Every finding on record at Nodaway Healthcare

Based on interview and record review, the facility failed to treat one sampled resident, Resident #1 with dignity and respect when a staff member transferred the resident from a chair to bed without securing the assistance of another staff member or use a gait belt, as directed in the residents plan of care, and put the resident to bed when the resident was not ready to go to bed. This affected one of four sampled residents (Resident #1). The facility census was 20. On 4/21/2026, the Administrator was notified of the past noncompliance which occurred on 4/5/26. On 04/05/2026, facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented to include a facility wide in-service that included abuse, resident rights, compliance and ethics policy, elder abuse hotline Number, gait belts, and call lights. Additionally, nursing staff completed a full physical assessment of the resident, implemented close monitored for any outcome, and the staff member involved in the incident was suspended and later terminated. The noncompliance was corrected on 4/6/26. Review of facility policy, Safe Lifting and Movement of Residents, revised 2013, showed:- Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.- Manual lifting of residents shall be eliminated when feasible.- Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.Review of facility policy, Resident Rights, undated, showed:Resident Rights include: - A dignified existence;- Treated with respect, kindness, and dignity;- Self-determination;- Be supported by the facility in exercising his or her rights;Review of facility training records, dated 4/5/26, showed an employee in-service education was conducted and included Resident Rights, Compliance and Ethics, Hotline Number, Gait Belts, and Call Lights.Review of Resident #1's Quarterly Minimum Data Sheet, (MDS, a federally mandated assessment tool completed by facility staff), dated 3/3/26, showed:- Resident was moderately cognitively impaired;- Resident needed substantial or maximal assistance from staff for lower body dressing;- Resident was dependent on staff for footwear assistance;- Resident had independent mobility for rolling left or right;- Resident needed staff supervisor or touching for sitting to lying and lying to sitting mobility;- Resident needed partial or moderate assistance staff assistance for mobility sit to stand, transfer from chair to bed, toilet and shower transfers;- Diagnoses: Coronary Artery Disease, Hypertension, Kidney Disease, Hip Fracture, Dementia, Psychotic Disorder, Asthma, Acute Pain due to Trauma;Review of Resident's Care Plan, revised 4/7/26, showed:- Resident required psychoactive medications for diagnosis of adjustment disorder with mixed disturbance of emotions and conduct. Resident requires two assist to transfer to the bed. Resident is able to stand and pivot transfer with two assist if medicated. - The resident had an Activities of Daily Living self-care performance deficit related to activity intolerance. Resident had a healed fracture of right femur and fractured vertebrae in his/her back. Resident was required to have two assist with transfer from chair to bed and bed to chair. Resident had a history of having difficulty with asking for assistance due to his/her strong sense of independence. - Resident had two falls on 4/2/26 with pain in the left hip and left shoulder;Review of the facility abuse investigation, dated 4/7/26, showed:- Incident occurred on 4/5/26 at 8:15 P.M.- Resident stated she told Certified Nursing Assistant (CNA) (A) that he/she did not want to go to bed. - Nursing Assistant (NA) (A) and Certified Medical Technician (CMT) (A) reported that they saw CNA (A) being aggressive with the resident. They heard CNA (A) not give the resident a choice about going to bed. Resident was transferred from his/her wheelchair to the bed by CNA (A) and the resident said the transfer hurt his/her body and that his/her shoulder was in pain. CNA (A) had held him/her under the arms and roughly tossed him/her onto the bed. The resident also stated that his/her legs hurt after CNA (A) grabbed and pushed the resident's legs onto the bed. - Medical evaluation and statements from the resident showed no indication of harm or pain experienced by the resident when evaluated by nursing staff after the incident on 4/5/26. - Interventions implemented by the facility included in-service education for staff on abuse and neglect, abuse prevention, gait belts, resident rights, and cares in pairs. Specific guidance was provided to staff on the resident's needs regarding assistance.During an interview on 4/16/25 at 10:40 A.M., the Director of Nursing (DON) said:- The resident is a poor historian and is currently on hospice care. Immediately after the incident involving staff and the resident, the facility did in-service training on various topics including abuse, transfers, and resident rights. The staff are well educated and can identify abuse or neglect when they observe it and they are not hesitant about reporting these incidents. - After the incident, the Administrator did interviews to determine causes and issues related to the resident's treatment. CNA (A) should have asked for assistance from the other staff members present to assist with providing a safe transfer. A gait belt should have been used during a two-person transfer of the resident. During an interview on 4/16/25 at 2:15 P.M., CNA (A) said: - He/she was working with CMT (A) and NA (A) on the evening shift on 4/5/26 and they were helping the resident to his/her room. The resident was sitting on the edge of his/her wheelchair so he/she felt it was imperative that he/she immediately transfer the resident to the bed so he/she would not fall. He/she knew that a gait belt should have been used but he/she did not have time to use one. - He/she transferred the resident to the bed by doing a face-to-face transfer. He/she placed his/her arms under the resident's rib area and moved the resident in one fluid motion to the bed. The resident said that his/her shoulder was hurting after the transfer. - The resident protested about going to bed, but he/she educated him/her on why it was beneficial for him/her to go to bed right now. During an interview on 4/16/26 at 1:15 P.M., the Administrator said based on the investigation, she determined the incident was not abuse and CNA (A) was rough with the resident and denied the resident his/her right of choice by putting him/her to bed when he/she didn't want to go to bed. The resident said the next morning that he/she was not hurt and that no one was abusive towards him/her the evening before. The Administrator waited to interview the resident until the next morning since the resident was sleeping when the Administrator arrived at the facility on the evening of 4/5/26. After reviewing all of the statements, CNA (A) was terminated for not using a gait belt and performing a one-person transfer and violating the resident's right to be treated with dignity and respect when she put the resident in bed when the resident was not ready to go to bed. During an interview on 4/16/26 at 4:25 P.M., CMT (A) said his/her recollection of the incident was all contained in the statement that he/she submitted to the Administrator. His/her statement showed that CNA (A) was aggressive with the resident and performed a one person transfer without a gait belt from the resident's wheelchair to the bed. The resident was not given a choice about going to bed. During an interview on 4/17/26 at 2:25 P.M., NA (A) said he/she was working with CMT (A) and CNA (A) on 4/5/26 during the evening shift. CNA (A) forced the resident to go to bed and did a one person transfer without a gait belt. The resident's transfer was done roughly, and CNA (A) was verbally harsh to the resident. Overall CNA (A) did not treat the resident with dignity or respect during the incident. The transfer of the resident was not an emergency and could have been done with a two-person assist. At no time did he/she feel that the resident was going to fall out of his/her wheelchair and required immediate intervention to prevent an accident. Intake 2973932

Based on observation, interview and record review the facility failed to complete Tuberculosis (TB) skin testing for three out of ten employees. The facility additionally failed to establish and maintain an effective water management program to aide in identifying and reducing the risk of Legionella and other waterborne pathogens that can grow and spread and lead to Legionnaires' disease (a type of serious pneumonia caused by a type of bacteria called Legionella.) The facility census was 30. Review of the facility's Employee TB Screening and interpretation of Results Policy, Revised July 2010 showed: All employees shall be screened for tuberculosis (TB) infection and disease, using a two-step tuberculin skin test (TST) prior to beginning employment. The need for annual testing shall be determined by the annual TB risk classification or as per State regulations. The facility will administer and interpret TB skin test in accordance with recognized guidelines and pertinent regulations. A qualified nurse or health practitioner interprets the TB skin test 48-72 hours (2-3 days) after administration. Initial testing will be a two-step procedure with the first dose give before beginning work and the second booster dose to be given 7-21 days after the first dose: New employees will not be allowed to work until the Tuberculin Skin Test (TST), or chest x-ray results are known. Employees who will be receiving the two-step TST may begin work after the first step results are negative. The facility did not provide a water management plan or policy regarding prevention of water borne pathogens. 1. Review of employee records on 08/06/25, showed: CMT A, hire date 11/04/24, showed no 2 step TB in employee file. CNA A, hire date 11/11/24, showed no 2 step TB in employee file. CNA B, hire date 03/14/25, showed no 2 step TB in employee file. During an interview on 08/07/25 at 9:51 A.M., the Director of Nursing/Infection Preventionist, said that all new hire employees are to have a 2 step TB skin test upon being hired and documentation is kept in a binder in her office. She also stated that there are times that staff may need to a copy of their results and the originals get taken out and never returned. She was not able to explain where the missing TB skin testing results were. 2. During an interview on 8/7/25 at 11:08 A.M., the Maintenance Supervisor said: - There currently was no established program to address prevention of legionella in the water system at the facility; - Testing for legionella at the facility had not been done; During an interview on 8/7/25 at 2:30 P.M., the DON said there was currently no water management plan or program in place for legionella prevention at this facility;

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This had the potential to affect all residents. The facility census was 30. The facility did not provide a policy for RN coverage. Review of the facility's Payroll Based Journal data (PBJ - a report that provides staffing data set information submitted by nursing homes on a quarterly basis) for Quarter 2 2025 (January 1 - March 31) showed no RN coverage hours on 2/23, 3/2, 3/16, 3/29 and 3/ 30. Review of staffing schedule for February 2025 showed no RN on the day: 2/23. Review of the staffing schedules for March 2025 showed no RN on the following days: 3/2, 3/16, 3/29 and 3/30.During an interview on 8/5/25 at 9:52 A.M., the Regional Nurse said she knew something was not right with the PBJ and did not think it had been filled out correctly. During an interview on 8/7/25 at 11:53 A.M., the Assistant Director of Nursing (ADON) said:- The Administrator had been there since July of this year;- He/She had been at the facility since November of last year;- The MDS/Care Plan Coordinator took over as the DON about three months ago;- He/She was unable to find any documentation to show their was RN coverage on those dates;- They had a rough time with staffing early in the year but it was better now. During an interview on 8/7/25 at 2:20 P.M., the Administrator said:- The PBJ should be filled out correctly;- They should have an RN working eight hours a day, seven days a week.

Based on the interview and record review, the facility staff failed to check the Certified Nurses Assistant (CNA) Registry for nine of 10 sampled staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). this affected 10 of 10 sampled staff (Licensed Practical Nurse(LPN) B, Certified Medication Technician (CMT) A, Social Service Designee (SSD), Nursing A, Nursing B, and Nursing C, [NAME] A, Nursing Assistant (NA) A, Care Partner (CP)A, and Administrator 2. The facility also failed to have a criminal record check on file prior to employee's first date working for two of 10 sampled staff: CMT A and Nurse A. The facility census was 30.Review of facility policy, Abuse and Neglect Procedure, revised [DATE], showed pre-employment screening will be completed on all employees, to include:- Criminal History Check, Background Check, Reference check from previous employers, Professional licensure, certification, or registry check as applicable, Registry and OIG.- The facility will not hire or retain any employee with a history of abuse or neglect if that information is known to the home.1.Review of SSD's employee file showed: - Hire date on 04/06/2025;- No CNA registry check found.2. Review of LPN B's employee file showed:- Hire date on 06/01/25- No CNA registry check found.3. Review of CMT A's employee file showed:- Hire date on 11/04/24;- No Criminal Background Check prior to first working day or on file;- CNA registry check on file.4. Review of NA A's employee file showed:- Hire date 07/02/25;- No CNA registry check on file.5. Review of CP's employee file showed:-Hire date 05/23/25; -No CNA registry check on file.6. Review of [NAME] A's employee file showed:- Hire date 07/09/25;- No CNA registry check on file.7. Review of Nurse A's employee file showed:- Hire date 11/11/24- No Criminal Background Check prior to first working day or on file;- No CNA registry check on file.8. Review of Nurse B's employee file showed:-Hire date 03/14/25;- No CNA registry check on file.9. Review of Nurse C's employee filed showed: - Hire date 03/31/25;- No CNA registry check on file.10. Review of Administrator 2 employee file showed:-Hire date 01/16/25;-No CNA registry check on file.During an interview on 08/07/25 at 9:58 A.M. the BOM said:- She was able to provide 8 out of 10 of CBC, 10 of 10 EDL's and one of 10 Certified Nurse Registry's. - The 2 CBC that she failed to supply were done but not uploaded to the system. - Every new employee should have a background check completed before they start work, but she was unable to provide all documentation.In an interview on 08/07/25 at 2:48 P.M the Administrator said CBC and EDL's are to be completed prior to staff being able to start work.

Based on observation and interview, during a group interview six out of six participants said the facility failed to protect resident rights when the facility did not prominently display information on how to file a grievance or how to call or contact the Missouri Adult Abuse & Neglect hotline in the facility for its residents. The facility census was 30. Review of facility policy, Resident and Family Concerns and Grievances Policy and Procedure, dated 2020, showed the facility will notify residents, individually or through posting in prominent locations throughout the facility, of the right to file a grievance. The notification must include the following information: Contact information for the relevant state agency or Ombudsman program for filing a complaint. Review of facility policy, Resident Rights, not dated, showed; - Federal and state laws guarantee certain basic rights to all residents of this facility. -These rights include the resident's right to: communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protections or advocacy organizations, etc.) regarding any matter.During a group interview on 8/5/25 at 2:15 P.M., the residents said six of six residents did not know where the State Agency contact information for filing a complaint was displayed in the building;-Six is six residents did not have knowledge of the phone number to the State Agency for filing a complaint; -Six of six residents did not know how to file a grievance. During observation on 08/05/2025 at 11:00 A.M., showed no sign posted in the facility with information to contact the State Agency to file a complaint. During an interview on 08/06/2025 at 8:11 A.M., CNA B said the hotline number is on the wall. No resident had asked him/her for the State phone number, so he/she had not looked for it. He/she was unable to locate the phone number for the adult abuse and neglect hotline. During an interview on 08/06/2025 at 8:58 A.M., CNA A said he/she was not sure where the telephone number for the State abuse hotline was located.During an interview on 08/06/2025 at 10:03 A.M., LPN A said if a resident wanted to make a phone call to state hotline, he/she would take resident into the office so the business manager could give the resident the phone number. He/she is not sure where the phone number would be posted. During an interview on 08/07/2025 at 10:05 A.M., The DON (Director of Nursing) said she was not sure if the State phone number was posted anywhere currently. The State phone number used to be posted in the dayroom. During an interview on 08/07/2025 at 10:52 A.M., The Administrator said: She was not sure if State abuse hotline phone number was posted. During observation on 08/07/2025 at 11:00 A.M., showed no sign posted in the facility with information to contact the State Agency to file a complaint.

