters should have been sent out by the facility when residents were over the limit but were not. Just the quarterly statements were sent. There had been issues with this concern and the last office manager quit suddenly in December 2023. There were balances due for policy premiums that would have corrected the fund balances.

Based on observation, interview, and record review, facility staff failed to administer medications in a safe and effective manner for one resident (Resident #23) out of six sampled residents. The facility census was 62. The facility did not provide a policy regarding medication administration. 1. Review of Resident #23's medical record showed: - Date of admission 09/14/22; - Diagnosis of kidney failure and required dialysis (process of purifying the blood of a person whose kidneys aren't working normally); - An order for sevelamer carbonate (medication to treat too much phosphate in the blood) 800 milligram (mg) five tablets by mouth with meals at 7:00 A.M., 11:00 A.M., 4:00 P.M., when food is in front of resident, dated 02/05/24; - No documentation of an order for the resident to administer his/her own medication; - No documentation of assessments for the resident's competency to administer his/her own medication. Review of the resident's care plan, last revised 03/27/24, showed: - Administer sevelamer carbonate when food is in front of resident; - The care plan did not address self-administration of the medication. Observations on 03/27/24 of the resident showed: - At 3:35 P.M., the resident sat at a dining room table with a medication cup which contained five pills; - From 3:35 P.M., through 4:43 P.M., the resident sat unsupervised with a cup of five pills in front of him/her; - At 4:43 P.M., the resident received his/her food and self-administered the five pills in the medication cup. During an interview on 03/27/24 at 3:37 P.M., Resident #23 said he/she took the pills when he/she received his/her meal. During an interview on 03/29/24 at 1:30 P.M., Certified Medication Technician (CMT) N said he/she always gave Resident #23 his/her medications at the dining room table and left them. He/She had been told that it was care planned to leave the medication with the resident to self-administer. During an interview on 03/29/24 at 2:40 P.M., the Assistant Director of Nursing (ADON) said there should be an order and/or care plan for the resident to receive and self-administer medication at the dining room table. During an interview on 03/29/24 at 3:30 P.M., the Administrator said she knew Resident #23 received the medication at the table and sat with it in the dining room. The resident can't take it until his/her food arrives.

Based on observation, interview and record review, the facility failed to ensure proper placement of a Foley catheter (a tube inserted into the bladder to drain urine) tubing and drainage bags for two residents (Residents #10 and #307) out of five sampled residents. The facility census was 62. Review of the facility's policy titled, Urinary Cath Care, undated, showed: - Catheter care is performed appropriately; - Wash hands or hand sanitize before any manipulation of the catheter site and/or apparatus; - The only place in the closed system intended to be open is the empty spout at the bottom of the drainage bag; - The drainage bag should be kept below the level of the bladder. The facility did not provide a policy regarding Foley catheter placement, keeping the catheter tubing off of the floor for infection control issues or keeping the catheter bag covered for privacy/dignity. 1. Review of Resident #10's medical record showed: - admitted [DATE]; - Diagnoses of unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety disorder (persistent worry and fear about everyday situations), acquired absence of kidney (missing one or both kidneys due to an injury or operation), major depressive disorder (long-term loss of pleasure or interest in life), and retention of urine (an inability to empty the bladder of urine); - The Physician Order Sheet (POS), dated March 2024, showed an order to change the catheter twice a month and as needed, dated 03/13/24. Review of the resident's care plan, reviewed on 03/13/24, showed to maintain the catheter drainage bag in a privacy cover. Observations of Resident #10 showed: - On 03/26/24 at 10:37 A.M., the resident lay in bed and the uncovered catheter drainage bag hung from the bed frame. The bottom of the drainage bag and tubing touched the floor; - On 03/26/24 at 12:12 P.M., the resident sat in a wheelchair in the dining room, the catheter tubing touched the floor, and no privacy bag covered the drainage bag; - On 03/27/24 at 9:18 A.M., and on 03/28/24 at 8:47 A.M., and 1:35 P.M., the resident lay in bed while the bottom of the uncovered catheter drainage bag touched the floor. The catheter tubing lay on the floor; - On 03/28/24 at 2:50 P.M., and on 03/29/24 at 11:30 A.M., the resident lay in bed while the bottom of the uncovered catheter drainage bag touched the floor. 2. Review of Resident #307's medical record showed: - Date of admission 03/13/24; - Diagnoses of unspecified dementia with agitation, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety disorder, pyoderma gangrenosum (a rare skin condition that causes painful ulcers), neuromuscular dysfunction of the bladder (condition that results in lack of bladder control due to a brain, spinal cord or nerve problem), and overactive bladder (when the muscles of the bladder start to tighten on their own even when the amount of urine in the bladder is low); - Nurse's Note, dated 03/13/24, showed the resident with an indwelling Foley catheter, patent and draining amber urine; - The POS, dated March 2024, with orders to change the indwelling catheter every 30 days and to perform catheter care every shift, dated 03/26/24. Observation on 03/26/24 at 12:01 P.M., showed Resident #307 sat in a high back wheelchair in the dining room and fed by staff. The catheter tubing lay in the floor under the wheelchair. Observation on 03/26/24 at 3:40 P.M., showed Certified Nursing Assistant (CNA) A and CNA H transferred the resident from the wheelchair to the bed by a mechanical lift. The catheter drainage bag was placed on the foot of the bed by CNA H. CNA A rolled the resident and the catheter drainage bag fell off the bed onto the floor. CNA H picked up the bag and placed it back onto the foot of the bed. During an interview on 03/28/24 at 4:30 P.M., Registered Nurse (RN) I said catheter tubing and bags should be lower than the bladder and secured. Staff should wipe from the catheter insertion point and down the tube. The drainage bag and tubing should never touch the ground, the urine should flow by gravity away from the bladder, and the catheter drainage bag should be covered in a privacy bag, especially when leaving the resident's room. During an interview on 03/28/24 at 4:32 P.M., CNA J said catheter drainage bags and tubing should never touch the ground. The catheter should be cleaned from the insertion point down the tube. The catheter drainage bags should be kept covered in a privacy bag. During an interview on 03/28/24 at 4:36 P.M., RN C said catheters shouldn't touch the floor and should be kept in a privacy bag. During an interview on 03/29/24 at 11:30 A.M., the Assistant Director of Nursing (ADON) said catheters shouldn't touch the floor and should be kept covered in a privacy bag. 47445

Based on observation, interview and record review, the facility failed to ensure proper care of the enteral feeding (the intake of food through a gastrostomy tube (G-tube) (a tube placed directly through the abdomen into the stomach for feeding and/or medication administration) for two residents (Residents #46 and #308) out of a sample of two residents. The facility census was 62. The facility did not provide a tube feeding policy. 1. Review of Resident #46's medical record showed: - admitted [DATE]; - Diagnoses of nontraumatic subdural hemorrhage (a kind of intracranial hemorrhage (bleed) which is the bleeding in the area between the brain and the skull), acute embolism (a blood clot, air bubble, or piece of fatty deposit inside the bloodstream) and thrombosis (a blood clot that forms inside one of the veins or arteries) of an unspecified vein, dysphagia (difficulty swallowing), G-tube status, and the presence of cerebrospinal fluid (a clear, colorless body fluid found within the tissue that surrounds the brain and spinal cord) drainage device; - An order for Jevity 1.5 calories (CAL) (calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for tube feeding) 320 milliliters (ml) four times a day with 200 ml free water flush four times a day at 5:00 A.M., 10:00 A.M., 5:00 P.M., and 10:00 P.M., dated 11/01/23. Observation on 03/27/24 at 9:30 A.M., showed: - The resident lay in bed with the head of the bed elevated; - Licensed Practical Nurse (LPN) K performed hand hygiene, put on gloves, and placed the tube feeding supplies on the resident's table; - LPN K checked the resident's residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding that are pulled through the tube by a syringe) and the placement of the G-tube by auscultation (instilling air into the feeding tube with a syringe while using a stethoscope placed over the stomach to listen for rushing air); - LPN K added 15 ml of water to the medication cup and mixed it with the crushed medication in it; - LPN K administered 30 ml of water into the tube; - LPN K administered the crushed medication mix into the tube; - LPN K administered 30 ml of water into the tube; - LPN K administered 120 ml of Jevity by gravity (letting the formula drain through the tube with no assistance); - LPN K administered another 60 ml of Jevity; - The LPN thinned out the remaining Jevity by adding 120 ml of water in increments of 20 ml, 40 ml, 10 ml, 40 ml, and 10 ml and administered it through the tube; - LPN K flushed the tube with 60 ml of water; - LPN K administered a total of 255 ml of water, 55 ml over the ordered 200 ml. During an interview on 03/27/24 at 9:33 A.M., LPN K said he/she added the extra water to the Jevity 1.5 CAL to thin out the product a little to aid in administration. 2. Review of Resident #308's medical record showed: - admitted [DATE]; - Diagnosis of sinus cancer; - An order for tube feeding formula Jevity 1.5 CAL 240 ml every eight hours, dated 03/18/24; - An order for 60 ml water before and after the feeding every eight hours at 6:00 A.M., 2:00 P.M., and 10:00 P.M., dated 03/18/24 Observation on 03/27/24 at 2:10 P.M., showed: - Resident #308 sat in a recliner in his/her room; - Registered nurse (RN) C performed hand hygiene, put on gloves, and sat the tube feeding supplies on the resident's cleansed table; - RN C checked the resident's residual; - RN C checked the resident's placement of the tube by auscultation; - RN C administered 60 ml of water into the tube and then 60 ml of Jevity 1.5 CAL by gravity; - RN C administered another 60 ml of Jevity and used the plunger (the moving part of a syringe which forced the formula through the tubing) to push the last 50 ml; - RN C administered another 60 ml of Jevity and used the plunger to push the last 40 ml; - RN C administered the last 30 ml of Jevity by gravity; - RN C flushed the tube with another 60 ml of water; - The RN failed to allow the feeding to flow by gravity and used the plunger to push it. During an interview on 03/28/24 at 4:36 P.M., RN C said he/she should not have used the plunger during the tube feeding for Resident #308. All physicians' orders should be followed. During an interview on 03/29/24 at 11:30 A.M., the Assistant Director of Nursing (ADON) said nurses should not use a plunger during tube feedings. It was the expectation for staff to follow orders as written.