Based on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to maintain proper standards of cleanliness and storage in the kitchen area, and failed to use proper handwashing hygiene in the kitchen. This affected all residents by putting them at risk for a food borne illness. The facility census was 30.Review of facility policy Bare Hand Contact with Food and Use of Plastic Gloves, undated, showed:- Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handler' hands to the food product being served;- Hands are to be washed when entering the kitchen and before putting on the single-use gloves and after removing single use gloves;- Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed;Review of facility policy Food Receiving and Storage, revised July 2014, showed:- Food services, or other designated staff, will maintain clean food storage areas at all times;- When food is delivered to the facility it will be inspected for safe transport and quality before being accepted; - Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents;- Dry food that are stored in bins will be removed from original packaging, labeled and dated ( use by date); - All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date);- Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat-foods;- Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines;Review of facility policy Sanitization, revised October 2008, showed:- All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish;- All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils;- The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas; Observation of the dining room on 8/4/25 at 9:30 A.M., showed:- Food stains on the inside shelving of the resident refrigerator;- Ice Machine cleaning log showed last cleaning date as 4/26/24;Observation of the kitchen on 8/4/24 at 9:35 A.M., showed:- Ice machine had dirt build up on the inside lip directly above the dispensed ice;Observation of the Dry Storeroom on 8/4/25 at 9:40 A.M., showed:- Marshmallows on the floor in the corner under the shelving;- Cup cart had moldlike substance along the interior edges of the bottom tray near the wheels;- Right forward corner had heavy moldlike substance on the floor covering a 48 square inch area;- Karo Syrup container had moldlike growth on cap and bottle;- Moldlike growth throughout forward wall near the floor under the racks covering a 8' by 3' area;- Beef flavor soup base not sealed;- 2nd and 3rd racks from the floor on back wall had shelving that was rusted throughout covering an 8' area;- Beans stored in an unsealed container, container is sticky and has food debris on top. The container is unlabeled and undated;- Breadcrumbs dated 3/21/24 expired;- All-purpose flour (2 bags) dated 7/17 without indication what year it was stored;- Rust on forward shelving racking;- Ventilation duct against forward wall near overhead had moldlike substance covering a 16 x 8 area;- Cereal unlabeled and dated 2/20;- Lemon Gelatin mix single package had no date and moldlike growth on packaging;- Cherry pie filling can had rust on both ends of #10 can;- Debris and pepper shaker lying on floor near full bait trap underneath the bread rack;- Yeast resealed 4/5/25;- Trash can against storeroom wall had an unsealed, unlabeled, undated grain in an open bag with a scoop in it;- Heavy dirt on top of hash browns 2.125oz cardboard container;- Moving cart 1.5' in height underneath the shelving was covered in moldlike substance;During an interview on 8/4/25 at 10:00 A.M., Dietary [NAME] (B) said:- He/she had been working in the kitchen since February 2025;- He/she had not seen any mold in the storeroom or anywhere else in the kitchen;- Sometimes there's condensation build up in the storeroom which might cause mold;- He/she had not seen the mold on the products on the shelves since he/she doesn't go to that area very often; - If he/she saw mold he/she would tell the Dietary Manager (DM) and then clean it up;- The moisture from the food trucks causes the cans to rust out;- When opening a can he/she will inspect the contents to make sure it had not spiled and any dented cans are automatically rejected;- The staff do not use the pinto beans that are in the unlabeled and undated container anymore, they use a substitute item instead;Observation of the dishwashing area on 8/4/25 at 10:10 A.M., showed:- Vent duct covered in grime;- Heavy grime and food build up under the dishwasher;Observation of the walk-in refrigerator on 8/4/25 at 10:15 A.M., showed:- Two rotten vegetables on the floor in the back corner of the refrigerator; - Dried milk stain on floor covering a one foot area under the shelving where milk is stored;- Defrosting beef on the first shelf, not dated; - Cottage Cheese (2) 5lb containers dated 7/20/25 expired; - Sour Cream 5lb container dated 8/1/25 expired;- Condensation puddles on floor in front of racks;- One box of mighty milk shakes stored directly on the floor;- Apple crisp on rack no dates;- (4) packs of hot dog buns expired 5/22/24;- English muffins (2) packages expired 1/8/25;- Two of five raw cucumbers stored in cardboard box was moldy;- Coffee cake dated 7/31 as leftover was expired;Observation of the walk-in freezer on 8/4/25 at 10:25 A.M., showed:- Condenser leak resulted in ice buildup on floor six inches high and chunks of ice on the floor;Observation of the dining room on 8/4/25 at 12:15 P.M., showed:- CP A did not sanitize hands in between serving resident trays in the dining room;- Dietary Aide A did not sanitize hands in between serving resident trays in the dining room;Continuous Observation of the kitchen on 8/5/25 starting at 10:54 A.M., showed:- Raw beef in walk-in refrigerator from 8/4/25 still defrosting in a tub with no dates;- Boneless ham and unlabeled meat in walk-in refrigerator defrosting together in a tub with no dates;- CP B entered the kitchen and did not wash hands but instead put on gloves and started working on food items for the meal;- At 11:10 A.M. CP B removed gloves after working with frozen strawberries and put on a new pair of gloves without washing hands;During an interview on 8/5/25 at 11:12 A.M., CP (B) said:- He/she changed gloves because he/she got strawberries on them and normally he/she would wash his/her hands between glove changes but he/she was just going to go over and work with the dessert bowls by pouring strawberries over the shortcake;Observation on 8/6/25 at 8:21 A.M., showed:Dietary Aide (B) did not sanitize hands between serving breakfast hall trays for resident rooms on the 200 hall;During an interview on 8/7/25 at 9:45 A.M, the DM said:- The ice machines should be cleaned every other day on the outside by kitchen staff and maintenance will sanitize the inside components every four months;- Log in the dining room for cleaning the ice machines was not being kept up, the process had just been changed to one log in the kitchen that covers all the ice machines;- The DM is responsible for checking the cleaning of the ice machines and it should not have dirt and bacterial buildup;- There should be no raw moldy food items on the floor;- Carts in the storeroom should be free of mold and dirt;- There should not be black moldlike growth along the walls and floor of the storeroom. It would be expected that kitchen staff would see this and bring it to the DM's attention;- There should be no moldlike growth on packaging. If there is, it should be reported to the DM, then clean the product and check the integrity of the packaging and the expiration date;- Opened containers should be tightly resealed;- Containers should be free of sticky substances on the containers;- There should not be heavy rust on the storage racks;- Breadcrumbs that have been opened should not be stored for more than a year;- When dating products the year should be added to maintain clarity and avoid confusion;- There should not be built up dirt around the ventilation ducting and maintenance would be notified if there was an issue;- Cans should not be rusted in the storeroom;- Packages should be free of dirt and dust buildup in the storeroom;-Liquid spills in the refrigerator should be cleaned up immediately;- A date should be placed on all meat being defrosted and a label attached showing what is being defrosted;- Expired products should be discarded as soon as they are expired;- There should not be condensation puddles in the walk-in refrigerator;- Items should never be stored directly on the floor;- Leftovers can be kept for three days before they must be discarded;- There should not be ice chunks on the freezer floor and maintenance has been informed, the issue had been going on for a while;- Staff should wash their hands immediately upon entering the kitchen;During an interview on 8/7/25 at 2:30 P.M., the Administrator said:- The ice machine should be free of dirt and/or bacterial growth;- Raw food items should not be on the floor of the storeroom;- Carts in the dry storeroom should be free of mold and dirt;- There should be no black moldlike growth along the walls and floor of the dry storeroom;- There should be no moldlike growth on the food packaging in the dry storeroom;- Containers should be free of sticky substances on the surface of the containers;- There should not be heavy rust on the storage racks;- Cans should not be rusted in the storeroom;- Liquid spills in the refrigerator should be cleaned up;- Expired products should be discarded as soon as they are expired;- There should not be condensation puddles in the walk-in refrigerator;- Items should not be stored directly on the floor in the storeroom;- There should not be ice chunks on the freezer floor or icicles formed on the floor from water leaks;- Staff entering the kitchen should wash their hands immediately;

Based on observation, interview and record review, the facility failed provide proper respiratory care when staff failed to date the oxygen tubing for two residents (Resident #7 and #30), failed to clean the oxygen concentrator filters for one resident (Resident #7), failed to have an oxygen filter installed for one resident (Resident #5), and failed to obtain an order for oxygen prior to administering to a resident (Resident #30). This affected three of 12 sampled residents. The facility census was 30. Review of the facility's Oxygen Administration policy, revised October 2010, showed:- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration;- Review the resident's care plan to assess for any special needs of the resident;- Equipment and supplies: Portable oxygen cylinder strapped to the stand, nasal cannula, nasal catheter, mask (as ordered), humidifier bottle, No Smoking/Oxygen in Use signs, regulator, and PPE as needed;- Check the mask, tank, humidifying jar to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through;- Periodically re-check water level I humidifying jar;- Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record (Date and time procedure performed, name of staff member performing procedure, rate of oxygen flow, frequency of treatment); 1. Review of Resident #7's Annual MDS, dated [DATE] showed;- Cognitive skills intact; - Lower extremity impaired on one side; - Diagnoses included depression, schizophrenia, and COPD. Review of the resident's nurse treatment administration record (TAR), dated July 2025 showed: - Change oxygen tubing and date new bag monthly every night shift every four weeks on Wednesday; - Cleanse and change oxygen concentrator filter monthly every night shift every four weeks on Wednesday; - Staff documented it was completed on 7/23/25. Review of the resident's care plan, revised 7/30/25 showed: - The resident required assistance with his/her activities of daily living (ADLs). The resident wore oxygen at all times at two liters per nasal cannual (2L/NC); - The resident had altered respiratory status/difficulty breathing related to anxiety, sleep disorder related to morbid obesity and difficulty lying down to sleep. Elevate the head of the bed to at least 45 degrees at bedtime. The resident used oxygen at three liters per nasal cannula (3L/NC) at bedtime to assist with oxygenation during sleep cycle. Observation on 8/4/25 at 10:46 A.M., showed: - The oxygen was set on 2L/NC; - The oxygen tubing was dated 5/23/25; - The humidified water bottle was dated 5/23/25; - The filters were covered in gray lint. Review of the resident's POS dated August 2025 showed: - Start date: 5/3/25 - Change oxygen tubing and date new bag monthly every night shift every four weeks on Wednesday; - Start date: 5/3/25 - Cleanse and change oxygen concentrator filter monthly every night shift every four weeks on Wednesday. During an interview on 8/5/25 at 11:51 A.M., Licensed Practical Nurse (LPN) D said: - The oxygen tubing should be changed and dated every Sunday on the night shift; - The whole set up should be changed (tubing, humidified water bottle and the filters cleaned) every Sunday night. During an interview on 8/7/25 at 2:20 P.M., the Assistant Director of Nursing (ADON) and the DON said: - The Charge Nurse (CN) was supposed to change the oxygen tubing every Sunday on the night shift. Staff should date the tubing and the filters should also be cleaned every Sunday night on the night shift. 2. Review of Resident #30's Quarterly MDS dated [DATE], showed:- Resident was severely cognitively impaired;- Resident was experiencing shortness of breath or trouble breathing when sitting at rest, during exertion, and when lying flat;- Resident was on oxygen therapy;- Diagnosis: cancer, kidney disease, coronary artery disease, pneumonia, and malnutrition; Review of Resident's Care Plan, revised 6/30/25, showed:- Resident has limited physical mobility related to weakness and shortness of breath;- No documentation regarding oxygen therapy for the resident; Review of physician's orders for July and August 2025., showed no physician order for oxygen in the medical record. Observation on 8/4/25 at 11:00 A.M. showed:- Resident breathing with an oxygen concentrator operating in the room;- Date on the tubing going into the oxygen concentrator showed 7/14/25 as the last date cleaned and changed; During an interview on 8/4/25 at 11:03 A.M., the Resident said:- He/she uses the oxygen concentrator all the time to help him/her from becoming dizzy. He/she used a walker and since the machine is so bulky he/she doesn't leave the room very often because it's hard to ambulate with a walker and that machine;- Resident can't recall how long he/she had been using oxygen but thinks he/she started using it as soon being admitted to the facility a few months ago; During an interview on 8/7/25 at 8:30 A.M., the DON said:- Oxygen orders are required to be in a resident's medical record to get oxygen therapy or use of the oxygen concentrator;- Oxygen also needs to be care planned and orders for cleaning and changing of tubing included;- The resident would have oxygen orders if they are using oxygen; 3. Review of Resident #5's Care Plan showed: -Diagnosis of Chronic Obstructive Pulmonary Disease (COPD); -The resident is dependent on supplemental oxygen; Review of Resident #5's order summary report showed: -Staff are to cleans and change oxygen concentrator filter weekly- at bedtime every Wednesday; -Change oxygen humidifier weekly- at bedtime every Sunday; -Change/date oxygen tubing and storage bag weekly on Sunday nights; Observation on 08/06/2025 at 10:33 A.M. showed: No filter on the oxygen concentrator for the resident. Observation on 08/07/2025 at 9:48 A.M. showed: No filter on his/her oxygen concentrator for the resident. During an Interview on 08/07/2025 at 10:05 A.M., the DON said: -Oxygen and nebulizer tubing was to be changed every Sunday night; -Oxygen concentrators have filters that are changed on a weekly scheduled basis. During Interview on 08/07/2025 at 10:52 A.M. the Administrator said: Oxygen concentrator filters and oxygen tubing are to be changed on Sunday's during the night shift.

Based on observations, interviews and record review, the failed to ensure staff discarded expired medications and biologicals stored in the medication room and in the nurse's medication cart. The facility census was 30. Review of the facility's undated policy for Storage of Medications, showed:- The facility shall store all drugs and biologicals in a safe, secure, and orderly manner;- Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers;- Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing;- The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 1. Observation and interview on 8/5/25 at 2:37 P.M., of the medication room showed:- One opened vial of Tuberculin, purified protein derivative,0.1 ml., dated 6/13/25. The label on the box said it was good for 30 days after opening;- 11 Influenza vaccine Fluzone HIgh Dose prefilled syringes expired 6/25;- Certified Medication Technician (CMT) A said he/she did not know how long the TB vial was good for after opening and was not for sure when the flu vaccine expired. All CMTs and nurses had a color coded chart when the medication rooms and medication carts are supposed to be checked. 2. Observation and interview on 8/5/25 at 3:05 P.M., of the South CMT/Nurse medication cart showed:Latanoprost 0.005% eye drops (Xalatan) - bag with label said 11/25/24, discard after 11/24/25; no date when it was opened. CMT C said it was good for 30 days after it was opened;A plastic bag with the label torn off which indicated who it belonged to had two 4 mg. tabs of Ondansetron. CMT C said he/she did not know who it belonged to and all medications should have a pharmacy label to indicate who they belonged to;Resident #23 had an opened bottle of Lidocaine Viscous solution 2%., expired June 2025;An albuterol sulfate inhalation aerosol, opened date 11/24/23, did not have a pharmacy label to indicate who it belonged to and was in a box with a pharmacy label for Resident #31, but had a piece of tape on the top of the box and staff hand wrote Resident #32's name in a red marker. CMT C said he/she did not know who it belonged to. It had been in the medication cart since he/she started a year ago'An opened bottle of MOM expired 5/25CMT C expired medications should not be used and should be destroyed. All medications should have a date when they were opened, During an interview on 8/5/25 at 11:51 A.M., Licensed Practical Nurse (LPN) D said:The Nurses and CMTs are supposed to check the medication room and medication carts per the schedule. Staff should not use expired medications. Medications should be dated when opened;He/She was not for sure how long TB was good for after it had been opened;If a label has been removed from the medication, it should not be used.During an interview on 8/7/25 at 2:20 P.M., the Assistant Director of Nursing (ADON) said:Expired medications should not be used, they should be removed and discarded;TB should be discarded after 30 days;All medications should have a date when opened.