Based on observation, interview and record review, the facility failed to follow a physician's order for oxygen for one resident (Resident #33) and failed to obtain a physician's order for oxygen for one resident (Resident #307) out of two sampled residents. The facility census was 62. Review of the facility's policy titled, Respiratory Therapy, undated, showed: - Oxygen therapy will be initiated only by a Respiratory Therapist, a Registered Nurse (RN) or Licensed Practical Nurse (LPN) on the order of a physician or physician extender, except in case of emergency. When oxygen therapy is initiated without an order in an emergency situation, the physician will be contacted as soon thereafter as possible; - Respiratory therapy will be given only upon the order of a physician. 1. Review of Resident #33's medical record showed: - An admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dependence on supplemental oxygen, and essential primary hypertension (high blood pressure); - An order for oxygen at four liters per minute (L/min) via nasal cannula (NC) nasal cannula (a tube inserted into the nostrils to deliver supplemental oxygen), dated 01/22/24; - An order to change the oxygen tubing weekly on Sunday evening, dated 01/22/24. Review of the resident's care plan, last reviewed on 03/14/24, showed: - Administer oxygen at five L/min per NC; - Oxygen change per protocol. Observation of Resident #33 showed: - On 03/26/24 at 1:10 P.M., 03/28/24 at 2:25 P.M., and 03/29/24 at 1:56 P.M., the resident lay in bed with oxygen on at three L/min per NC and the tubing undated; - The facility failed to ensure the resident received the oxygen as ordered. During an interview on 03/29/24 at 1:56 P.M., Resident #33 said he/she couldn't breathe without wearing the oxygen. 2. Review of Resident #307's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with agitation, atherosclerotic heart disease (the buildup of cholesterol, fats and other substances in and on the artery walls), peripheral vascular disease (PVD) (a condition that causes partial or complete obstruction of blood flow), and dysphagia (difficulty swallowing); - Nurse's note, dated 03/20/24, 03/21/24, 03/23/24, and 03/24/24, showed the resident with oxygen on at two L/min per NC. Review of the resident's Physician's Order Sheet (POS), dated March 2024, showed: - No documentation of an order for oxygen use; - No documentation of an order for oxygen tubing or humidifier changes. Review of the resident's care plan, last revised 03/27/24, showed oxygen not addressed. Review of the resident's admission Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff), dated 03/18/24, showed the resident did not receive oxygen therapy. Observations of Resident #307 showed on 03/26/24 at 12:01 P.M., and 3:30 P.M., 03/27/24 at 8:30 A.M., and 2:25 P.M., and 03/28/24 at 10:00 A.M., 3:45 P.M., the resident sat in a wheelchair with oxygen on at three L/min per NC. During an interview on 03/29/24 at 3:30 P.M., the Assistant Director of Nursing (ADON) said there should be orders for oxygen and the orders should be followed. 46521

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Resident #23 and #27) out of two sampled residents. The facility census was 62. Review of the facility's policy titled, Care of a Resident Who Receives Hemodialysis, undated, showed: - Obtain a physician order, may include dialysis schedule, number of treatments per week, and fluid restrictions; - If needed, weights to be obtained if in addition to routine weights; - Pre and post dialysis weight may be obtained at the dialysis center or at the facility; - This should be communicated between the dialysis clinic and facility; - Nurse should assess/monitor and document the shunt (a surgically created connection between a vein and artery used for dialysis) site for bleeding and infection, fluid volume and restrictions if ordered by the physician, weights as ordered, edema, shortness of breath, elevated heart rate, and abnormal breath sounds. 1. Review of Resident #23's Physician's Order Sheet (POS) dated March 2024, showed: - admitted [DATE]; - An order for dialysis on Monday, Wednesday and Friday, dated 01/24/23; - An order for daily weights, call if gains more than two pounds in one day or five pounds in one week, start date 12/31/22, with no stop date; - An order to palpate (examine a part of the body by touch) for the thrill (a palpable murmur that feels like a ringing phone or fly trapped in one's hand) and auscultate (examine a patient by listening to sounds from the heart, lungs or other organs) for the bruit (a sound, especially an abnormal one, heard through a stethoscope) every shift, dated, 01/24/23. Review of the resident's care plan, reviewed on 02/26/24, did not address renal dialysis and the assessment/monitoring of the resident. Review of the resident's medical record showed: - Diagnoses of end stage renal disease (ESRD) (when the kidneys are no longer able to work at a level needed for day-to-day life), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), left lower below the knee amputation, and unsteadiness on feet; - Documentation of the communication report from the facility to the dialysis center, dated 2/26/24 - 3/28/24, with six out of twelve opportunities missed; - No documentation of daily weights for 01/16/24, 01/18/24, 01/19/24, 10/21/24, 01/23/24, 01/25/24, and 01/27/24, with seven missed out of 31 opportunities; - No documentation of daily weights for 02/06/24, 02/07/24, 02/15/24, 02/16/24, 02/20/24, 02/25/24, and 02/26/24, with seven missed out of 29 opportunities; - No documentation of daily weights for 03/06/24, 03/10/24, and 03/24/24, with three missed out of 28 opportunities ; - The facility failed to provide and obtain consistent pre and post dialysis communication with the dialysis center; - The facility failed to consistently monitor daily weights. 2. Review of Resident #27's POS, dated March 2024, showed: - admitted [DATE]; - An order for dialysis on Monday, Wednesday and Friday, dated 01/24/24; - An order for daily weights, call if gains more then two pounds in one day or five pounds in one week, start date 01/11/24, with no stop date. Review of the resident's medical record showed: - Diagnoses of ESRD, dyspnea (shortness of breath), DM, right and left lower below the knee amputation, and impaired mobility; - Documentation of the communication report from the facility to the dialysis center, dated 2/26/24 - 3/28/24, with four out of nine opportunities missed; - No documentation of the communication report from the dialysis center, dated 2/26/24 - 3/28/24, to the facility with nine out of nine opportunities missed; - No documentation of daily weights for 01/12/24, 01/15/24, 01/16/24, 01/17/24, 01/19/24, 01/21/24, 1/23/24, 01/25/24, 01/26/24, 01/27/24, and 01/29/24, with 11 missed out of 31 opportunities; - No documentation of daily weights for 02/03/24, 02/06/24, 02/09/24, 02/11/24, 02/20/24, 02/24/24, 02/25/24, and 02/29/24, with eight missed out of 29 opportunities; - No documentation of daily weights for 03/04/24, 03/10/24, 03/13/24, 03/15/24, and 03/23/24, with five missed out of 28 opportunities; - The facility failed to provide and obtain consistent pre and post dialysis communication with the dialysis center; - The facility failed to consistently monitor daily weights. During an interview on 03/29/24 at 10:25 A.M., the Assistant Director of Nursing (ADON) said the dialysis center would not complete their portion of the communication form. During an interview on 03/29/24 at 1:15 P.M., the Administrator said the dialysis center refused to fill out the paperwork and send it back. During an interview on 03/29/24 at 1:46 P.M., the ADON said she would expect daily weights to be completed as ordered and documented. If the weight was inaccurate, she would expect the resident to be reweighed and the physician to be notified if needed. During an interview on 03/29/24 at 2:20 P.M., Registered Nurse (RN) D said he/she did not usually send any paperwork as the residents were already established with the dialysis center. The residents did not normally return with any. Daily weights were done and the physician should be notified per the orders of certain changes. Surveyor: Carpenter, [NAME] 46521

Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for two residents (Resident #27 and #44) with a diagnosis of Post-Traumatic Stress Disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of five sampled residents. The facility's census was 62. Review of the facility's policy titled, Trauma-Informed Care, undated, showed: - Use the attached abbreviated Trauma Screen; - Use the two item version of the Trauma screen at the time of admission to determine the need for further investigation; - This should be done within seventy-two hours of admission and with the patient if at all possible; - Review patient diagnoses of PTSD also within seventy-two hours of admission; - If positive screen results from the two-item Trauma Screening questions or diagnosis of PTSD, then we complete the six item version of the Trauma Screen for the five day assessment and put interventions in place and care plan accordingly; - For current patients, review diagnosis list for PTSD and complete six item version of the Trauma Screen and if positive, ensure appropriate interventions and care plans are in place; - As patient's quarterly and annual assessments occur, complete the six item version of the Trauma Screen and if positive, ensure appropriate interventions and care plans are in place. 1. Review of Resident #27's medical record showed: - admitted on [DATE]; - discharged on [DATE], and readmitted on [DATE]; - Diagnoses of PTSD, insomnia (a common sleep disorder) and depression (a mental disorder that involves a depressed mood or loss of interest in activities); - No documentation of a PTSD assessment. Review of the resident's Physician's Order Sheet (POS), dated March 2024, showed: - An order for sertraline (an antidepressant medication) 25 milligram (mg) once a day, for depression, dated 03/28/24. - An order for temazepam (a sedative medication) 7.5 mg at bedtime to treat insomnia, dated 03/28/24. Review of the resident's care plan, reviewed 03/27/24, showed: - PTSD not addressed; - No documentation the resident had past trauma or any triggers that would cause the resident to have behaviors. 2. Review of Resident #44's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD and depression; - No documentation of a PTSD assessment. Review of the resident's POS, dated March 2024, showed an order for duloxetine (an antidepressant medication) 60 mg once a day for pain/depression, dated 02/28/24. Review of the resident's care plan, reviewed 02/19/24, showed no documentation the resident had past trauma or any triggers that would cause the resident to have behaviors. During an interview on 03/28/24 at 2:58 P.M., the Social Service Director (SSD) said he/she usually completed the PTSD screening and it was not completed for Resident #27 and #44. During an interview on 03/29/24 at 4:15 P.M., the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) Coordinator said residents with a PTSD diagnoses should have a care plan that addressed the triggers with individualized interventions. Surveyor: Carpenter, [NAME] 46521

Based on interview and record review, the facility failed to ensure a resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure services to promote the resident's highest level of functioning and psychosocial needs for two residents (Residents #10 and #50) out of three sampled residents. The facility census was 62. Review of the facility's policy titled, Dementia - Clinical Protocol, revised March 2015, showed: - For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life; - The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise; - Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses notes and documentation tools); - The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of the dementia, development of new acute medical conditions or complications, and changes in the resident's or family's wishes, etc. 1. Review of Resident #10's medical record showed: - An admitted [DATE]; - Diagnoses of age-related dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and cognitive loss. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 02/16/24, showed moderate cognitive impairment. Review of the resident's care plan, last reviewed 03/13/24, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. 2. Review of Resident #50's medical record showed: - An admitted [DATE]; - Diagnoses of dementia, unspecified severity, with mood disturbance, anxiety (persistent worry and fear about everyday situations), cognitive communication deficit, and Down's Syndrome (a genetic disorder causing developmental and intellectual delays). Review of the resident's admission MDS, dated [DATE], showed: - Diagnosis of dementia; - Severe cognitive impairment. Review of the resident's care plan, last reviewed 03/26/24, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. During an interview on 03/29/24 at 1:39 P.M., the MDS Coordinator said dementia should be addressed on a resident's care plan and include personalized interventions such as medications, activities of daily living, care, wandering and behaviors. During an interview on 03/29/24 at 1:45 P.M., the Assistant Director of Nursing (ADON) said she would expect dementia to be addressed on a resident's care plan and include personalized interventions. She would expect the care plan to be person-centered and reflect a resident's current diagnoses.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during incontinent care for three residents (Resident #10, #16, and #19) out of five sampled residents, Foley catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #10) out of five sampled residents and one resident (Resident #43) outside the sample, and wound care for one resident (Resident #307 ) out of two sampled residents. The facility failed to maintain proper infection control practices during medication administration for one resident (Resident #46) out of six sampled residents when staff touched a pill with his/her bare hand. The facility census was 62. Review of the facility's policy titled, Hand Hygiene, last revised May 2023, showed: - Hand hygiene is a generic term that applies to either hand washing, antiseptic handwashing, antiseptic hand rub, or surgical hand antisepsis; - There are two methods for hand hygiene: Alcohol-based hand sanitizer (60-95 percent (%) alcohol) and washing the hands with soap and water; - Use alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal; - Wash hands with soap and water when hands are visibly soiled, after caring for a person with known or suspected infection, and after known or suspected exposure. Review of the facility's policy titled, Perineal Care, undated, showed: - Gather supplies, wash hands, and put on gloves; - For females, wash inner legs, outer peri area along the outside of the labia (the folds of skin around the vaginal opening), use clean wash cloth/wipe for each wipe of peri area, and wash front to back; - For males, wash the penis from the tip downward and dry, wash the scrotum, wash and dry the skin between the legs, and wash and dry the anal area; - Remove soiled gloves, dispose, and finish the bed change, put on clean gloves and apply barrier cream; - Remove soiled gloves and dispose; - Remove bagged linen and trash. 1. Observation on 03/27/24 at 9:30 A.M., of incontinent care for Resident #19 showed: - Certified Nursing Assistant (CNA) A and CNA J performed hand hygiene and put on gloves; - CNA A and CNA J removed the resident's pants and unfastened the brief; - CNA J performed peri care; - CNA J changed gloves and did not perform hand hygiene; - CNA J performed incontinent care, wiping from the back to the front peri areas when cleansing between the buttocks; - CNA J changed gloves and did not perform hand hygiene, touched the resident's pants and blanket, removed the gloves and did not perform hand hygiene. 