Base on observation, interview, and record review the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good, grooming, personal hygiene, when the facility failed to provide proper peri care for four of the 12 sampled residents, (Resident #3, #12 and #28), and when the facility failed to provide proper catheter care for resident #16. The facility census was 30. Review of facility Perineal Care policy, dated February 2018, showed: -For a female resident wash perineal area, wiping from front to back, separate labia and wash area downward from front to back; -If the resident has an indwelling catheter, gently was the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area; -For a male resident wash perineal area starting with urethra and working outward. 1.Review of Resident #28's Care Plan dated 06/26/2025 showed: -Resident was limited physical mobility related to neurological deficits and inability to use legs; -Resident was incontinent of bowel and had a catheter inserted into bladder to drain urine; Observation on 08/06/2025 at 11:24 A.M. showed: -CNA A and CNA B assisted resident to get up for lunch and the resident was soiled with urine; -CNA B used the same area of the wipe and wiped front to back multiple times; -CNA B did not change gloves after providing perineal care and placed a new incontinent brief on the resident; -CNA B took off gloves, did not perform hand hygiene; During an interview on 8/6/25 at 11:30 A.M., CNA B said he/she should have used a clean wipe with each swipe and not re-use the same wipe 2.Review of Resident #16's Care Plan showed: -The resident has activity intolerance related to Chronic Obstructive Pulmonary Disease (COPD); -The resident has episodes of shortness of breath with and without activity; -The resident is incontinent of bowel and has a urinary catheter. Observation on 08/06/2025 at 11:48 A.M. showed: -CNA A donned gown and gloves due to resident being on enhanced barrier precautions (EBP); -CNA A assisted resident to the toilet from his/her wheelchair; -CNA A wiped the residents catheter from insertion site down the catheter tubing approximately three inches using the same wipe multiple times; -CNA A wiped the residents perineal area from front to back using the same wipe twice; -CNA A placed new incontinent brief on the resident without changing gloves or performing hand hygiene; During an interview on 08/07/2025 at 9:50 A.M. CNA A said: -He/She should have wiped down on the catheter with a new wipe each time when providing catheter care; During an interview on 08/07/2025 at 10:20 A.M. LPN D said: -When providing peri care wipe front to back; -Use one wipe for each swipe; -Always wipe clean to dirty. -Always wipe away from urinary opening. 3. Review of Resident #3's Significant Change in Status MDS, dated [DATE] showed; - Long term and short term memory problems; - Dependent on the assistance of staff for eating, toilet use, dressing, showers, and personal hygiene; - Required substantial to maximum assistance with transfers; - Frequently incontinent of bowel and bladder; - Diagnoses included non traumatic brain dysfunction, cancer, anxiety, arthritis, and dementia. Review of the resident's care plan, revised 7/24/25 showed:- The resident had mixed bladder incontinence related to confusion, disease process with behavioral disturbances and impaired mobility. The resident used disposable briefs and should be changed every two hours and as needed. Clean the peri area thoroughly with each incontinence episode. Observation on 8/6/25 at 7:37 A.M., showed: - CNA B wiped down one side of the resident's groin and with the same area of the wipe, went under the skin folds and back up the other side of the groin. CNA B used a new wipe and with the same area of the wipe cleaned different areas of the front skin folds; - CNA A and CNA B turned the resident on his/her side. CNA B wiped from front to back with fecal material noted on the wipe, folded the wipe and wiped again from front to back with fecal material on the wipe. CNA B used three new wipes and each time wiped from front to back with fecal material on each wipe and folded each wipe and wiped again with fecal material on each wipe; - CNA A and B and place a clean incontinent brief on the resident and dress him/her for the day; - CNA B propelled the resident to the dining room in his/her wheelchair; - CNA A and CNA B did not offer or provide oral care and did not wash the resident's face and hands or comb his/her hair; - CNA B did not separate and clean all the skin folds and did not clean the resident's buttocks. 4. Review of Resident #12's care plan revised 5/21/25 showed: - The resident had functional bladder incontinence related to recent brain injury from non-traumatic bleed, and impaired mobility to non-dominant side. The resident used disposable briefs and changed as needed. Clean the peri area with each incontinent episode. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper and lower extremities impaired on one side; - Dependent on the assistance of staff with toilet use and lower extremity dressing; - Required substantial to maximum assistance with upper extremity dressing, personal hygiene and transfers; - Always incontinent of urine; - Frequently incontinent of bowel; - Diagnoses included non-traumatic brain dysfunction, stroke and hemiplegia. Observation on 8/6/25 at 6:59 A.M., showed: - CNA B unfastened the resident's incontinent brief and said the resident was dry; - CNA A and CNA B turned the resident on his/her side; - CNA A wiped from front to back with fecal material on the wipe, folded the wipe and wiped again from front to back with fecal material on the wipe. folded the wipe and wiped again front to back with smear of fecal material on the wipe. CNA A used a new wipe and with the same area of the wipe and cleaned both sides of the buttocks, folded the wipe and wiped both sides of the buttocks again. CNA A used a new wipe and wiped back and forth on both sides of the buttocks, folded the wipe and wiped the rectal area, folded the wipe again and wiped the rectal area; - CNA A and CNA B placed a clean incontinent brief on the resident and dressed the resident for the day. - CNA A and CNA B did not clean the front perineal folds and did not brush or comb the resident's hair, wash his/her face and hands and did not provide oral care. During an interview on 08/06/2025 at 10:30 A.M., CNA B said: - He/She thought it should have been one swipe with one wipe; - He/She should not have used the same area of the wipe to clean different areas of the skin and should have separated and cleaned all the skin folds; - He/She should not have folded the wipe with fecal material on the wipe; - HeShe should have washed the resident's face and hands, offered or provided oral care and combed the resident's hair before the resident went to breakfast. During an interview on 08/07/2025 at 11:14 A.M., CNA A said: - Should use a new wipe with each swipe and should not fold the wipe with fecal material on it; - Should separate and clean all the skin where urine or feces had touched; - Should have cleaned the buttocks and the front skin folds; - Should have brushed or combed the resident's hair, washed the resident's face and hands and provided oral care before the resident went to the dining room for breakfast. During an interview on 08/07/2025 at 2:20 P.M., the DON and the Assistant Director of Nursing said: - Staff should separate and clean all areas of the skin folds where urine or feces had touched. If the resident was dry, the staff still should provide incontinent care to the front perineal folds; - Staff should not fold the wipe, it should be one wipe, one swipe; - Staff should not use the same area of the wipe to clean different areas of the skin; - Staff should wash the resident's face and hands, comb or brush the resident's hair and should provide oral care before they took the resident to the dining room for breakfast.

Based on observation, interviews, and record review, the facility failed to ensure staff developed and implement a person-centered comprehensive care plan to meet preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for three of 12 sampled residents when the facility failed to update a (Resident #3) care plan after a significant change, and when the facility failed to include the use of oxygen therapy in the care plans for (Resident #30 and Resident #31). The facility census was 30. Review of the facilities Comprehensive Person-Centered Care Plans policy showed: -The Interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -Each resident's comprehensive person-centered care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care; -The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1.Review of resident #31's face sheet showed: -Resident had a diagnosis of chronic obstructive pulmonary disease (COPD); -Resident had mild cognitive impairment; -Resident had acute respiratory failure with hypoxia. Record review of physician order summary report for July and August 2025 showed: -Resident had an order to titrate oxygen up to six liters per minute via nasal cannula to maintain SpO2 (a noninvasive method of measuring the oxygen saturation in a person's blood to indicate how well the lungs are delivering oxygen to the body) greater than 91% as needed; -Resident had an order to change oxygen humidifier weekly-every night shift on Wednesday; -Resident had an order to change/date oxygen tubing and storage bag weekly on Wednesday nights. Review of resident's current care plan showed: -Staff did not care plan the use of oxygen as needed to maintain SpO2 above 91%. 2. Review of Resident #3's Significant Change in Status MDS, dated [DATE] showed; - Long term and short term memory problems; - Dependent on the assistance of staff for eating, toilet use, dressing, showers, and personal hygiene; - Required substantial to maximum assistance with transfers; - Frequently incontinent of bowel and bladder; - Had two or more falls with no injury noted. Had one fall with a minor injury; - Diagnoses included non traumatic brain dysfunction, cancer, anxiety, arthritis, and dementia. Review of the resident's care plan, revised 7/24/25 showed: - The resident was at a high risk for falls related to confusion deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unaware of safety needs. The resident has had falls since his/her admission. Interventions include anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure the resident is wearing appropriate footwear such as non-skid socks when ambulating or mobilizing in wheelchair; - The staff did not update the resident's care plan with each new fall. Review of the resident's medical records showed the resident had a fall on the following dates: - 5/24/25, 5/25/25, 5/27/25 and 5/31/25; - 6/1/25, 6/2/25, 6/4/25 and 6/5/25; - 7/2/25, 7/8/25, and 7/11/25. . 3. Review of Resident #30's Quarterly MDS dated [DATE], showed:- Resident was severely cognitively impaired;- Resident currently on oxygen therapy and hospice care;- Diagnosis: cancer, kidney disease, coronary artery disease, pneumonia, and malnutrition; Review of Resident's Care Plan, revised 6/30/25, showed:- No documentation regarding end-of-life care from Hospice;- No care planning for condition of colon cancer;- No care planning for the use of oxygen for identified condition of shortness of breath; Review of Resident's Face Sheet dated 8/5/25, showed:- Primary Payer is Hospice Medicaid;- Diagnosis Information shows Malignant Neoplasm of Ascending Colon (cancerous tumor growth a type of colorectal cancer); Review of Resident's Hospice Physician's Orders, dated 4/25/25, showed:- Resident admitted to hospice care with terminal diagnosis of colon cancer;- Morphine concentrate 20mg/ml every four hours as needed for shortness of breath or pain;- Levsin 0.125 mg 1 tablet every four hours as needed for secretions; Observation on 8/4/25 at 11:00 A.M. showed:- Resident lying in his/her bed using an oxygen concentrator; During an interview on 8/4/25 at 11:03 A.M., the Resident said:- He/she thinks they are on hospice but not sure if they are getting care still from them;- He/she utilizes the oxygen concentrator most of the time during the day, he/she is able to leave the room without it but his/her preference is to use it at all times to prevent getting dizzy; During an interview on 8/4/25 at 1:57 P.M., RN (A) said:- Resident is on hospice care for terminal colon cancer;- He/she was not able to identify specifically what extra care hospice would provide the resident;- Hospice care and oxygen therapy should be in a resident's care plan; During an interview on 08/06/2025 at 11:22 A.M., the DON said:- He/she did the MDS, care plans and infection control;- The care plans can be updated by any nurse;- He/She tried to go through the care plans daily;- The care plans should be updated with new interventions with each new fall a resident had.

Based on interview and record review, the facility failed to provide the bed hold policy, a discharge summary regarding Resident #8, and the reason for discharge to the resident's representative in writing, including the statement of appeal rights or the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in long-term care facilities) for (Resident #1, #4, #6 and #12) and failed to notify the Ombudsman of the discharge. This affected five of 12 residents sampled. The facility census was 30.Review of facility policy Transfer or Discharge Notice, revised 12/2016, showed:- The facility shall provide a resident and/or resident's representative with a thirty-day written notice of an impending transfer or discharge;- A notice will be given for the following reasons: transfer is necessary for the resident's welfare and their needs cannot be met in the facility, resident no longer needs the services provided by the facility, the safety of individuals in the facility is endangered, failure to pay by the resident, or immediate transfer or discharge is required due to urgent medical needs;- The resident and/or representative will be notified in writing with the following information: reason for the transfer or discharge, effective date, location to which the resident is being sent, a statement of the resident's rights to appeal the transfer or discharge including where to send the appeal and obtain the appeal form, facility bed hold policy, Ombudsman contact information;- A copy of the notice will be sent to the Office of the State Long-Term Ombudsman;- The reasons for the transfer or discharge will be documented in the resident's medical record; Review of facility policy Transfer or Discharge, Preparing a Resident for, revised December 2016, showed:- When a resident is scheduled for transfer or discharge nursing services will complete a discharge note in the medical record;- When a resident is scheduled for transfer or discharge the business office will inform the resident or his/her representative of the facility's readmission appeal rights and bed hold policy; 1. Review of Resident #1 closed medical record on 08/06/2025 showed:- Resident #1 was admitted to the facility on [DATE] after receiving a bowel resection. - Diagnosis include Crohn's Disease, Kidney disease, Respiratory failure, anemia and sepsis. - On 06/09/25, resident was sent to the hospital due to shortness of breath.- Nurses' notes showed the resident was in the hospital from [DATE]-[DATE]. The record did not include documentation regarding why the resident did not return to the facility, if the residents personal belongings were picked up or not, and where resident was discharged to.- The record did not show a bed hold notice was provided or the Ombudsman was notified of the discharge. 2. Review of Resident #6 closed record on 08/06/25 showed; - Resident #6 was admitted on [DATE] with diagnosis of Adult Failure to Thrive, Anorexia, Heart Disease, Hypertension and Type 2 Diabetes. - On 07/29/25 this resident was given the choice to go to hospice or to be sent to hospital due to failure to thrive and weight loss, by Physician. The resident chose to go to the hospital instead of going to on hospice and was sent out for possible admission. Notes in the chart did not indicate the DPOA was notified of the resident being transferred nor was she notified the resident was able to return to facility after discharge from hospital. - No documentation that the Ombudsman was notified of discharge. - After the resident was discharged , the charting noted: Not coming back over the next 5 days. - Documentation did not indicate how the nurse was notified that resident was coming back nor who notified him/her that the resident was not coming back. - Documentation in chart did not indicate the family came to facility and picked up resident's personal belongings.- Charting does not state what happened to this resident after discharge or reason for not returning to facility. During an interview on 8/6/25 at 11:15 A.M., LPN A said when a resident is transferred out of the facility the nurse is to send with the resident, a copy of the medication list, medication administration record, diagnosis list, face sheet, code status, notice of emergency discharge, bed hold agreement, all go in the packet and are sent with the resident to the hospital. Documentation should include where the resident is sent, why the resident was sent, how they were sent, and who was notified of the transfer. During an interview on 08/06/25 at 10:33 A.M., DON was asked what paperwork is sent in regard to records regarding transfer and discharge and said staff are to send a discharge packet for each resident and the packet is at the nurse's station in a binder for each individual resident. When a resident is discharged out of facility, their individual packet is copied and sent with resident. The packet contains a medication list, MAR, diagnosis list, face sheet, DNR (purple sheet) and if applicable, a notice of emergency transfer or discharge and bed hold. Paperwork in placed in transfer packet and should be sent with the resident. During an interview on 08/07/25 at 2:48 P.M., ADON said:- When a transfer/discharge of a resident is completed, she would expect the discharge paperwork to be uploaded into the medical records.- He/she said the Ombudsman is to be contacted when a resident is transferred out of the facility. - He/she said there should be a physician's order in the system for discharge or emergency transport, and the charting should indicate what time the physician was notified. - He/she said that when the resident does not return back to facility, charting should indicate who notified the nurse.- Documentation should be in the chart that showed when a resident's personal property is picked up. 3. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/25, showed:- Resident was severely cognitively impaired;- Diagnosis: deep venous thrombosis (blood clot formation), kidney disease, obstructive uropathy (blockage of urine flow), hip fracture, epilepsy, and down syndrome;- MDS updated with a change of status due caused by hip fracture; Record review of Resident's medical progress notes, showed:- Resident was hospitalized on [DATE] due to leg pain and an order for an x-ray was given; Record Review of Resident's medical records showed:- There was no documentation that the bed hold policy or discharge summary was provided to the resident their representative; Record Review of the Admission/Discharge Report, dated June 2025, showed:- No record of resident being discharged on 6/17/25 to the hospital or date when resident was re-admitted back into the facility;During an interview on 8/7/25 at 2:15 P.M., the Ombudsman said:- Before August 2025 she did not receive any documentation from the facility on admissions, transfers, or discharges from the facility;- She has not received in the past any notifications or reasons why residents have been discharged or transferred; 4. Review of Resident #12's progress notes, dated 4/23/25 R 5:17 P.M., showed:- The resident was observed sweating and vomited. The resident stated he/she did not feel good. Vital signs within normal limits (WNL). Alert and oriented at baseline. Primary Care Physician (PCP) was contacted and said to sent the resident out for further evaluation. Family contacted. EMS in route.- There was no documentation to indicate when the resident returned to the facility and no documentation to indicate the transfer discharge paperwork and bed hold had been discussed with the resident's responsible party or signed. Review of the resident's Quarterly MDS, dated [DATE] showed:- Cognitive skills severely impaired;- Upper and lower extremities impaired on one side;- Dependent on the assistance of staff with toilet use and lower extremity dressing;- Required substantial to maximum assistance with upper extremity dressing, personal hygiene and transfers;- Always incontinent of urine;- Frequently incontinent of bowel;- Diagnoses included non-traumatic brain dysfunction, stroke and hemiplegia. During an interview on 8/5/25 at 11:39 A.M., LPN D said:- When a resident is sent out to the hospital, the staff sent the face sheet, Medication Administration Record (MAR), transfer/discharge report, bed hold, order summary and the advance directives;- The facility did not keep a copy of the paperwork for the resident's chart, it was sent to the hospital with the resident; During an interview on 8/7/25 at 7:56 A.M., the Social Services Designee said he/she was not aware the Ombudsman had to be notified monthly of any transfers or discharges. During an interview on 8/7/25 at 2:20 P.M., the Assistant Director of Nursing (ADON) said:- Staff should keep a copy of the transfer form and the bed hold;- The Ombudsman should be notified monthly of the transfers and discharges;- Staff should document in the resident's chart why the resident was being transferred out, who was notified, and when the resident returned to the facility or if they did not return to the facility; 5. Review of Resident #8's face sheet showed:-The resident had a diagnosis of type two diabetes (a chronic condition where the body does not use insulin effectively); -Unspecified abnormalities of gait and mobility;-Repeated falls. Review of resident discharge summary showed:-Discharge summary report was not filled out;-No charting was completed to indicate that the Ombudsman had been notified of the resident's discharge. Review of the resident's electronic medical record showed there was no discharge summary to include continuance of care at time of discharge. Interview on 08/06/2025 at 3:31 P.M. The DON said:-The resident was admitted to the facility for therapy;-The resident had been admitted to this facility in the past and had gone home with his/her spouse when he/she was discharged the first time;-The last time the resident was discharged the discharge summary was completed but it was not complete during the most recent discharge.

Based on interview and record review, the facility failed to submit the Payroll Based Journal (PBJ) data (a mandatory submission by nursing facilities to the Centers for Medicare & Medicaid Services detailing facility staffing levels, including staff identification, hours worked, and job titles, on a quarterly basis correctly for Quarter 2 2025 (January 1 to March 31). The facility census was 30 The facility did not provide a policy for PBJ. Review of the facility's Payroll Based Journal data (PBJ - a report that provides staffing data set information submitted by nursing homes on a quarterly basis) for Quarter 2 2025 (January 1 - March 31) showed no RN coverage hours on 2/23, 3/2, 3/16, 3/29, and 3/ 30 and no licensed nurse on 1/25, 2/11, 3/13 and 3/29. Review of staffing schedule for February 2025 showed no RN on the day: 2/23. Review of the staffing schedules for March 2025 showed no RN on the following days: 3/2, 3/16, 3/29 and 3/30.During an interview on 8/5/25 at 9:52 A.M., the Regional Nurse said:- He/She knew something was not right with the PBJ and did not think it had been filled out correctly. During an interview on 8/7/25 at 11:53 A.M., the Assistant Director of Nursing (ADON) said:- The Administrator had been there since July of this year;- He/She had been at the facility since November of last year;- The MDS/Care Plan Coordinator took over as the DON about three months ago;- He/She was unable to find any documentation to show there was RN coverage on those dates;- He/She provided documentation to show there was a licensed nurse on the dates indicated;- They had a rough time with staffing early in the year but it was better now. During an interview on 8/7/25 at 2:20 P.M., the Administrator said:- The PBJ report should be filled out correctly;- They should have an RN working eight hours a day, seven days a week.

Based on observation, interviews and record reviews, the facility failed to maintain the privacy of three of the 12 sampled residents (Resident #15, #2 and #30), when staff failed to post signage at the front door, and outside each sampled residents room to indicate 24 hour camera surveillance was in progress and failed to obtain consents from (#15) and (#30)'s responsible party. The facility census was 30.The facility failed to provide a policy for video surveillance with or without audio.Interview, observation and record review of resident #15, on 08/05/25 at 1:45 P.M. showed: Resident is alert and orientated to self and place, uses a walker with ambulation and wants to be as independent as possible. Resident is his/her own person and able to make his/her own decisions. Resident has diagnosis of: Sequelae following Cerebrovascular disease, Foot drop,(Left), Muscle weakness, Gastro-Esophageal Reflux Disease, Conversion Disorder with Seizures, Restless Leg Syndrome, Abnormalities of gait and mobility, Pain in Left Ankle and Joints of Left Foot and History of Falls. Last fall being 07/17/25, in the hall.Review of the resident's Physician Order Sheet. (POS), dated 07/01/25-08/31/25, did not include an order for video surveillance with audio.Observation on 08/06/25 at 9:40 A.M., showed: The resident was on his/her side of the room getting dressed, video//audio surveillance on his/her roommates side of room but had to pass by when leaving room or using the BR.Did not have a sign outside the resident's room to indicate video monitoring with audio was in use;No signage was posted at the entrance to the facility to indicate video monitoring with audio was in use.The video monitor was at nurse's station and the volume was turned down at time so you were unable to hear what was being said in the resident's room. Review of Resident #15's progress notes for last 7 days and care plans, revised 6/27/25, on 08/6/25 at 9:50 A.M., showed: Care plan did not address the use of video/audio surveillance in residents room. Progress notes did not address receiving consent from resident for the use of video/audio surveillance in room. On 08/07/25 at 11:00 A.M., the audio from video was noted to be turned on at nurses station and you could hear the TV. On 08/07/25 at 2:30 P.M., Review of the residents medical record showed he/she did not have a consent signed by her for 24 hour camera surveillance. 2. Review of Resident #2's care plan, Revised on 06/17/25, on 08/04/25 at 2:53 P.M., showed:Resident has a BIMs of 10, he/she is alert to Person, Place and Time. Resident uses a wheelchair for mobility and is able to ambulate with walker in room but has a note in room to remind him/her to ask for assistance. Resident is unsteady at times and is unaware of limitations.Resident is on hospice for heart failure and is noted to have 2+ edema in bilateral lower extremities with ace wraps applied in the morning and removed at night. Residents diagnosis's are Heart disease, Non-Hodgkin's Lymphoma, Chronic Kidney disease(stage 4), Hypertension, Major Depressive Disorder, History of Transient Ischemic Attack, Cellulites to Bilateral lower limbs. The resident was a high risk for falls related to deconditioning, incontinence, psychoactive drug use, osteoarthritis and knee pain and I have poor safety awareness. The resident has had several falls since his/her admission, last one dated 6/17/25. Interventions include, anticipate and meet residents needs. Be sure call light is within reach and encourage the resident to use it for assistance as needed. A sign has been placed in residents room to remind him/her to ask for assistance to get to the bathroom. Ensure resident is wearing appropriate footwear such as non-skid socks when up ambulating or mobilizing in wheelchair; The care plan did not address the use of video surveillance.Did not have a sign outside the resident's room to indicate video monitoring with audio was in use;No signage was posted at the entrance to the facility to indicate video monitoring with audio was in use.Review of resident #2's progress notes for last 7 days (7/28/25-8/4/25) showed, residents POA(Power of Attorney) has given verbal consent on 7/31/25 at 4:20 P.M., for video surveillance in residents room [ROOM NUMBER]/7 monitoring.On 08/07/25 at 11:00 A.M., the audio from video was noted to be turned on at nurses station and you could hear the TV. On 08/07/25 at 2:15 P.M., Review of the residents medical record showed he/she did not have a consent signed by her POA for 24 hour camera surveillance. 3. Review of Resident #30's Significant Change in Status MDS, dated [DATE] showed;- Long term and short term memory problems;- Dependent on the assistance of staff for eating, toilet use, dressing, showers, and personal hygiene;- Required substantial to maximum assistance with transfers;- Frequently incontinent of bowel and bladder;- Had two or more falls with no injury noted. Had one fall with a minor injury;- Diagnoses included non traumatic brain dysfunction, cancer, anxiety, arthritis, and dementia. Review of the resident's care plan, revised 7/24/25 showed:- The resident was at a high risk for falls related to confusion deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unaware of safety needs. The resident has had falls since his/her admission. Interventions include anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure the resident is wearing appropriate footwear such as non-skid socks when ambulating or mobilizing in wheelchair;- The care plan did not address the use of video surveillance. Review of the resident's medical record showed it did not have a consent signed by the responsible party for 24 hour camera surveillance. Observation on 08/04/2025 at 10:15 A.M., showed:- The resident sat in his/her recliner;- There was a video monitor on the resident's bedside table aimed at where he/she sat;- There was not a sign outside the resident's room to indicate there was camera surveillance. During an interview on 08/04/2025 at 2:15 P.M., Family Member A said:- He/She noticed about a week ago staff had placed a video monitor in the resident's room;- He/She was not for sure if there was audio capabilities or not because no one had discussed it with him/her;- He/She was not asked to sign any kind of a consent for the video monitor;- He/She did not know if it was linked to anyone's phone;- He/She would have expected to have been informed about it prior to the staff setting it up. Observation on 08/04/2025 at 2:58 P.M., showed:- A VTECH video monitor at the nurse's station and showed the resident in his/her room;- The volume on the monitor was able to be adjusted and you could hear staff talking in the resident's room. During an interview on 08/06/2025 at 3:22 P.M., the Assistant Director of Nursing (ADON) said:- He/She thought the resident has had the camera surveillance since he/she was readmitted ;- The resident has had multiple falls in his/her room;- He/she was under the impression that whomever put the monitor in the resident's room had obtained a verbal consent;- There should have been a written consent obtained, a physician's order and it should have been care planned;- A sign should be posted outside the resident's room and at the front entrance. During an interview on 08/07/2025 at 2:20 P.M., the Director of Nursing said:- The family should be made aware of the video surveillance and a consent signed.- Should have a physician's order and it should be care planned.- Should have signage posted outside the resident's room and at the front entrance.

Based on observation and interview the facility failed to promote an environment respectful of the rights of each resident to make choices, when six out of six residents in a group interview were concerned about specific aspects of their life when staff did not offer a bedtime snack to the residents. This potentially affected all residents who would like a snack. The facility census was 30. Review of facility Resident Nutrition Services Policy, dated November 2015, showed snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. Review of facility Resident Rights Policy, undated policy included federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to exercise his or her rights as a resident of the facility and as a resident or citizen of the United States, be supported by the facility in exercising his or her rights, exercise hir or her rights without interferences, coercion, discrimination or reprisal from the facility.During a group interview on 08/05/2025 at 2:08 P.M., the residents said no bedtime snacks were brought to residents. Five of six residents said that they would take a snack at bedtime if it was offered. During an interview on 08/07/2025 at 10:36 A.M. Resident #31 said no snacks are passed out before bedtime and would take a snack at bedtime if offered.During an interview on 08/06/2025 at 8:11 A.M., CNA B said: - Drinks and snacks are set on a cart by nursing station at 10:00 A.M. - There is supposed to be a snack cart after supper also. - He/she only works on the dayshift, so he/she is unsure of time that snack cart arrives after supper. During an interview on 08/06/2025 at 8:58 A.M., CNA A said:- No one goes room to room to pass snacks. - The snacks sit out by the nurse's station. - Staff will bring the residents a snack if they say they are hungry. - He/she stated that times vary for when snacks arrive at the nurse's desk, and it depends on who is working in the kitchen. During an interview on 08/06/2025 at 10:03 A.M. LPN A said: - It depends on who is working in the kitchen on what time snacks arrive. - Residents can ask any time for a snack and staff will get them one. - There is a snack cart on evening shift and night shift, not on day shift. CNAs pass out snacks and leave the cart by the nurse's station for the residents at night. During an interview on 08/06/2025 at 11:16 A.M., [NAME] B said: - Kitchen staff gets the snacks ready. - A snack cart is made after dinner and left in the hallway by the nurse's station. - CNAs pass out snacks or if residents want a snack, they can ask for one and the CNAs will get a snack for them. During an interview on 08/07/2025 at 9:30 A.M. The Dietary Manager said:- CNAs are supposed to pass out snacks, then bring the snack cart back to the kitchen. -He/she is not sure if snacks get passed out every day. -He/she said that as of yesterday (8/6/25) the snack cart was sent out three times. -Before yesterday the snack cart was only sent to the nurse's station at 6:30P.M. (night shift). -The snack cart typically consists of- baked goods, crackers, chips, bananas, and peanut butter and jelly sandwiches. Food that is gluten free is marked indicating that it is gluten free. - He/she recently informed staff that the snack cart needs to go behind the nurse's station so snacks will get passed and residents cannot grab a food item that they are not supposed to have. During an interview on 08/07/2025 at 9:50 A.M., CMT B said snacks are available at nighttime. The snack cart is left by the nurse's station for residents to get snacks.During an interview on 08/07/2025 at 10:05 A.M. The DON (Director of Nursing) said the snack cart is refilled after the noon meal, and snacks are usually passed after the evening meal. Residents can ask for snacks during the day if they want one. The CNAs asks the residents before bedtime if they want a snack.