2. Observation on 03/27/24 at 9:40 A.M., of incontinent care for Resident #16 showed: - CNA A and CNA J did not perform hand hygiene after care of Resident #19; - CNA A and CNA J put on gloves and did not perform hand hygiene; - CNA A and CNA J transferred the resident from the wheelchair to the bed with a gait belt; - CNA A and CNA J removed the gloves, performed hand hygiene, and put on gloves; - CNA A and CNA J removed the resident's pants and unfastened the brief; - CNA J cleaned the resident's genitals with the same area of the wipe; - CNA A and CNA J did not perform hand hygiene and change gloves; - CNA J cleaned the resident's buttocks; - CNA J removed the gloves, did not perform hand hygiene, and touched the resident's lollipops, a blanket, a drink, and exited the room with the trash; - CNA J entered another resident's room and exited without performing hand hygiene, walked to the medication cart and touched the water picture to obtain water; - CNA J entered another resident's room and closed the door. During an interview on 03/28/24 at 4:32 P.M., CNA J said hands should be sanitized between glove changes and gloves changed when going from dirty to clean care. For incontinent care, a different wipe or a different area of the wipe should be used for each stroke. Should clean front to back during incontinent care. Review of the facility's policy titled, Urinary Cath Care, undated, showed: - Catheter care is performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter; - Wash hands or hand sanitize before any manipulation of the catheter site and/or apparatus; - The only place in the closed system intended to be open is the empty spout at the bottom of the drainage bag; - Drainage bag should be kept below the level of the bladder. 3. Observation of incontinent care for Resident #43 on 03/26/24 at 01:21 P.M. showed: - The resident sat in a wheelchair in his/her room and the catheter drainage bag hung underneath the wheelchair; - CNA A and CNA M transferred the resident from the wheelchair to the bed via mechanical lift (a device designed to lift and transfer residents from one surface to another); - CNA A and CNA M performed hand hygiene and put on gloves; - CNA A placed the catheter drainage bag on the bed, beside the resident's left thigh. As the resident was turned to get his/her pants down, the catheter drainage bag fell to the floor; - CNA A did not perform hand hygiene or change gloves, and provided catheter care; - CNA M rolled the resident to the right; - CNA A did not perform hand hygiene or change gloves, cleaned the resident's left buttock and thigh, picked up the catheter drainage bag and placed it back on the bed, and did not perform hand hygiene or change gloves; - CNA M rolled the resident to the left, the catheter drainage bag fell back to the floor, touching the toe of CNA A's shoe; - CNA A cleaned the resident's right buttock and thigh, did not perform hand hygiene or change gloves, reached over to the bedside cabinet, and opened two drawers to get barrier cream; - CNA M changed gloves but did not perform hand hygiene, and applied barrier cream to the resident's buttocks; - CNA A placed the catheter drainage bag back onto the bed; - Registered Nurse (RN) I entered the room and assisted in replacing the catheter statlock (a strap free stabilization device) and the handle on the catheter drainage bag was broken; - RN I changed out the catheter drainage bag and left the room; - CNA A and CNA M pulled up the resident's pants and the tubing from the drainage bag to the Foley catheter came apart and moved down the pant leg. CNA A, wearing the same gloves, pushed the drainage tubing up the left pant leg, reconnected it to the Foley catheter tubing, and failed to clean the tip of the drainage bag tubing. During an interview on 03/28/24 at 4:36 P.M., CNA A said the catheter drainage bag should be below the bladder, it should not be in the floor and he/she probably should've got the nurse back in to reconnect the tubing. During an interview on 03/28/24 at 430 P.M., RN I said hands should be sanitized between glove changes, gloves should be changed going from dirty to clean care. A different area of a wipe should be used when cleaning during incontinent care. 4. Observation on 03/28/24 at 2:14 P.M., of incontinent care for Resident #10 showed: - CNA L and CNA H did not perform hand hygiene, put on gloves, and transferred the resident from the wheelchair to the bedside with a gait belt (an assistive devices used to help safely transfer a person); - CNA L and CNA H removed the resident's pants while his/her catheter drainage bag lay in the floor, and assisted the resident to lay down on the bed; - CNA L removed his/her gloves, did not perform hand hygiene, put on gloves, and unfastened the brief; - CNA L performed peri care to the front peri area and the groin; - CNA H assisted the resident to turn and handed a wipe to CNA L; - CNA L performed peri care to the buttock area, rolled the brief under the resident, removed the gloves, did not perform hand hygiene, and put on gloves; - CNA L applied barrier cream to the resident's coccyx (tail bone) and between the buttocks, removed gloves, did not perform hand hygiene, and put on gloves; - CNA L performed catheter care with a wipe, removed gloves, did not perform hand hygiene, and put on gloves; - CNA L positioned a clean brief under the resident and touched the clean sheet and the blanket; - CNA H touched the bed controls to lower the bed; - CNA H and CNA L removed the gloves, performed hand hygiene, and left the room; - The catheter drainage bag hung on the bed frame and the bottom of the drainage bag lay on the floor with no privacy bag. During an interview on 03/28/24 at 2:30 P.M., CNA L said hand hygiene should be completed before and after care, gloves should be changed when moving from the front to the back sides, before and after cleaning a catheter, and sanitize hands each time gloves were changed. He/She said the drainage bag should not touch the floor and should be in a privacy bag. During an interview on 03/28/24 at 2:40 P.M., CNA H said to sanitize hands and put on gloves when entering a room. Peri care was done front to back using wipes, moving top to bottom, clean to dirty, roll the resident, and change gloves. Should clean the middle from front to back, use a new wipe to clean the buttocks, change gloves, roll the resident, and provide catheter care down and away from the insertion site 9-12 inches. Should change gloves, re-brief and apply cream, cover the resident and place the call light in reach, hang the catheter drainage bag on the side of the bed frame, the drainage bag had to be up off the floor, and in a dignity bag. Review of the facility's policy titled, How to Perform a Dressing Change, undated, showed: - Review the order; - Prepare ointments in a medicine cup, ointments in jars are removed with a tongue blade, or cotton swab and applied to the dressing or wound bed using a tongue blade or cotton swab; - Wash hands; - Clean the bedside table, set up the clean field; - Open all dressings and trays before beginning procedure; - If scissors are needed, clean with bleach wipes and place on the clean field; - Position patient and expose the area to be treated; - Wash hands, put on gloves; - Remove soiled dressing; - Place soiled dressing in a plastic bag; - Remove gloves, wash hands or sanitize hands, put on clean gloves; - Clean wound from the center out; - Remove gloves, wash hands or sanitize, put on clean gloves; - Apply ordered dressing and secure. 5. Review of Resident #307's medical record showed an order to cleanse the open areas to the bilateral lower extremities with wound cleanser, apply Xeroform (a wound dressing) to the open wounds and wrap with kling (absorbent gauze roll, which stretches and conforms to the body shape and clings to itself as it is wrapped) daily. Observation of wound care for Resident #307 on 03/27/24 at 1:30 P.M., showed: - RN C put on gloves, cleaned the table, put the wound care supplies on the table, changed gloves, and did not perform hand hygiene; - RN C used personal scissors to cut the dressing to the left lower leg, changed gloves without performing hand hygiene, and failed to clean the scissors after cutting the old dressing; - RN C left the room to get a CNA, returned, changed gloves and did not perform hand hygiene; - CNA A put on gloves and held the lower leg up; - RN C's gait belt touched the open wound; - RN C cleaned the wounds with wet gauze and dried the wounds with dry gauze; - RN C, wearing the same gloves and using the same scissors, cut the Xeroform and applied it on the wounds, and did not clean the scissors; - RN C, wearing the same gloves, applied clobetasol (an anti-inflammatory medication) cream with a gloved finger around the wound; - RN C changed gloves and did not perform hand hygiene; - RN C wrapped the left lower leg with kling wrap; - RN C moved to the resident's right lower leg without changing gloves or performing hand hygiene, and used the same scissors to cut the old dressing from the right lower leg; - RN C removed the dressing and changed gloves without performing hand hygiene; - RN C cleaned the area with wet gauze and dried with dry gauze; - RN C, wearing the same gloves, applied clobetasol cream with a gloved finger around the wounds; - RN C changed gloves without performing hand hygiene; - RN C applied Xeroform gauze to the wounds, dropped the package of kling wrap onto the floor, and picked up the package; - RN C, wearing the same gloves, opened the kling wrap, and wrapped the right leg wounds; - RN C removed the gloves and performed hand hygiene. During an interview on 03/28/24 at 4:36 P.M., RN C said hands should be sanitized between glove changes and that he/she didn't know that until now. He/She knew it should be done at the start and end of care, and for incontinent care, should clean from the front to back. The facility did not provide a policy regarding medication administration. 