Based on interviews and record review, the facility failed to ensure two of the 12 sampled residents reviewed for unnecessary medications, (Resident #3 and #33) and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic medication. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 30. Review of the facility's policy for antipsychotic medication use, revised December 2016, showed: - Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. - Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The Attending Physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions; - Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident; - Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders: Schizophrenia, Schizo-affective disorder, Schizophreniform disorder, delusional disorder, mood disorders (bipolar disorder, depression with psychotic features, and treatment refractory major depression), Psychosisi in the absence of dementia, medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania, Tourette's Disorder, Huntington Disease, Hiccups or nausea and vomiting associated with cancer or chemotherapy; - Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: the behavioral symptoms present a danger to the resident or to others AND: the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or behavioral interventions have been attempted and included in the plan of care, except in an emergency; - For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: not due to a medical conditions or problem that can be expected to improve or resolve as the underlying condition is treated or the offending medication are discontinued; and persistent or likely to reoccur without continued treatment; and not sufficiently relieved by non-pharmacological interventions; and not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety; and not due to psychological stressors or anxiety or fear stemming from misunderstanding related to his/her cognitive impairment that can be expected to improve or resolve as the situation is addressed; - Antipsychotic medications will not be used if the only symptoms are one or more of the following: wandering; poor self-care; restlessness; impaired memory; mild anxiety; insomnia; inattention or indifference to surroundings; sadness or crying alone that is not related to depression or other psychiatric disorders; fidgeting; nervousness; or uncooperativeness; - The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications; - Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: general/anticholinergic : constipation, blurred vision, dry mouth, urinary retention, sedation; cardiovascular: orthostatic hypotension, arrhythmias; Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain: or Neurologic: Akathisia, dystonia, extrapyramidal effects akinesia; or tardive dyskinesia, stroke or mini strokes; - The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected of confirmed adverse consequences. 1. Review of Resident #3's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 7/22/25 showed: - Long term and short term memory problems; - No behaviors; - Dependent on the assistance of staff for eating, oral care, toilet use, showers, dressing and personal hygiene; - Required substantial/maximum assistance with transfers; - Frequently incontinent of bowel and bladder; - Had two or more falls with no injury noted; one fall with minor injury; - Diagnoses included Non traumatic brain dysfunction, cancer, anxiety, high blood pressure, arthritis, dementia, TBI, malnutrition, and anxiety; - In the last seven days the resident had seven antipsychotic medications, antidepressant medications and anticoagulant medications; - Antipsychotic medications were used on a routine basis; - No gradual dose reduction was attempted. Review of the resident's care plan, revised 7/24/25 showed: - The resident used psychotropic medications. Depakote, trazodone and Haldol related to behavior management, depression, and anxiety with delusions. Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. Consult with pharmacy to consider dosage reduction when clinically appropriate at least quarterly; - Discuss with the physician, family for ongoing need for use of medications. Review behaviors/interventions and alternate therapies attempted and their effectiveness. Educate the resident, family, caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/document/report as needed any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the resident. Review of the resident's Medication Administration Record (MAR), dated July 2025 showed: - Haldol 5 mg. by mouth in the evening for behavioral disturbance, mood disorder. Review of the resident's medication regimen review (MRR) dated July, 2025 showed: - The resident was admitted [DATE]; - July 2025- no pharmacy recommendations. Review of the resident's Physician Order Sheet (POS), dated August 2025 showed: - Start date: 7/31/25 - Haldol 5 mg. by mouth in the evening for behavioral disturbance, mood disorder. Review of the resident's MAR, dated August 2025 showed: - Haldol 5 mg. by mouth in the evening for behavioral disturbance, mood disorder. Review of the resident's medical records, dated 8/6/25 showed: - No consents or education of risks and benefits for psychotropic medication use were found from 7/1/25 through 8/6/25. During an interview on 8/7/25 at 2:20 P.M., the Director of Nursing (DON) said staff should have obtained a written consent from the resident or responsible party prior to the resident starting on antipsychotic medications. 2. Review of Resident #33's Quarterly MDS, dated [DATE], showed:- Resident was moderately cognitively impaired;- Resident required substantial assistance for eating;- Resident was dependent on staff assistance for oral hygiene, toileting hygiene, showering, dressing, and personal hygiene;- Resident was taking antipsychotic, antidepressant, and opioid medications;- Diagnosis: neurogenic bladder, dementia, paraplegia, multiple sclerosis, depression, and psychotic disorder; Review of Resident's Care Plan, revised 7/22/25, showed;- Resident was prescribed an anti-psychotic medication; - Resident was prescribed psychotropic medications (Aripiprazole, Topamax, and Citalopram) for depression and anxiety disorder. Monitor/document/report as needed any adverse reactions from these medications; Review of Resident's Order Recap Report, dated 8/5/25, showed:- Aripiprazole oral tablet 5mg, one tablet daily for depression related to delusional disorders. Started 6/27/24 – Discontinued 7/22/25;- Aripiprazole oral tablet 5mg, one tablet daily for delusions and major depressive disorder related to delusional disorders, started 7/22/25; Review of Resident's Medication Administration Record, dated 8/1/25 – 8/5/25, showed:- Aripiprazole 5mg tablet 1x daily administered for delusions and major depressive disorder;- Citalopram hydrobromide 10mg tablet 1x daily administered for depression;- Hydrocodone-Acetaminophen 7.5-325 mg tablet administered two times daily for pain; Review of Resident's Medication Administration Record, dated 7/1/25 – 7/31/25, showed:- Aripiprazole 5mg tablet 1x daily administered for delusions and major depressive disorder;- Citalopram hydrobromide 10mg tablet 1x daily administered for depression;- Hydrocodone-Acetaminophen 7.5-325 mg tablet administered two times daily for pain; Record Review of Resident's medical record showed:- No documentation showing the facility fully informed the resident in advance of the risks and benefits to taking anti-psychotic, psychotropic, or anti-depressant medications;

Based on interviews and record review, the facility failed to follow care plan directions for maintaining and using hearing aids for one resident of 12 sampled (Resident #30). The facility census was 30. Review of facility policy Care Plans, Comprehensive Person-Centered, revised September 2013, showed the care plan will include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;Review of facility policy Activities of Daily Living (ADL), Supporting, revised March 2018, showed:- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry ot activities of daily living (ADLs);- Appropriate care and services will be provided for residents including appropriate support and assistance with communication (speech, language, and any functional communication systems;1. Review of Resident #30's Quarterly MDS dated [DATE], showed:- Resident was severely cognitively impaired;- Resident has moderate difficulty in the ability to hear without a hearing aid;- Resident usually understands verbal content but misses some part or intent of message;- Diagnosis: cancer, kidney disease, coronary artery disease, pneumonia, and malnutrition; Review of Resident's Care Plan, revised 6/30/25, showed:- Resident has a communication problem related to a hearing deficit;- Resident requires bilateral hearing aides to communicate, ensure availability and functioning of adaptive communication equipment;- Ensure hearing aids are fully charged and in place;Observation on 8/4/25 at 11:00 A.M. showed the Resident as very hard of hearing, staff must speak directly and loudly to resident in order for him/her to understand the message. During an interview on 8/4/25 at 11:03 A.M., the Resident said:- He/she should have two hearing aids, and they are somewhere around their room, but he/she did not know where they were;- He/she would like to have both hearing aids to hear better hear but is unsure now if they have any hearing aids at all;During an interview on 8/4/25 at 1:40 P.M., CNA (A) said the resident doesn't have hearing aids and sometimes can get a bit moody but if staff speak louder and directly to him/her they can be better understood;During an interview on 8/4/25 at 1:57 P.M., RN (A) said the resident doesn't have hearing aids and even after searching the room he/she could not find any for the resident;During an interview on 8/7/25 at 8:45 A.M., the DON said:- The resident does not like his/her hearing aids and we've had trouble getting the resident to wear them;- The ADON knows exactly what happened to the resident's hearing aids;- Hearing aids and any changes to their use should be reflected in the care plan;During an interview on 8/7/25 at 9:12 A.M., the ADON said she was not familiar with the resident's hearing aids and if he had them or not;During an interview on 8/7/25 at 2:30 P.M., the Administrator said she would expect hearing aids to be care planned and directions pertaining to them followed by staff and updated when needed;

Based on observations, interviews and record review, the facility failed to provide an environment free from accident hazards when staff did not implement new interventions to prevent falls for one of the 12 sampled residents, (Resident #3), who was at risk for falls and who had experienced multiple falls and failed to update the resident's fall risk assessment with each new fall. The facility census was 30. 1. Review of Resident #3's medical record showed the resident was admitted on [DATE] at 12:15 P.M. Review of the resident's progress notes showed:- 5/24/25 at 12:30 P.M., the resident was found on the right side of the bed on the floor. No injury noted;- 5/25/25 at 1:15 P.m., the resident had an unwitnessed fall. The resident was found on the floor, no injury noted. Review of the resident's fall risk assessment, dated 5/25/25 showed the resident scored 20 (indicated the resident was at risk for falls). Review of the resident's progress notes showed:- 5/27/25 at 6:50 A.M., a Certified Nurse Aide (CNA) noticed the resident stumbling over his/her feet and fell backwards. The resident did not hit his/her head. No injury noted;- 5/31/25 at 5:16 A.M., the resident was seen trying to get up on patient camera. It appeared the resident slipped out of bed onto the floor next to the bed. No injury noted'- 6/1/25 at 4:00 P.M., the resident had a fall. No injury noted;- 6/2/25 at 7:30 P.M., the resident had a fall. Resident was observed by CNA laying on the floor on his/her right side. No injury noted. - 6/4/25 at 4:53 A.M., the resident was assisted by two staff off the ground into a standing position to walker and assisted to the bathroom. No injury noted;- 6/5/25 at 9:27 A.M., the resident was found laying on his/her right hp next to the recliner with his/her food knocked onto the floor. The resident had a red area on his/her left side of the head and on the right side of his/her head, right knee and down the leg was swollen and the resident was unable to bear weight. Also had a purplish, yellowish bruise on his/her right hip from a previous fall. The resident was confused, lethargic, and complained of his/her head hurting. The resident was transferred to the local hospital. Review of the resident's fall risk assessment dated [DATE] showed the resident scored a nine (indicated the resident was a low risk for falls). Review of the resident's progress notes showed:- 7/2/25 at 9:28 P.M., the resident sat on the floor in-between the bed and was incontinent of bowel. No injury was noted;- 7/5/25 at 8:00 A.M., the resident had a fall. No injury noted;- 7/8/25 at 11:50 P.M., the resident was observed by the nurse aide (NA) on the floor with his/her back against the bed with his/her legs out straight. No injury noted;- 7/11/25 at 2:33 P.M., the resident was observed on the floor on his/her left side in between the bed and the wheelchair. No injury noted. Review of the resident's Significant Change in Status Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/25 showed;- Long term and short-term memory problems;- Dependent on the assistance of staff for eating, toilet use, dressing, showers, and personal hygiene;- Required substantial to maximum assistance with transfers;- Frequently incontinent of bowel and bladder;- Had two or more falls with no injury noted. Had one fall with a minor injury;- Diagnoses included non-traumatic brain dysfunction, cancer, anxiety, arthritis, and dementia. Review of the resident's care plan, revised 7/24/25 showed:- The resident was at a high risk for falls related to confusion deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unaware of safety needs. The resident has had falls since his/her admission. Interventions include anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure the resident is wearing appropriate footwear such as non-skid socks when ambulating or mobilizing in wheelchair. Follow facility fall protocol. Physical therapy to evaluate and treat as ordered and as needed. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Educate resident, family, care givers, interdisciplinary team (IDT) as to causes;- The care plan was not updated with new interventions after each fall. Review of the resident's fall risk assessment, dated 7/28/25 showed the resident scored a 20 (indicated the resident was at risk for falls). During an interview on 8/7/25 at 2:20 P.M., the Director of Nursing (DON) said fall interventions should be developed and added to the care plan. In addition, after each new fall the fall risk should also be updated.