6. Observation on 03/28/24 at 9:30 A.M., of medication administration preparation for Resident #46 showed: - Licensed Practical Nurse (LPN) K opened a package of sertraline (an antidepressant) 25 milligram three tablets; - LPN K dropped one sertraline tablet onto the top of the medication cart; - LPN K picked up the pill with his/her bare hand and added to the medication cup with the other tablets; - LPN K crushed the pills and administered the medication through a feeding tube. During an interview on 03/28/24 at 2:45 P.M., the Assistant Director of Nursing (ADON) said the catheter drainage bag should not touch the floor and should be in a dignity bag. Staff should wash hands and put on gloves before care, change anytime going clean to dirty care, sanitize hands with every glove change, after care, and should wash hands. 47445 50260

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 61. Record Review of facility's Food Service Department Preventative Maintenance policy, dated January 2011, showed: - For the hood, clean the inside and the outside, clean or change the filters; - For the air conditioner, clean or change the filter; - For the ice machine, clean the condenser and the filter, check for the correct air gap in the drain, and consider professional cleaning twice each year; - For the refrigerators and the freezers, clean the dust from the motor and the condensers. Check the door closures, the gaskets, and the heat strips for proper operation. Check for any leaks or ice build-up and check the temperatures; - For the floors, check and replace the tiles as needed, check the floor drains for covers and proper draining; - For the air vents, clean; - For the walls and ceilings, check and repair the paint; - For ceiling vents, clean routinely (minimum quarterly). Check for rust/deterioration and repair/paint as needed; - For the water, check the pressure, temperature, leaks, etc. on the faucets, sprayers, sinks, pipes, and the dish machine, ice machine, etc. Record review of facility's Safety and Sanitation Best Practice Guidelines, Dry Storage/Refrigerator and Freezer Storage policy, dated November 2017, showed: - Food items may not be stored in locker rooms, toilet rooms, dressing rooms, garbage rooms, mechanical rooms, under sewer lines not shielded to intercept potential drips, under leaking water lines (including automatic sprinkler heads) or under line on which water would condense, under open stairwells or under other sources of contamination (Food Code 3-305.12). - All foods must be at least 18 in. from the sprinkler heads; - No chemicals or cleaners may be stored in the dry food storage area; - Refrigerators and freezer units will be cleaned (and defrosted, if needed) routinely/ Ice should not be allowed to build-up, as this may cause falls. Foods may be moved to other units to maintain correct temperatures while cleaning being completed. 1. Observations of the kitchen on 9/20/22 at 12:10 P.M., showed: - The ice machine drain pipe with an air gap set at three inches (in.) near the floor drain, the drain pipe and floor drain covered in black grime; - A four in. kitchen floor drain near the freezers in the main kitchen surrounded by broken and cracked linoleum floor pieces; - The chemical dishwasher dirty on the exterior; - The dishwashing sink faucet dripped continuously and would not shut off; - The overhead style door opener which separated the main kitchen dishwashing area from the dining area covered with dirt, dust and grime; - The overhead style door opener which separated the main kitchen serving area from the dining area covered with dirt, dust and grime; - The exit door closer mechanism in the main kitchen serving area covered with dirt, dust and grime; - A bug zapper in the hallway corridor covered in dead bugs with food carts and bread stored below; - A steam table used in the food storage area. During an interview on 9/20/22 at 12:06 P.M., the Director of Food and Nutrition said a new steam table was ordered and the temporary steam table was in a space normally used for food storage. 2. Observations of the kitchen on 9/21/22 at 10:26 A.M., showed: - The commercial linoleum flooring damaged in the main kitchen dry food storage area; - The linoleum flooring near the freezers 16 in. away from the four in. floor drain with a two in. by four in. hole and a 10 in. by one in. crack between the flooring pieces; - The linoleum flooring in front of the steam table with an eight in. by one in. gap between the finished surfaces; - A four in. kitchen floor drain in the food preparation area surrounded by broken and cracked linoleum floor pieces; - A one in. diameter hole and numerous one in. tears in the floor in front of the walk in refrigerator; - A rectangular section of repaired flooring three foot (ft.) by one ft. area with 1/2 in. cracks along the edge of the repair; - Both freezer units in the main kitchen contained ice formations; - The caulking between the stove exhaust vent and the wall loose and hung over the stove and oven; - A section of partially repaired wall 16 in. by six in. unsanded and unpainted; - The stove and exhaust vent above the stove with grease build up inside and outside; - The sprinkler escutcheon above the stove corroded; - A section of partially repaired wall unsanded and unpainted along the serving window frame in the kitchen; - A one ft. long section of damaged wall with peeling paint in the drink preparation area near the coffee dispensers; - A two ft. by two ft. attic crawl space overhead cover in the serving area near the drink preparation with the paint peeling and the metal cover bent along one edge; - An eight ft. section of the vinyl cove base missing along the floor in the food serving area near the window; - A one ft. section of the vinyl cove base missing along the floor below the juice dispenser; - A two ft. by four ft. wall section above the kitchen door to the hallway unsanded and unpainted; - The main kitchen door closer covered with dust and grime. 3. Observations on 9/22/22 at 12:31 P.M., showed: - The secondary kitchen and dining area in the Memory Care Unit with a two-door refrigerator gasket covered with mold and mildew. During an interview on 9/22/22 at 11:26 A.M., the Director of Facility Maintenance said that he/she plans to have a new steam table on 9/29/22, and there were plans to paint the walls and put up paneling before the steam table would be installed. 4. Observations on 9/23/22 at 8:18 A.M., showed: - Twelve or more pea-sized ice formations on top of the right side freezer in the main kitchen; - Twelve or more one in. to two in. ice [CONDITION(S)]-shaped formations hung from the inside of the freezer on the left side and a solid ice formation 1/8 in. thick covering half of the top of the freezer; - Inside the walk-in refrigerator in the main kitchen with a two ft. by two ft. ventilation grill covered entirely with dust and debris between all the louvers; - Outside the walk-in refrigerator, above the door, a four ft. by two ft. ventilation grill covered with grease, dust, and debris between the louvers. During an interview on 9/23/22 at 8:34 A.M., the Director of Food and Nutrition said the freezer was equipped with an automatic defroster and he/she wasn't aware ice was built up in the freezers. He/she said the Director of Maintenance inspects the freezers. During an interview on 9/22/22 at 11:26 A.M., the Director of Facility Maintenance said that he/she expects kitchen staff to monitor the freezers for ice formations and temperature checks. He/she helps with freezer inspections and wasn't aware of any problems with the freezers. During an interview on 9/23/22 at 11:53 A.M., the Administrator said that he/she would expect kitchen and maintenance staff to follow procedure guidelines.