Based on interview and record review the facility failed to ensure pain management was provided for one resident, (Resident #1) when staff failed to obtain any medications for the resident for the first 48 hrs after admission from an acute hospital stay following a vehicle accident. The facility census was 39. Review of facility policy, protocol for pain management and as needed medication, undated, showed: -Pain management must be provided to a resident who requires such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences; -Nurses will complete a pain evaluation on each resident for pain upon admission to the facility every week for four weeks, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. -The nurses will either use the FACES pain rating scale (for non-verbal or cognitively impaired residents or residents that do not speak English) or the 10 point pain intensity scale. -Nursing staff and physician will identify the nature and severity of pain. -The physician will order appropriate non-pharmacologic and medication interventions to address the resident's pain. -With input from the resident or resident representative, the physician and staff will establish goals of pain treatment. The resident's care plan will include the resident's goals, desired outcomes, and preferences. -The nursing staff will monitor for adverse effects of pain medications and report to physician. -PRN (as needed) pain medication may be ordered for occasional or break through pain. -Document PRN pain medication in Medication administration record and narcotic control record if applies. -Document results of the follow up pain assessment. -Nurses will notify the supervisor if the resident refused the medication. 1. Review of Resident #1's Admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/1/24, showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and had clear comprehension of others; -His/Her pain frequency was frequent with a numeric rating of 8 on a one to ten scale; -He/She had recent orthopedic surgery requiring long term care from repair fractures; -He/She was dependent on walker and wheelchair; -He/She required substantial/maximal assistance with all transfers -Diagnoses included displaced fracture of body of left talus (bone in foot that connects the ankle to the leg), fractures and other multiple trauma, fracture of the shaft of the left fibula, ocular laceration and rupture with prolapse or loss of intraocular tissue, laceration without a foreign body of part of the head, laceration without a foreign body unspecified lower leg, chronic obstructive pulmonary disease, I48.20-chronic atrial fibrillation that is unspecified, generalized anxiety disorder. Review of care plan, dated 11/1/24, showed: -Resident had acute and chronic pain due to physical disability, chronic obstructive pulmonary disease (COPD), chronic pain, fracture of left leg, foot and ankle, and medical procedure open reduction and internal fixation (ORIF) (a surgical procedure that treats broken bones or dislocations by realigning the bones and stabilizing them with internal hardware) of left ankle and leg fracture. -Resident's pain is aggravated by movement and letting the leg be dependent; -Resident's pain was alleviated/relieved by specifically oxycodone at current time; -Administer analgesia oxycodone as per orders. Give half hour before treatments or care; -Identify, record, and treat resident's existing condition which may increase pain and/or any discomfort: arthritis, neuropathy, COPD, and limited ability to move due to swelling of ankles. -Monitor, record, report to nurse resident complaints of pain or requests for pain treatment. Review of physician's order recap, dated 10/24/24-11/7/24, showed: -Ordered 10/25/24, pain scale twice daily every day and evening shift for pain assessment pain level 0-10, started 10/28/24; -Ordered 10/26/24, Acetaminophen oral tablet 500 milligrams (mg), give 2 tablet orally every 8 hours for pain, start date 10/26/24; -Ordered 10/26/24, Alprazolam oral tablet .25 mg, give 1 tablet by mouth every four hours as needed for anxiety, start dated 10/26/24, discontinued 10/27/24; -Ordered 10/26/24, Gabapentin capsule 300 mg, give 1 capsule by mouth three times a day for neuropathy, started 10/26/24; -Ordered 10/26/24, Methocarbamol oral tablet 750 mg, give 1 tablet by mouth four times a day for muscle spasm, started 10/26/24; -Ordered 10/26/24, Oxycodone hcl oral capsule 5 mg, give 1 capsule by mouth every 4 hours as needed for pain, started 10/26/24, discontinued 10/27/24 -Ordered 10/27/24, Alpraxolarm oral tablet 25 mg, give 1 tablet by mouth every 8 hours as needed three times a day in the morning, at noon, and bedtime for anxiety; -Ordered 10/27/24, Oxycodone hcl oral tablet 5 mg, Give 1 tablet by mouth ever 4 hours as needed for severe pain (8-10) for up to 3 days until 10/30/24, started 10/27/24; discontinued 10/30/24. -Ordered 11/1/24, Oxycodone hcl oral tablet 5 mg, give 5 mg by mouth every 4 hours as needed for severe pain. During an interview on 11/7/24 at 11:24 A.M., Resident #1 said: -When he/she first admitted to the facility he/she did not have his/her medications at all for two days; -Not having his/her medications made him/her feel terrible as he/she hurt all over; -His/Her pain level increased due to not having his/her medication and he/she felt miserable; -He/She had high anxiety due to not knowing when he/she would receive his/her pain relief; -He/She had a very rough few days upon admission; -He/She wouldn't want anyone to have to go without their medications like he/she did. Review of Medication Administration Record, dated October 2024, showed: -Pain Scale BID, every day and evening shift for pain assessment pain level 0-10, showed: -10/28/24 -Evening shift had first entry;-Started 10/26/24, Acetaminophen oral tablet 500 mg, give 2 tablet orally every 8 hours for pain, -10/26/24 showed: -12:00 A.M. had an x; -8:00 A.M. had no entry and was blank; -4:00 P.M. had no entry and was blank; -10/27/24 showed: -12:00 A.M. had no entry and was blank; -8:00 A.M. medication was administered; -Started 10/26/24, Gabapentin capsule 300 mg, give 1 capsule by mouth three times a day for neuropathy: -10/27/24 showed: -Morning had no entry and was blank; -Noon had no entry and was blank; -Hour of sleep med had no entry and was blank; -10/28/24 showed: -Morning had entry of 9, medication was unavailable; -Noon showed medication was administered. -Started 10/26/24, Methocarbamol oral tablet 750 mg, give 1 tablet by mouth four times a day for muscle spasm; -10/26/24 showed: -8:00 A.M. had no entry and was blank; -12:00 P.M. had no entry and was blank; -4:00 P.M. had no entry and was blank; -8:00 P.M. had no entry and was blank; -10/27/24 showed: -8:00 A.M. had entry of 9, medication unavailable; -12:00 P.M. had entry of 9, medication was unavailable; -4:00 P.M. had entry of 9, medication was unavailable; -8:00 P.M. showed medication was administered; -Started 10/26/24, Alprazolam oral tablet .25 mg, give 1 tablet by mouth every four hours as needed for anxiety, Order discontinued 10/27/24 at 7:07 P.M: -10/26/24 showed: -As needed, had no entry and was blank; -10/27/24 showed: -As needed, had no entry and was blank; -Started 10/27/24, Alpraxolarm oral tablet 25 mg, give 1 tablet by mouth every 8 hours as needed three times a day in the morning, at noon, and bedtime for anxiety, showed: -10/27/24 showed: -PRN - had no entry; -10/28/24 showed: -PRN received at 8:56 P.M. -Started 10/26/24, oxycodone Hcl oral capsule 5 mg, give 1 capsule by mouth ever 4 hours as needed for pain, discontinued 10/27/24 at 9:06 P.M.: -10/26/24 -PRN as needed had no entry and was blank; -Started 10/27/24, oxycodone hcl oral tablet 5 mg, give 1 tablet by mouth every hours as needed for severe pain (8-10) for up to 3 days until 10/30/24 at 11:59 P.M.: -10/27/24 -PRN was blank and had no entries; -10/28/24 -PRN received at 3:46 P.M; Review of electronic medical record, showed -On 10/25/24, resident was admitted to facility census; -On 10/25/24 2:06 P.M., Licensed Practical Nurse (LPN) A wrote resident arrived via emergency medical services stating he/she was in moderate pain with a script for oxycodone. -On 10/26/24 11:10 P.M., LPN B wrote resident vocalized pain as primary issue with pain score of 7 with pain being sharp, aching, and radiating. Pain note showed that resident's pain medication was pending due to needing doctor approval signature. -On 10/27/24 at 12:19 A.M. LPN B wrote resident was having discomfort due to recent vehicular accident; -On 10/27/24 at 10:22 A.M., RN B wrote resident had non verbal sounds, protective body movements, vocal complaints of pain. Pain was located in several areas throughout the body. The first area was frontal area as sharp, aching, non radiating with the frequency being intermittent. A cool compress was applied and distraction techniques were utilized. Residents as needed medication were given. The second pain area was resident's chest with generalized pain score of 8 described with stiffness, worse with movement and frequency being daily. Third location was his/her right knee with a pain score of 8 described as stabbing, aching, burning, sharp, and worse with movement with the frequency being constant. Fourth location was his/her left knee with pain score of 8 which was sharp, aching, stabbing, burning, stiff, and worse with movement and the frequency was constant. The fifth pain location was lower leg with a pain score of 9 that was described as sharp, aching, stabbing, radiating, with frequency of his/her pain being constant. The sixth pain location was right anterior elbow with pain score of 4 that was burning, non radiating, and the frequency was intermittent. Resident had fractured left ankle, laceration to left knee with six sutures in place, scabbed abrasion to right knee, two round areas on right elbow with the first layer of skin missing. -On 10/27/24 at 4:50 P.M. RN B wrote that the primary care provider was notified of situation with resident not having narcotic medications since arrival to facility on Friday 10/25/24. Orders obtained to change Alprazolam .25 mg three times a day as needed, oxycodone 5 mg every 4 hours as needed for severe pain (8-10) for three days. -On 10/27/24 at 5:15 P.M., narcotic pain medication was delivered from pharmacy. During an interview on 11/4/24 at 8:08 A.M., RN B said: -Resident #1 admitted to facility approximately 2:30 P.M. on 10/25/24 from the hospital after having been in a car accident; -Resident #1 had been receiving oxycodone, Xanax, and other medications to manage his/her pain levels; -When he/she arrived for his/her shift on 10/27/24 resident had not received any of his/her pain medications; -Resident #1 was in pain and very anxious; -Resident #1's blood pressure was extremely high due to his/her pain level; -He/She contacted the primary care provider who did not know resident had entered facility; -Primary Care Provider was very upset resident had entered facility and had not received his/her pain medication; -Orders were showed as still pending in the electronic medical record system; -Resident #1 had went two days without pain medication; -He/She attempted to contact Director of Nursing; -He/She was the third Registered Nurse who had interacted with resident since resident had entered the facility on 10/25/24. During an interview on 11/7/24 at 10:08 A.M., Registered Nurse A said: -When a resident is a new admit to facility the new orders are put in and ordered within the first hour of arrival; -If an admission arrived late in the evening will not get medication until the middle of the night; -If the medication is showing up in the electronic medical record as pending it meant the medication is on order; -When a medication had not arrived to facility staff can go in and mark in the medication administration record that the med was not given due to not being available; -He/She would not expect a resident to wait two days to receive a narcotic pain medication upon admission and that would not be acceptable; -Facility did have an emergency medication kit available for staff to obtain medication from; -He/She expected that medications would be received from the pharmacy by that evening if a new admission arrived to the facility by 2:00 P.M.; During an interview on 11/7/24 at 10:15 A.M., Certified Nurse Aide (CNA) A said: -He/She was working the second day after Resident #1 admitted to the facility; -Resident #1 verbalized that he/she had chest pain so he/she told the nurse; -The nurse advised he/she didn't have any medications because the medication scripts had not got transferred over in the electronic medical record; -Resident #1 was unable to receive any of his/her medications on his/her second day in the facility as they were not available in the facility During an interview on 11/7/24 at 10:22 A.M., Certified Medication Technician (CMT) A said: -The facility nurses were responsible for obtaining resident's medications; -The charge nurse should notify the Director of Nursing or Administrator with issues with medications. During an interview on 11/7/24 at 10:38 A.M., CNA B said: -He/She was working Friday, Saturday, and Sunday when resident #1 first admitted to the facility; -Resident #1 arrived to facility approximately 4:00 P.M. on 10/25/24; -The RN on duty was very upset on Saturday as he/she was trying to figure out what to do regarding resident not having medications; -The RN on duty made several calls to Administrator and Director of Nursing; -The RN on duty called the pharmacy a couple of times; -Resident #1 still had no medications available on Sunday 10/27/24; -Resident #1 went Friday evening, all day Saturday, and Sunday without his/her medications; -Resident #1 had his/her call light on entire day on Saturday and Sunday due to having anxiety of not having his/her pain medication which made his/her pain worse; -Resident #1 had a lot of anxiety of not understanding why his/her pain medication was not delivered; -Resident #1's pain was worse on Saturday because his/her pain medication he/she had received before leaving the hospital had worn off; -There was a lot of frustration with all nursing staff that weekend in regards to resident not having his/her medications. During an interview on 11/12/24 at 12:20 P.M., RN C said: -All medications for Resident #1 were showing in the system as pending; -He/She could not access Resident #1's Medication Administration Record at all; -Resident #1 was very anxious and having discomfort and needed his/her medications; -Resident #1 did not receive any of his/her medications at all during his/her shift; -He/She attempted calling Administrator and Director of Nursing several times; -Many times Administrative staff did not call back when he/she called for support; -He/She contacted the pharmacy two to three times but they advised they could not do anything because of the pending status in the electronic medical record. During an interview on 11/12/24 at 12:41 P.M., LPN A said: -When he/she arrived to the facility at 10:00 P.M. on 10/25/24 the admission packet for resident had not been done so he/she worked on packet when he/she arrived; -The hospital did not send a script with him/her for the oxycodone; -He/She did not have any active orders for Resident #1 so he/she gave him/her Tylenol which helped because resident had just come from hospital and still had some pain relief support from pain medication received at the hospital. During an interview on 11/12/24 at 3:55 P.M., Director of Nursing said: -The nurses have a check off list they complete with new admissions which included ordering all medication; -Medication arrivals are dependent on which pharmacy they are using; -The nurse was responsible to order the medication and that is on the admission check list; -He/She would not have expected a resident to go 48 hours without any medications for pain; -Facility had a StatSafe (an electronic emergency /stat-dose cabinet that allows long term care facilities to provide more responsive patient care), but the StatSafe did not have oxycodone in it; -He/She expected that if resident was having pain that the staff follow up on why the pain medication was not in facility and seen if there was any other medication that could have been given for his/her pain; -He/She was not available the weekend Resident #1 admitted ; -He/She did not hear about the pain medication not being available for Resident #1 until 10/29/24 During an interview on 11/12/24 at 3:55 P.M., Administrator said: -He/She received a call on 10/26/24 from RN working regarding Resident #1 and they said he/she had spoken to the pharmacy and the medications would be delivered at the first available time between 4:00 P.M.-6:00 P.M; -He/She did not know resident #1's pain medication did not arrive to facility; -He/She expected staff to obtain medications timely and for residents to have effective pain management. MO244586