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 #73) outside the sample. Staff failed to notify the physician of the residents change in condition and report critical lab values. The facility census was 73. 1. Review of Resident #73's medical chart showed: - admitted to the facility on [DATE]; - [DIAGNOSES REDACTED]. - an order for [REDACTED].>- An order, [MEDICATION NAME] (medication for fluid retention) 1 milligram (mg) by mouth daily. Review of the resident's weight record showed: - On 10/20/17 admission weight 224.1 pounds (lbs); - On 10/21/17 weight 215.9 lbs (a 9 lbs loss in one day); - On 10/22/17 weight 218.2 lbs (a 3 lbs gain); - On 10/23/17 weight 219.6 lbs; - On 11/1/17 weight 229.1 lbs (10 lb gain in one week); - On 11/9/17 weight 239.7. lbs (10 lb gain in one week). Review of the nurses' notes from 11/9/17 through 11/14/17 showed: - On 11/9/17 no nursing notes; - On 11/10/17 generalized non-[MEDICAL CONDITION] and wheezing; - On 11/11/17 [MEDICAL CONDITION] bilateral lower extremities, [MEDICAL CONDITION] in feet; - On 11/12/17 no nursing notes, assessments or skin assessments; - On 11/13/17 no nursing note or assessments; - On 11/14/17 generalized wheezing, non-[MEDICAL CONDITION]; - On 11/14/17 a change in condition completed with notation of increased amount of [MEDICAL CONDITION] to face and increased shortness of breath, eyes puffy and red, lungs clear but diminished. Physician phoned and new orders for STAT (immediately) BNP, (B type natriuretic peptide) (a blood test that measures levels of a protein called BNP that is made by your heart and blood vessels. BNP levels are higher than normal when you have heart failure.), basic metabolic panel (BMP), complete blood count (CBC) and chest x-ray due to the [MEDICAL CONDITION], weight 239.7 lbs. - On 11/14/17 at 7:30 P.M. Licensed Practical Nurse (LPN) A took resident to his room, resident had small emesis, emesis cleaned and oxygen placed on resident. Waiting on chest x-ray results. Record review of the resident's lab showed: - On 11/3/17 BNP lab results 212 (normal lab value is 0-100); - On 11/6/17 the facility faxed the BNP lab results to the physician's office; - On 11/7/17 new orders were received to recheck the BNP in two weeks and may repeat if changes in [MEDICAL CONDITION] or signs of [MEDICAL CONDITION]; - On 11/14/17 the labs received and BNP 623 (normal 0-100). The facility failed to repeat lab as ordered on [DATE], notify the physician of the 10 lb weight gain on 11/1/17, 11/9/17 and the abnormal BNP on 11/14/17. Review of the nurses' notes on 11/15/17 at 10:15 A.M. Certified Nurse Aide (CNA) summoned nurse to room, upon entering the resident was laying in bed on oxygen, unresponsive, no pulse. EMS arrived and the resident was taken to nearest emergency room . During an interview on 2/2/18 at 1:56 P.M. LPN B said if there is a discrepancy in weight the resident should be re-weighed right then. If a resident has cardiac problems and there is a significant weight increase the physician should be contacted immediately, and get stat orders. He/she said when charting [MEDICAL CONDITION], it should be charted as trace of [MEDICAL CONDITION], pitting, non-pitting, 1-2 [MEDICAL CONDITION], what you see and assess. Staff should call the doctor with any STAT lab results whether they are normal or abnormal. During an interview on 2/2/18 at 2:43 P.M. LPN C said if a resident has a weight gain and has [MEDICAL CONDITION], he/she would call for orders, probably a BNP and discuss diuretics with the physician. If it is on the weekend the facility has an on-call physician and staff can receive orders from the on-call physician. During an interview on 2/2/18 at 2:54 P.M. Registered Nurse (RN) D said the physician should be notified when a resident has a weight gain and a [DIAGNOSES REDACTED]. When [MEDICAL CONDITION] is present it should be documented 1+, 2+, 3+ pitting and location of [MEDICAL CONDITION]. He/she said if there is a low or high critical lab the physician should be notified immediately and a on-call physician can be called on weekends. During an interview on 2/2/18 at 3:15 P.M. and 2/5/18 at 12:40 P.M., the physician said he had reviewed the resident's medical record and he had not seen the resident; the nurse practitioner (NP) had seen the resident one time. He would expect the staff to contact him for an elevated BNP or weight gain of two lbs. or more in 24 hours or 3-5 lbs. in a weeks time. If he had known about the weight gain he would have given the resident more diuretics and restrict his/her fluids.

Based on interview and record review, the facility failed to assess the cause of falls and implement interventions in an attempt to reduce the risk of falls and/or injuries for one (Resident #3) of four reviewed residents. The resident experienced injuries as a result of the falls. The facility's census was 69. 1. Record review of Resident #3's face sheet showed the resident entered the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent side rail assessment, dated [DATE], showed staff identified the resident with a history of falls, decreased safety awareness, ambulatory and had difficulty with balance or poor trunk control. Staff noted the resident had been placed in a low bed with a fall mat. Review of the most recent fall risk assessment, dated [DATE], showed staff identified the resident at high to very high risk for falls, had a history of [REDACTED]. The assessment directed staff to implement high risk interventions. The assessment did not further address the interventions. Review of a Physical Therapy (PT) screen, dated [DATE], showed staff did not identify fall risk or recommend interventions. Review of the care plan, dated [DATE], showed: - Under problems, staff identified the resident had Alzheimer's disease. Staff noted under interventions for Alzheimer's disease that the resident was a fall risk and should be monitored. - Under problems, staff identified the resident required assistance with dressing, grooming and bathing. Staff noted under approaches for required assistance that the resident ambulated with a cane and assistance of one, usually propelled self in a wheelchair and had anti-tip locks on the wheelchair. - Staff did not thoroughly develop a care plan to address interventions to reduce the risk of falls. Review of a nurse's note, dated [DATE], showed staff found the resident lying face down in the floor in front of his/her wheelchair with the resident's shoes under the wheelchair. The nurse noted the resident had an abrasion, active bleeding to the right temporal lobe (one of the four quadrants of the brain), pupils reacted sluggishly to light stimuli and vital signs within normal limits. Staff sent the resident to the hospital for further evaluation. Review of a hospital radiologist report, dated [DATE], showed the resident fell and landed on his/her forehead. The radiologist identified no acute intracranial hemorrhage (bleeding of the brain). Review of a hospital transfer sheet, dated [DATE], showed the resident experienced a fall and had decreased responsiveness due to a new [DIAGNOSES REDACTED]. Review of the care plan showed staff did not update the resident's care plan to address interventions to reduce fall risk. Review of a post fall nursing assessment, dated [DATE], showed the resident fell from the wheelchair on [DATE] at 6:45 P.M. Staff found the resident lying face down in the hall with a three centimeter (cm), actively bleeding abrasion (site not identified). Staff noted the intervention to prevent further falls as safe shoes and slippers. Staff did not identify the cause of the fall or identify further interventions to reduce the risk of falls. Review of a fax, dated [DATE], showed staff notified the physician that the resident fell out of the wheelchair and hit his/her head on the floor resulting in a 3 cm abrasion to the forehead. Review of a PT screen, dated [DATE], showed staff did not address the fall of [DATE], identify fall risk or recommend interventions. Review of the Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed staff identified the resident had two falls without injury since the previous assessment. Review of a nursing summary report, dated [DATE], showed staff identified the resident last fell on [DATE]. The resident transferred self; required extensive assistance with transfers; walked in room by self; required limited assistance to walk in room; independent with locomotion on the unit; required set-up help with locomotion on unit; had to be lifted manually with a transfer aid; and used a cane/walker/crutch and self-propelled wheelchair for locomotion. Staff identified the resident's primary means of locomotion as a wheelchair. Staff provided passive range of motion three days a week and walked the resident three days per week. The summary did not further address the fall or identify interventions to reduce the risk of falls. Review of a post fall nursing assessment, dated [DATE], showed staff found the resident lying in the floor in a supine position with legs extended outward with his/her wheelchair overturned. Staff did not identify if the resident experienced injuries from the fall. Staff noted the resident fell from the low bed. Staff identified the resident's blood pressure as low on the first reading (,[DATE]) but improved on the second reading (reading not noted). Staff did not identify interventions to reduce the risk of further falls. Review of a fax, dated [DATE], showed staff notified the physician that the resident fell out of bed with no apparent injuries. Review of the care plan showed staff did not update the care plan to address interventions to reduce fall risks. Review of a nurse's note, dated [DATE] showed the resident's blood pressure measured ,[DATE] with the resident not exhibiting signs of injury. Review of a fax, dated [DATE], showed staff notified the physician that the resident had been having low blood pressure readings since falling out of bed. The resident's blood pressure ranged from ,[DATE] to ,[DATE]. Review of a PT screen, dated [DATE], showed staff did not identify the fall risk or fall on [DATE]. Staff noted caregiver instructed to raise the bed when getting up due to patient difficulty in getting up in bed. The PT did not further address interventions to reduce the risk of falls. Review of an Occupational Therapy (OT) screen, dated [DATE], showed staff identified the resident fell on [DATE] with no OT interventions needed. Staff noted the suggested intervention plan had been discussed with nursing. The OT screen did not further identify the intervention plan to reduce the risk of further falls. Review of a post fall nursing assessment, dated [DATE], showed staff identified the resident fell in the dining room while attempting to exit the wheelchair. The resident wore foot wear at the time of the fall. He experienced a 2 cm hematoma (bruise) to the left side of the forehead. The resident's blood pressure was ,[DATE]. Staff did not identify interventions to reduce the risk of further falls. Review of a nurse's note, dated [DATE], showed staff identified the resident lay in bed and had a reddish-purple area above the right eyebrow. Staff applied a tabs (personal alarm) and reminded the resident to use a call light for transfers. Review of a physician's note, dated [DATE], showed the physician noted the resident fell from bed on [DATE] and fell on [DATE] due to low blood pressure. Review of a nurse's note, dated [DATE], showed the resident was non-responsive to stimuli with a blood pressure of ,[DATE]. The resident was transferred to the hospital. Review of a OT screen, dated [DATE], showed staff identified the resident had a fall and had anti-tip bars and automatic brakes on his/her wheelchair. Staff noted nursing recently applied a tabs alarm to the resident. Staff did not identify further interventions to reduce the risk of further falls. Review of the care plan, updated [DATE], showed staff identified the resident had recent falls and an order had been received to apply a tabs alarm. Staff noted the resident removed the alarm. Review of a nurses' note, dated [DATE], showed the resident unable to grip with the right hand and unable to raise the right arm. Staff contacted the physician who ordered an X-ray of the right shoulder and a Cat Scan (CT-computed tomography) scan of the head. Review of a nurse's note, dated [DATE], showed staff called the Veteran's Administration (VA) Hospital and was told to call the following Monday for the date and time of the CT scan. Review of nurses' notes, dated [DATE], showed staff found the resident lying on his/her left side in the floor by the bed at 4:00 A.M. The resident experienced a 3 cm laceration with active bleeding (site not identified) and a 3 cm skin tear to the top of the right hand. Staff noted the resident's pupils reacted sluggishly. The resident was transferred to the hospital at 4:45 A.M. At 6:45 A.M., the hospital called and notified staff the resident was being air evacuated to another hospital with C2 and C3 (cervical vertebrae) fractures. At 8:35 P.M., the resident returned to the facility via ambulance. The resident was non-responsive with rapid, gurgling breathing. The resident was transferred back to the hospital at 9:05 P.M. Review of a post fall nursing assessment, dated [DATE] and faxed to Section for Long-Term Care Regulation (SLCR) on [DATE], showed on [DATE] at 4:00 A.M., the resident attempted to exit the wheelchair and fell on the left side while in his/her room. The resident sustained [REDACTED]. The resident's blood pressure was ,[DATE]. Staff did not further address the fall. Review of notes from the resident's initial hospitalization showed a radiologist report, dated [DATE], identified the resident had non-displaced (broken but still in place) fractures of the C2 and C3 vertebrae. The resident was transferred to another hospital for further care. Review of an orthopaedic consult, dated [DATE], completed while in the hospital, showed, Resident #3 had non-displaced fractures of the C2 and C3 vertebra and no evidence of spinal cord injury based on physical exam. Review of a hospital discharge summary, dated [DATE], showed the resident had [DIAGNOSES REDACTED]. A repeat CT scan of the head showed no acute hemorrhaging. The hospital transferred the resident to another hospital for end-of-life care. Review of a hospital discharge summary, dated [DATE], showed the resident entered the facility for Hospice care with multiple injuries due to a fall while in the nursing home, including a neck fracture of the C2. The resident died on [DATE]. Review of the facility's falls program guidelines showed it directed staff to document a description of what was observed, position when found, complete description of inquiries (including location and type of injury) and complete assessment. The policy did not address identification of the cause of the fall or the development of interventions to reduce the risk of further falls. During an interview on [DATE] at 1:35 P.M., Certified Nurse Aide (CNA) B said Resident #3 was very confused, transferred self to the wheelchair, walked in his/her room with a walker and did a lot of things without assistance. Staff applied a tabs alarm but the resident removed the alarm and hid it. During an interview on [DATE] at 1:50 P.M., the Director of Nursing (DON) and the Unit Coordinator said the resident ambulated and was very mobile in his/her room; used an anti-lock brake, no tip wheelchair; transferred self; and provided some of his/her own care. Following falls, staff assessed the resident and contacted the physician. During an interview on [DATE] at 10:20 A.M., the DON and MDS/Care Plan Coordinator said: - Resident #3 transferred self from the bed to the wheelchair and toileted self. - Staff placed the resident on a low bed because all residents who resided on the unit used a low bed. Staff did not complete an assessment related to the appropriateness of a low bed. - Resident #3 fell out of a wheelchair on [DATE]. Staff noted the intervention to prevent further falls as safe shoes and slippers. The DON said it was a good question as to why shoes and slippers would have prevented the resident from falling. The computer program allowed staff to choose from only a limited list of interventions and staff should have further explained interventions. Staff did not update the care plan following the fall. - On [DATE], the resident fell while transferring self from the (low) bed to wheelchair. - The MDS/Care Plan Coordinator said she could not explain why no care plan had been fully developed to address interventions to reduce the risk of falls. During an interview on [DATE] at 10:30 A.M., the Administrator, DON and MDS/Care Plan Coordinator said: - Resident #3 fell on [DATE] while attempting to stand in the dining room. The intervention to prevent further falls was to monitor more closely. On [DATE], the resident became non-responsive while siting at the dining room table. On [DATE], the OT discussed nursing interventions that were already in place. - On [DATE], the resident fell again and went to the hospital. - Staff did not develop a specific care plan to address falls and did not list interventions to reduce the risk of falls but had implemented interventions. - The resident would not keep a bed or tabs alarm on. Staff did not document application and/or remove of the alarms. - The resident ambulated, transferred self and used a wheelchair with anti-lock brakes. - The side rail assessment included a notation that the resident had a low bed with fall mat. - Staff did not complete further documentation related to cause of falls. During an interview on [DATE] at 10:55 A.M., the Administrator and MDS/Care Plan Coordinator said following Resident #3's fall on [DATE], staff did not complete a post fall assessment. During an interview on [DATE] at 10:56 A.M., the Administrator, DON and MDS/Care Plan Coordinator said: - The resident was non-responsive when returned to the facility from the hospital following the fall on [DATE] and was immediately transferred back to the hospital. - The Administrator thought Resident #3 might have had neurological changes prior to [DATE] that could have been related to previous falls when the resident hit his/her head. During an interview on [DATE] at 12:15 P.M., the Administrator said that documentation was lacking but she thought everything was done and all interventions did not make it to the chart. During an interview on [DATE] at 1:28 P.M., the Physician said: - The resident was ambulatory and transferred self. - Staff notified the Physician of the resident's falls and he ordered treatment as indicated. - The resident's fall on [DATE] was related to low blood pressure and medications were adjusted accordingly. The pharmacy reviewed the medications in June and July and did not make further recommendations. - He was unaware the resident fell from bed while transferring self on [DATE]. If the resident transferred self, the use of a low bed would not have been beneficial. - The Physician expected nurses to assess the cause of the falls and notify him. He expected full assessments to determine the cause of falls and development of care plans to address interventions to reduce risks. - It sounded like staff did not fully document what was going on with the resident. Complaint MO