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nebulizer tubing and a nebulizer mouthpiece were cleaned after use and stored in a manner to prevent potential contamination between uses for 1 (Resident #22) of 1 resident reviewed for respiratory care. Findings included: A facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, revised 11/2011, specified, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The section of the policy addressing, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol indicated, 3. After completion of therapy: a. Remove the nebulizer container; b. Rinse the container with fresh tap water; and c. Dry on a clean paper towel or gauze sponge. 4. Reconnect to the administration set-up when air dried. 5. Take care not to contaminate internal nebulizer tubes. 6. Wipe the mouthpiece with damp paper towel or gauze sponge. 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. An Admission Record indicated the facility admitted Resident #22 on 06/02/2022. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, dyspnea (difficult or labored breathing), and mild intermittent asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #22's care plan included a focus area, initiated on 07/23/2024, that indicated the resident had altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease and anxiety. An intervention dated 07/23/2024 directed staff to administer medication/puffers as ordered. Resident #22's Order Summary Report, listing active orders as of 10/08/2024, included an order dated 10/31/2023 for ipratropium-albuterol (a nebulizer solution) 0.5-2.5 milligrams per 3 milliliter vial, one nebulizer treatment every day prior to breakfast related to DYSPNEA. The Order Summary report did not include any orders related to cleaning or storage of the resident's nebulizer tubing or mouthpiece. Resident #22's Nurse Medication Administration Record for 10/2024 revealed the resident was scheduled to receive their ipratropium-albuterol nebulizer treatment each day at 7:30 AM. According to the Nurse Medication Administration Record, Certified Medication Technician (CMT) #4 signed as having administered the resident's nebulizer treatment on the morning of 10/07/2024, and Licensed Practical Nurse (LPN) #10 signed as having administered the resident's nebulizer treatment on 10/09/2024. During a concurrent interview and observation on 10/07/2024 at 10:40 AM, Resident #22 stated they received a nebulizer treatment earlier in the morning. The resident's nebulizer still had the tubing and mouthpiece attached, and the mouthpiece was observed on the bedding of an extra bed in the resident's room. During an observation on 10/07/2024 at 1:15 PM, Resident #22's nebulizer still had the tubing and mouthpiece attached, and the mouthpiece remained directly on the extra bed in the resident's room. During a concurrent interview and observation on 10/07/2024 at 3:21 PM, LPN #9 said CMT #4 administered Resident #22's medications on the morning of 10/07/2024. LPN #9 stated that after a nebulizer treatment was administered, the tubing and mouthpiece should be disconnected, then cleaned and allowed to air dry. During the interview, Resident #22's nebulizer still had the tubing and mouthpiece attached, and the mouthpiece remained directly on the extra bed in the resident's room. During an interview on 10/09/2024 at 1:58 PM, CMT #4 said that after a nebulizer treatment was complete, the tubing and mouthpiece should be disconnected, cleaned, allowed to air dry, then reconnected and hooked to a latch on the side of the nebulizer machine. CMT #4 said Resident #4's nebulizer mouthpiece should not have been on the bed, but she forgot to clean it. During a concurrent observation and interview on 10/09/2024 at 10:25 AM, Resident #22's nebulizer machine was on the resident's bed with the tubing and mouthpiece attached, resting directly on the bedding. Resident #22 said they had completed their nebulizer treatment, but the nurse had not been back in the room. During an interview on 10/09/2024 at 11:30 AM, LPN #10 said she administered Resident #22's nebulizer treatment before breakfast but had not been back to the resident's room. LPN #10 said the nebulizer tubing and mouthpiece should be cleaned, then stored inside a cubby hole on the nebulizer machine. During an interview on 10/10/2024 at 1:35 PM, the Regional Nurse indicated that following a nebulizer treatment, the nebulizer equipment should be cleaned and placed on a towel to dry to prevent potential infections. The Regional Nurse said Resident #22's nebulizer mouthpiece should not have been on the bed in the resident's room. During an interview on 10/10/2024 at 2:17 PM, the Administrator stated nebulizer mouthpieces should not be placed on residents' beds; they should be cleaned and put away.

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected two of five sampled residents (Resident #1 and #2) Facility census was 38. Review of facility policy, Conveyance upon discharge, eviction, or death policy, dated 2019, showed: -Upon discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days the resident's funds and final accounting of those funds, to the resident, his or her legal representative, or in the case of death, the individual, or probate jurisdiction administering the resident's estate, in accordance with state law. 1. Review of the facility's interim aging report, dated 8/21/24, showed the following residents had money in the facility's operating account: -Resident #1 discharged on [DATE], with a balance of $2,428.00; -Resident #2 discharged on [DATE], with a balance of $5,531.46. Review of Request for Resident Refund invoices showed: -On 7/16/24, Business Office Manager (BOM) submitted invoice #134 to corporate office to refund $2,428.00 -On 7/16/24, BOM submitted invoice #133 to corporate office to refund $3,855.26. 2. During an interview on 8/21/24 at 4:07 PM with the Business Office Manager (BOM) said: -He/She created invoices and submitted them to corporate office for payments; -He/She submitted invoice to corporate for Resident #1 and Resident #2 on 7/16/24; -Corporate printed check on 8/14 for Resident #1 in the amount of $2428.00 and they did not sign the check; -He/She did not mail Resident #1's check due to not having a signature; -He/She had contacted the Accounts Payable staff member at corporate office on 8/19/24 regarding the unsigned check and they said the check would be available by 8/21/24; -He/She had not yet received the signed check for Resident #1 as of 8/21/24 at 4:07 P.M.; -He/She had not received a check for Resident #2 after submitting invoice on 7/16/24; -He/She expected resident funds to be returned within 30 days; -He/She submitted During an interview on 8/22/24 at 1:26 PM the Administrator said: -He/She expected the facility to follow the facility policy to return resident funds within 30 days of discharged ; -His/Her staff submitted resident invoice in a timely manner but corporate failed to cut check within 30 day timeline. MO240773

Based on observations, interviews, and resident reviews, the facility failed to assure staff applied the correct sling to prevent a fall from a Stand Up Lift (sit-to-stand, a mechanical lift used to stand or transport residents. The resident must be able to bear weight on his/her legs and have upper arm strength to grasp and hold to the handle bar) which resulted in a fall and a large hematoma to the back of the resident's head. This affected one of 11 sampled residents (Resident #4). The facility failed to assure staff used the sit-to-stand lift to safely transfer and transport residents in a way to prevent the possibility of injury for two residents (Resident #4 and #7). The facility census was 46. 1. Review of the undated Invacare Stand Up Lift (sit-to-stand, STS) Operating Manual showed the following: - Safety Summary: The STS lift may be operated by one staff for all lifting preparation and transfers with a cooperative, weight bearing resident with the ability to support the majority of his/her own weight. However, since medical conditions vary, Invacare recommends that the staff evaluate the need for assistance and determine whether more than one staff would be appropriate in each case to safely perform a transfer. - The standing sling: Must be able to support the majority of their own weight, otherwise injury may occur. Do not use the standing sling in combination with the STS lift as a transport device. It is intended to transfer a resident from one resting surface to another. Moving a resident using the standing sling in combination with the STS lift over any distance is not recommended. Before lifting the resident make sure the bottom edge of the standing sling is positioned on the lower back of the resident and the resident's arms are outside the standing sling. The sling must be snug, but comfortable on the resident, otherwise the resident can slide out of the sling during transfer, possibly causing injury. There are no leg straps for this sling. - The transport sling: Do not raise the resident to a full standing position while using the transport sling, otherwise injury may occur. Before lifting the resident, make sure the bottom edge of the transport sling is at the base of the spine and the resident's arms are outside the transport sling. Leg straps are part of the transport sling. - Always use the color-coded strap on the standing sling closest to the resident while still maintaining stability and comfort. - When the resident is elevated a few inches off the surface being transferred from and before moving the resident, check again to make sure that the sling is properly connected to the attachment points of the STS lift. If the attachments are not properly placed, lower the resident back down onto the surface and correct the problem. - During transfer, with a resident suspended in a sling attached to a lift, do not roll STS lift over objects such as carpet, raised carpet bindings, door frames, or any uneven surface that would cause an imbalance of the STS lift and could cause the stand up lift to tip over. 2. Review of Resident #4's care plan, dated 9/26/13, showed the following: - Problem: Not able to complete activities of daily (ADLs) living without assistance of staff. - Approaches: Since most recent hospital stay, the resident did not want to stand or transfer; mechanical lift (a lift which used a full body sling to lift and transfer a resident) and assist of two staff for all transfers. - Problem: At risk for falls related to paranoia and psychotropic (used to treat Schizophrenia) drug use. - Approaches: Resident did not want to stand and believed someone stole his/her kneecaps; mechanical lift with assistance of two staff; apply shoes and glasses before transferring resident; refuses to work with physical and occupational therapies; call light within reach. Review of the comprehensive Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 10/1/13, showed the following: - A Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition, never made decisions. - Extensive assist of two or more staff for bed mobility and transfers. - Balance not steady when moved from a seated to a standing position and getting on and off the toilet; able to stabilize with human assist. - No impairment of extremities. - One non-injury fall since admission/re-entry to facility. - Weight: 207 pounds. - [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment Sheet, dated 12/30/13, showed the following: - A score of 10 which indicated a high risk for falls. Review of the facility's Monthly Fall Tracking Log dated January, 2014 showed the following: - 1/4/14: Fall at 11:00 A.M. from the STS lift, sling came off resident. Review of the facility's physician's fax, dated 1/4/14, showed the following: - Staff transferred resident with the STS lift. - The sling came off the resident, which caused him/her to fall backwards, landed on his/her back, and hit the back of his/her head; sustained a "tennis ball" size hematoma to the left side of the head; no injuries; moved all extremities well; neurological checks started. - Faxed to and noted by Family Nurse Practitioner (FNP) A on 1/6/14. Review of the facility's Post Fall Investigation Report, dated 1/4/14, at 11:00 A.M., completed by Licensed Practical Nurse (LPN) D showed the following: - Three previous falls in the last 12 months. - Identified on the care plan as a high risk for falls. - Contributing factor: Sit-to-Stand sling; - Fall happened in the resident's room; - Witnessed fall; - No injury; - Found on floor by bed; - Goose egg hematoma to back of left side of head; - Staff transferred the resident with the STS lift; the sling came off the resident and caused the resident to fall, landed on back and hit head. - Used wheelchair; - Activity status: Up to chair. - Seroquel (used to treat Schizophrenia) and Ativan (used to treat anxiety) not a factor. - No health care status change prior to this fall. - Safety measures in place prior to fall. - Safety measures care planned. - Safety measures carried out per the care plan. - Neurological checks immediately started due to a witnessed fall and impaction of the resident's head to the floor. - Findings: Re-educate the STS use; make sure the resident helped and qualified for STS use. Staff to be re-trained on STS use. Review of nurse's notes, dated 1/4/14, showed the following: - 11:00 A.M.: Alert, weakness, and tremors; - Bed mobility and support provided: Extensive assist of one staff. - Certified Nurses' Aide (CNA) A summoned LPN D to the resident's room and observed the resident lying on the floor on his/her back. - CNA A transferred the resident with the STS lift and the sling came off one side of the STS attachment points and caused the resident to fall backwards onto the floor. - The resident landed on his/her back and hit the back of his/her head. - Assisted up with the assist of two staff and a gait belt (a safety device or belt placed around the waist which allowed for gripping of the belt to help a weak resident to stand and walk) to sit in the wheelchair. - The resident stated "My head is sore." - Tennis ball size hematoma noted to the back of the left side of the resident's head. - No other injuries, neurological checks started. - Tylenol (a mild pain reliever) 325 milligrams (mg), two tablets administered for complaints of head pain. - 12:40 P.M.: Washcloth to forehead; no complaints voiced; neurological checks within normal limits; - 8:35 P.M.: Resident in bed all shift; the resident stated "I'm sore from my fall;" Golf ball size hematoma to back of left side of head; neurological checks within normal limits. Review of the care plan, dated 1/6/14, showed the following: - Problem: Not able to perform ADLs without assistance. - Approaches: Since most recent hospital stay, the resident did not want to stand or transfer; use the STS lift for transfers with the assistance of one staff. - Staff did not update the care plan falls related to the correct use of the lift. During an interview on 1/8/14, at 10:55 A.M., Physical Therapy Assistant (PTA) A said the following: - The facility implemented a weekly fall meeting to discuss falls in the facility. - She knew the resident fell on [DATE], but the staff did not discuss the fall at the meeting today; only December, 2013 falls were discussed. - PT did not evaluate residents for the use of lifts or gait belts unless nursing decided a resident needed to be evaluated. - Nursing staff reported findings to the Director of Nursing (DON) and she made the decision for PT to evaluate for a change in transfer mode. - Resident #4 had no PT evaluation since April, of 2013. - At that time the STS lift was appropriate. - Resident #4 refused occupational therapy in September, 2013 after his/her hospitalization to the geriatric psychiatric unit. - Nursing staff used the STS lift after the resident's readmission to the facility in September, 2013. - The facility policy showed one staff assist with STS transfers. - The facility purchased a new STS recently and everyone was in-serviced by the manufacturer's representative. During an interview on 1/8/14, at 12:00 P.M., the DON said the following: - Staff used the STS to transfer Resident #4 after his/her hospitalization in September, 2013. - The facility policy showed one staff assist with the STS lift when used on residents. - CNA A worked with the resident the day of the fall, 1/4/14. - The sling came off the lift and the resident fell and hit his/her head on the floor. - CNA A was inserviced on the new STS and slings after the incident, on 1/9/14. During an interview on 1/9/14, at 8:45 A.M., CNA A said the following: - Only one staff was needed to use the STS lift with residents. - The facility had two STS lifts, one was a new lift. - He/she used the old lift but did not use the sling appropriate for the old lift. - The sling to be used for the old lift was a transport sling or body sling with leg straps. - He/she brought the STS into the resident's room and a sling lay over the machine on 1/4/14, the day of the fall. - He/she placed the new lift sling (stand up sling, a body sling with no leg straps) beneath the resident, sat the resident on the side of the bed, and attached the loops to the attachment points on the lift. - He/she did not check to see if the sling was the correct sling to use with the old lift. - He/she lifted the resident off the bed to transfer to the wheelchair; - The resident held to the handle bar, his/her feet sat on the foot platform when lifted. - Initially the resident stood without difficulty. - After the resident stood on the lift, CNA A pulled the lift away from the bed but needed to move the recliner in order to roll the lift and transfer the resident to the wheelchair. - As he/she moved the recliner, the resident became limp, became very weak, and could not stand. - Before CNA A could roll the resident to the bed and lower him/her safely to the bed, the stand up sling loops slipped off the lift attachment points, came off the resident, the resident fell on the floor, landed on his/her back, and hit his/her head on the floor. - The sling hung by one strap on the lift; the sling came off the resident and CNA A did not have time to stop the fall; - CNA A summoned LPN D to the room to assess the resident. - The resident sustained [REDACTED]. - CNA A did not attend the in-service on the new STS lift and sling given by the manufacturer's representative. - Staff in-serviced him/her on 1/9/14, on the STS lifts and slings after the resident's fall. - He/she should have used the old sling with the old lift because it had leg straps to attach the sling to the lift to help prevent the resident from falling. - The new STS lift used the stand up slings which was the type sling laying on the lift he/she brought into the resident's room. - He/she did not think and just used the sling that laid over the lift. - Resident #4 complained of pain in his/her head; - LPN D started neurological checks on the resident and helped to assist the resident off the floor; - Staff did not send the resident to the emergency room . During an interview on 1/9/14, at 11:30 A.M., LPN D said the following: - Resident #4's condition declined since last hospitalization . - His/her Parkinson's symptoms worsened but he/she could still stand; - LPN D did not feel the need to change the resident to the mechanical lift after the fall on 1/4/14; - Staff continued to use the STS lift to transfer the resident until 1/8/14. - The facility changed the type of transfer to the mechanical lift after intervention of the surveyor. During an interview on 1/9/14, at 11:45 A.M., the resident said the following: - He/she remembered falling on 1/4/14. - He/she fell out of the "machine thing;" - The sling came loose; he/she fell and hit his/her head on the floor; - His/her head was still sore from the fall. During an interview on 11/13/14, at 9:15 A.M., Restorative Aide (RA) A said the following: - On 1/9/14, he/she in-serviced CNA A on the STS lifts and the correct slings to us. - CNA A did not attend the original in-service with the manufacturers' representative who covered the new lift and sling. During an interview on 1/13/14, at 10:40 A.M., PTA A said the following: - Normally, staff is trained to use new equipment before using on a resident. - CNA A should have been in-serviced before using the new STS lift and sling. - She expected staff to use the correct sling with the correct lift anytime they used a lift to transfer or stand a resident. During an interview on 1/13/14, at 11:15 A.M., the DON said she expected staff to use the correct sling with the correct lift to prevent falls. 3. Review of Resident #4's care plan, dated 1/6/14, showed the following: - Problem: Not able to perform ADLs without assistance. - Approaches: Since most recent hospital stay, the resident did not want to stand or transfer; use the STS lift for transfers with the assistance of one staff. - Staff did not care plan falls. Observation on 1/7/14, at 12:20 P.M., showed the following: - Resident #4 sat in a wheelchair in his/her room.- CNA D and CNA E placed the STS transfer sling (with straps that go between the legs) behind the resident's back and brought the leg straps beneath the resident's legs. - CNA D and CNA E attached the loops of the sling to the attachment points on the STS lift. - CNA D and CNA E lifted the resident out of the wheelchair; the resident's eyes were closed. - The resident held to the handlebar with his/her hands but did not bear weight on his/her feet/legs. His/her eyes were remained closed during the transfer. - The resident's knees were bent, the sling pulled up under the resident's arms; the shoulder's were raised and the arms were out in chicken wing fashion; - The resident's feet were two inches above the foot platform as the resident hung in the air. - CNA D and CNA E rolled the STS lift around the end of the resident's bed, rolled the STS lift beneath the bed and lowered the resident onto the bed. - The resident's feet did not touch the foot platform during the transfer. During an interview on 1/7/14, at 1:00 P.M., CNA E said the following: - Resident #4 sometimes bears weight during a transfer. - Resident #4 was not difficult to lift. - CNA E thought about using the mechanical lift but the resident did not like to use the mechanical lift. - The resident's feet should not be off the foot platform and the resident should not hang by STS lift. During an interview on 1/7/14, at 1:10 P.M., CNA D said the following: - The resident should not hang in the STS lift and his/her feet should rest on the foot platform; his/her feet should not be above the platform. During an interview on 1/8/14, at 10:55 A.M., PTA A said the following: - Resident's feet should never be off the foot platform during a STS lift transfer. During an interview on 1/13/14, at 11:15 A.M., the DON said the following: - Resident's feet should never be off the foot platform during a STS lift transfer. 3. Review of Resident #7's history and physical, dated 9/4/13, showed: - Right shoulder surgery; - Bilateral knee replacements; - [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 11/13/13, showed: - Transferred with a sit-to-stand with assist of one staff; - Severe back pain caused by a pelvic fracture interferes with self performance of activities of daily living (ADLs); Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Extensive assisted for transferring, toileting, dressing, bed mobility, and personal hygiene; - Occasionally incontinent of bladder, always incontinent of bowel; - Scheduled pain medications with frequent pain. Observation on 1/7/14, at 1:00 P.M., showed: - CNA B entered the resident's room with a Hoyer Elevate sit-to-stand; - CNA B left the room stating he/she needed to ask another staff member a question about transferring with the sit-to-stand; - CNA B returned to the room, buckled the standing sling waist belt very loosely around the resident's upper chest, with a gap of approximately 6 inches between the sling and the resident's chest, and attached the straps to the sit-to-stand. - CNA B did not fasten the calf strap around the resident's legs. - CNA B raised the resident from a sitting position with the sit-to-stand. The resident's knees were bent 35 degrees, and the resident hung from the sit-to-stand in a semi-sitting position, held on to the handles of the sit-to-stand with his/her arms above his/her head, elbows unbent. The resident told CNA B to hurry and transfer him/her to the toilet because he/she could not hold on much longer. The standing sling waist belt was up under the arms of the resident, which raised the resident's shoulders to almost ear level. The resident's arms were still stretched upward, over the resident's head without any bend in the elbows as the resident hung on to the sit-to-stand hand grips. - The resident continued to cry out for staff to hurry and stated again he/she could not hold on much longer to the hand grips. - After CNA B lowered the resident to the toilet, the resident said he/she had bad shoulders and his/her shoulders hurt from hanging from the sit-to-stand. During an interview on 1/7/14, at 1:30 P.M., the resident said he/she doubted he/she could continue to hold on to the sit-to-stand during the transfer because his/her shoulders hurt and the resident feared he/she would fall. During an observation on 1/8/14, at 6:00 A.M.: - CNA C entered the resident's room with a Hoyer Elevate sit-to-stand; - CNA C placed the standing sling waist strap around the resident waist; - CNA C stated he/she did not know how to fasten the calf strap and left the room; - CNA C and CMT A returned to the room and CMT A stated he/she did not know how to fasten the calf strap; - CNA C and CMT A transferred the resident to the toilet with the sit-to-stand, with calf strap unfastened around the resident's legs. During an interview on 1/8/14, at 6:15 A.M., CNA C said he/she did not know how to fasten the calf belt on the sit-to-stand around the resident's legs. During an interview on 1/8/14, at 6:17 A.M., CMT A said he/she forgot how to use the calf strap on the sit-to-stand. During an interview on 1/8/14, at 6:20 A.M., RA A said; - All staff was trained on the sit-to-stand lift and staff should know how to fasten the calf strap and waist strap for a safe transfer. - Staff instructed to fasten the waist strap snugly and to always fasten the calf strap. - If waist strap is not fitted snugly around the resident, and if the calf strap is not attached, the transfer can be unsafe. - The DON determines how a resident will be transferred. During an interview on 1/8/14, at 10:00 A.M., the PT A said: - Staff has been instructed to tighten the waist belt snugly around the resident during a Hoyer Elevate sit-to-stand transfer; - Staff instructed to fasten the calf strap during a Hoyer Elevate sit-to-stand transfer; - Unless staff tighten the waist strap of the sit-to-stand around the resident and fastens the calf strap around the resident it is not a safe transfer. - When staff raise a resident up from a sitting position in a sit-to-stand, the resident's knees should be bent approximately 15 degrees when the lift is completed with the resident almost standing straight. The resident should never hang from the sit-to-stand because that is very hard on the resident's shoulders; - The sit-to-stand is a safe transfer for this resident if it is done correctly. During a telephone interview on 1/8/14, at 11:15 A.M., CNA B said; - The resident has strong days and weak days and should be a Hoyer lift; - CNA's have the authority to decide how a resident should be transferred; - When he/she transferred the resident with the sit-to-stand, he/she should have pulled the waist belt tighter so it was not gaping in front of the resident. - He/she does not think the calf strap has to be used for a safe transfer. During an interview on 1/13/14, at 12:05 P.M., the DON said: - Staff is to contact her if there are any concerns with how a resident is transferring, and she will assess the resident; - Staff does not need to tighten the waist strap on the sit-to stand snugly around the resident, but should be tightened some. - Staff should fasten the calf strap around the resident's legs, but its only purpose is to keep the resident's leg positioned. Review of the undated manufacture's operating instructions for the Hoyer Elevate Sit-to-Stand showed a diagram for correct positioning as follows: - Resident in a chest standing sling, standing on the platform of the sit-to-stand, bearing weight with knees nearly straight, hands on the hand grip bars, with elbows bent at chest level; - Calf strap in place, buckled around the resident's legs.