Based on observation, interview and record review, the facility failed to provide prompt treatment and services for two (Residents #1 and #2) of five reviewed residents following injury/change in condition. The facility's census was 78. 1. Record review of Resident #1's face sheet and physician's orders [REDACTED]. The physician ordered [MEDICATION NAME] (narcotic pain medication) 5/500 milligrams (mg) twice a day since 5/10/12, [MEDICATION NAME] 5/500 mg every six hours as needed (prn) since 5/10/12 and Tylenol ([MEDICATION NAME]) 650 mg three times per day prn. The Veteran's Administration (VA) admitted the resident to the facility. Review of a post fall nursing assessment, dated 6/5/12 at 4:40 A.M. showed the resident fell at 3:35 A.M. and reported pain in the right hip and knee. Staff notified the physician of the resident's fall by fax. In an addendum to the note, dated 6/11/12, staff noted at the time of assessment the resident stood with assist of three with right leg supported. The resident reported pain in the right hip and knee. When assisted to the bathroom, the resident reported pain when sitting on the toilet. The resident later reported pain in his toe. Review of nurses' notes, dated 6/5/12, showed: - At 4:10 A.M., staff notified the physician of the resident's fall by fax. - At 7:30 A.M.,the resident had two episodes of slumping to the right side while sitting at the table. The resident could not bear weight on the right leg and could not straighten the leg at the knee. The resident had a hard knot on the right outer femur and mild swelling to the right ankle. The resident reported pain to the hip and femur area upon palpation. - At 7:40 A.M., staff attempted to contact the resident's (in house, primary care) physician without success. - At 8:00 A.M., staff called the VA hospital and was told to contact the resident's primary care physician at the facility. - At 8:30 A.M., staff contacted the resident's (primary care) physician who ordered X-rays of the right hip, right femur, right knee and right ankle. - At 10:00 A.M. the resident responded "its OK" when asked about pain. - At 10:05 A.M., the knot to the right hip and femur was slightly larger. - At 1:00 P.M., the outside radiology provider called the facility and asked staff how long they had before the X-rays needed to be taken as they (the radiology provider) had staff call out. - At 2:30 P.M., X-rays were obtained. The resident grimaced and moaned with pain. The nurse documented he/she told the Certified Medication Technician (CMT) to administer prn pain medication and the CMT administered Tylenol. - At 5:00 P.M., staff administered routine pain medication ([MEDICATION NAME]) and called the radiology provider to request results of the X-rays. Staff did not document the effectiveness of the pain mediation at this time. - At 5:10 P.M., the radiology provider called and reported they were unable to upload X-ray images due to Internet problems. - At 7:00 P.M., the resident continued to have pain in the right hip and knee area and exhibited facial grimacing with palpations. The resident moaned during repositioning and reported pain as 100 on a scale of 1 to 10 with 10 being severe. Staff continued to wait for X-ray results. - At 8:00 P.M., staff contacted the radiology provider concerning the results of the X-ray. They did not have results of the X-ray. - At 9:00 P.M., X-ray results indicated no definitive fracture. The resident continued to experience pain and could not bear weight or straighten right leg. Staff noted the [MEDICATION NAME] was non-effective and contacted the physician. - At 9:25 P.M., the (primary care) physician returned the call and received results of X-rays. The physician ordered the resident sent to the emergency room for evaluation and treatment of [REDACTED]. - At 9:40 P.M., the resident left the facility via ambulance. The resident grimaced during transfer and guarded the right hip. Review of a nurse's note, dated 6/6/12 at 1:00 A.M., showed the resident admitted to the hospital with [REDACTED]. Review of medication administration records (MAR), dated 6/5/12, showed staff administered routine [MEDICATION NAME] but did not administer prn [MEDICATION NAME]. During an interview on 6/26/12 at 9:10 A.M., Resident #1 said he/she remembered falling but could not recall specifics other than it hurt. During interviews on 6/26/12 at 10:15 A.M. and 10:35 A.M., Registered Nurse (RN) A said he/she had been told in report at 6:30 A.M. that the resident had fallen on the night shift. RN A initially said the resident did not appear to be in pain. RN A then said the resident hurt with attempts to put weight on the leg, the resident could not flatten the knee and the resident reported pain in the hip, thigh, knee and ankle. RN A said he/she tried to call the resident's primary physician and VA physician. When RN A reached the VA physician, he/she was told to notify the primary care physician for orders. When the primary care physician returned the call, he/she ordered X-rays. RN A knew the X-ray provider had staffing issues and there would be a delay but did not notify the resident's physician. The resident received routine [MEDICATION NAME] and RN A had the CMT administer Tylenol. The medication was not effective and the resident appeared to be in a lot of pain when moved for the X-ray. RN A did not notify the physician of the resident's pain. RN A said the resident's primary care physician often did not answer calls. RN A said he/she did not know to contact the facility's Co-Medical Director or Director of Nurses (DON). After reviewing the physician's orders [REDACTED]. RN A said he/she saw the CMT administer prn Tylenol but did not know why the CMT had not documented it. During an interview on 6/26/12 at 12:31 P.M., the Administrator and DON said when the resident reported pain, they expected staff to call the physician and to administer prn pain medication. When staff became aware of a delay in obtaining an X-ray, they could have sent the resident's to the ER. RN A knew to call the DON but did not do so. During an interview on 7/10/12 at 11:58 A.M., the VA Physician said the nurse called on the day of the incident and reported the resident had fallen, could not bear weight, had swelling in the hip and had pain. The VA Physician said she told the nurse that it sounded like a [MEDICAL CONDITION] and to contact the Primary Care Physician for treatment. A few days later, the VA Physician reviewed Resident #1's medical records and found the resident had experienced significant pain throughout the day while waiting for X-rays. The VA Physician said the administration of the prn [MEDICATION NAME] may have helped some and staff should have administered the medication. The VA Physician said the delay in providing care and failure to provide appropriate pain control caused the resident to suffer needlessly. 2. Record review of Resident #2's face sheet and physician's orders [REDACTED]. The VA admitted the resident to the facility. Review of a nurses' notes showed: - On 5/20/12, time not noted, the resident reported severe pain when bearing weight on the lower left leg. Staff contacted the (primary care) physician who ordered an X-ray be done that day. - On 5/21/12 at 11:00 A.M., the outside radiology provider took X-rays of the resident's lower left leg. - On 5/21/12 at 3:30 P.M., the X-ray results showed the resident had a mildly displaced [MEDICAL CONDITION] and fibula. Staff called a social worker at the VA hospital and left a voice mail message - On 5/21/12 at 7:30 P.M., staff noted the resident's left lower leg remained red, swollen and tender to touch. The resident's could not bear weight due to increasing pain. The VA had not returned the call. Staff received an order from the (primary care) physician to apply an Ace wrap until return call received from the VA. - On 5/22/11 at 8:15 A.M., the VA physician ordered the resident sent to the hospital for treatment. At 8:50 A.M., the resident was transferred to the hospital. - On 5/22/12, staff documented a late entry note for 5/20/12. Staff noted the resident asked for an X-ray and showed them a quarter sized raised area on the left leg. The resident said he/she bumped the leg on a chair and it hurt when he/she put weight on the leg. Staff called the radiology provider and ordered an X-ray for that day. The radiology provider called back and rescheduled the X-ray for 5/21/12 due to scheduling conflicts. Staff noted the resident said the leg was sore but only hurt when he/she put weight on it. - On 5/22/12 at 10:15 A.M., staff documented a late entry note for 5/21/12 at 4:30 P.M. Staff noted the resident had slight swelling to the lower left extremely but denied pain or discomfort. - On 5/22/12, staff documented a late entry for 5/20/12, and noted the radiology provider called and asked if the X-ray needed to be done that day or could it wait until the following day. The nurse documented the physician did not order the X-ray stat (immediately) and the resident only reported pain when weight applied so that the X-ray could be completed the following day. During an interview on 6/26/12 at 8:55 A.M., Resident's #2 said he/she accidentally bumped his/her leg on a chair. Three days later, they took an X-ray and found out the leg had been broken. Four days after the incident, the resident's went to the doctor for treatment. During an interview on 6/26/12 at 12:31 P.M., the Administrator and DON said the resident said he/she bumped the leg on a chair several days prior to reporting pain. The nurse did not call the primary care physician to notify him/her of the delay in obtaining an X-ray. They expected the staff to get the X-ray on the day it was ordered. During an interview on 7/10/12 at 11:58 A.M., the VA Physician said she would have expected the facility to obtain the X-ray on the day ordered by the Primary Care Physician as the X-ray was ordered to rule out a fracture. The VA Physician said the resident may not have experienced significant pain and been able to continue with normal activities due to his/her diagnoses. 3. Record review of the residents' VA contracts with the nursing home provider showed, if emergency care was required, the facility should send the resident to the nearest hospital and notify the VA. Review of the facility's policy for physician notification showed it directed staff to immediately contact the physician following a fall with obvious deformity or inability to walk. During an interview on 6/26/12 at 9:45 A.M., Licensed Practical Nurse (LPN) B said staff sent VA residents straight to the hospital in emergency situations then notified the VA. During an interview on 6/26/12, the Administrator and DON said staff should have notified the residents' primary care physician's in a case of emergency and received orders for treatment then notified the VA. The facility had problems with the X-ray provider and was considering a change. During an interview on 7/10/12 at 11:58 A.M., the VA Physician said the expectation was that VA patients receive the same care as other residents. The facility should have contacted the Primary Care Physician for the residents' emergency care needs. Complaint # MO