Based on interviews and record review, the facility failed to assure staff thoroughly assessed and transferred one resident for evaluation in a timely manner when the resident complained of severe pain after a fall which resulted in a [MEDICAL CONDITION]. This affected one of 11 sampled residents(Resident # 8). The facility census was 46. 1. Review of the facility's Guidelines for Incident/Accident Documentation policy, dated [DATE], showed the following: - Documentation will include information as related to the resident's situation. - Initial documentation shall be completed by the nursing supervisor of the shift in which the incident occurred and should include: - Date and time of accident or incident. - Skin conditions including pain, swelling, change in temperature, site, size, depth, color, and breaks. - Pain, site, intensity, and characteristics. - Change in mental or physical status. - Treatment provided. - Notification of physician, family, or resident representative. - Assessment completed on resident such as range of motion (ROM) of joints, neurological assessment. - Vital signs. - Investigation procedure to include the following: - Examine the entire skin surface. - Interview the resident to determine cause or conditions. - Interview witnesses. - Measure vital signs. - Assess pain. - Identify all skin discolorations, redness, swelling, [MEDICAL CONDITION], tenderness, breaks, or change in temperature. - Gently perform passive and active ROM of all joints. - Assess any change in mental status and neurological signs. - Notify the resident's physician and the resident's representative of a change of condition or any concerns that have been identified. - Attempt to determine the cause of any conditions identified. - Implement preventive measures as appropriate. The facility did not provide a policy for assessing residents with pain. Review of the facility Glasgow Coma Scale and Neurological Check List sheet showed the following: - Information included in the neurological check of a resident included time assessed, vital signs, extremity strength all extremities, level of consciousness, pupil reaction to light, Glasgow Coma Scale-opening eyes, best verbal response, best motor response, and all were assessed every 15 minutes for two hours, every 30 minutes for two hours, every hour for two hours, every shift for three days, and then as needed. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated [DATE], showed the following: - A Brief Interview for Mental Status (BIMS) score of eight which indicated moderately impaired cognition, poor decision making, cuing needed to make decisions. - One non-injury fall since admission on [DATE]. - [DIAGNOSES REDACTED]. - Mood: Felt down, depressed, hopeless for ,[DATE] days. - No behaviors. Review of the resident's care plan, dated [DATE], showed the following: - Problem: Supervision with activities of daily living due to MR. - Approaches: Transferred and ambulated independently with a front wheeled walker. Monitor gait and report any changes to the charge nurse. - Problem: At risk for falls due to [MEDICAL CONDITION] and gait. - Goals: No injuries from falls. - Approaches: Encourage to wear non-skid socks or slippers when ambulating; ambulated and transferred independently with front-wheeled walker; Monitor gait, usually steady, but did not always hold to walker correctly, report any changes; keep room clear of clutter. Review of the Fall Risk Assessment, dated [DATE], showed the following: - A score of 16 which indicated the resident was a high fall risk. Review of nurse's notes, dated [DATE], showed Licensed Practical Nurse (LPN) F recorded the following: - 5:25 P.M.: The resident fell when he/she left the dining room as he/she ambulated with walker. - Resident #8's walker caught in wheels of another resident's wheelchair; small cut to the lower lip, right eye swollen and bruised. - No complaints of pain. Slow steady gait, assisted to bed. - 6:10 P.M.: Complained of head and hip pain due to recent fall. - Tylenol (mild pain reliever) 325 milligrams (mg), two tablets administered. - He/she did not record that he/she notified the physician of the resident's fall or complaints of pain. - Vital signs (V/S): Blood Pressure (B/P) ,[DATE], Pulse (P) 106, Respirations (R)18, Temperature (T) 97.8, Oxygen saturation (O2 Sat, the amount of oxygen in the blood stream, normal 92%-100%) 97%. - Neurological (neuro) checks were started. Review of a nurse's note, dated [DATE], showed the following: - 6:00 P.M.: Neuro checks within normal limits. - V/S: B/P ,[DATE], P 56, R 18, T 96.9, O2 Sat 98%. - No complaints of pain. Review of a nurse's note, dated [DATE], showed the following: - 12:15 A.M.: Neuro checks within normal limits. - V/S: B/P ,[DATE], P 60, R 16, T 97.2, O2 Sat 98%. - No complaints of pain. - 12:25 P.M.: Neuro checks within normal limits. - V/S: B/P ,[DATE], P60. R 18, T 97.3, O2 Sat 98%. - Moved all extremities well, bruising to right eye. - 6:15 P.M.: Neuro checks within normal limits. - V/S: B/P ,[DATE], P 89, R 18, T 98.1, O2 Sat 91%. - Moved all extremities well, right eye swollen and bruised. Review of a nurse's note, dated [DATE], showed the following: - 1:30 A.M.: Neuro checks within normal limits; - V/S: B/P ,[DATE], P 64, R 16, T 98.6, O2 Sat 97%. - Moved all extremities well, bruising to right eye. - 10:00 A.M.: Neuro checks within normal limits. - V/S: B/P ,[DATE], P 78, R 22, T 97.9, O2 Sat 94%. - Denied pain. - 5:45 P.M.: Neuro checks within normal limits. - Denies pain. - Bruising to right eye and face fading, lip still swollen. - V/S: B/P ,[DATE], P 68, R 16, T 97.1, O2 Sat 98%. Staff did not record status on [DATE]. Review of a nurse's note, dated [DATE], showed the following: - 3:00 P.M.: Resident complained of dizziness. BP ,[DATE], O2 Sat 98%P68. - Equal hand grips, gait slow and steady with walker. - Encourage to ask for help. - Drink fluids; and slow from lying to sitting to standing. Will monitor. - Did not record pain level. Review of nurse's notes, dated [DATE], at 11:00 A.M., showed the following: - The MDS Coordinator recorded the resident approached the nurse's desk and complained of foot, leg, and body pain. - Staff assisted the resident to his/her room, Tylenol administered. - Resident complained of upset stomach. - She did not record she notified the physician of the resident's pain. - Staff did not record vitals or neuro assessment. Review of nurse's notes, dated [DATE], at 2:20 P.M., showed the following: - LPN B recorded the resident approached the nurse's desk and went back to his/her room several times. - The resident said "no one likes me;" - He/she was upset and crying; - LPN B administered [MEDICATION NAME] (used to treat anxiety) 5 mg and reassured the resident. - Recorded will monitor. - He/she did not record he/she notified the physician of the resident's pain and anxiety. Review of the resident's record showed no physician entries on the physician's progress notes from [DATE], through [DATE]. Review of nurse's notes, dated [DATE], showed the following: - 1:20 P.M.: LPN C recorded he/she heard a scream from resident's room. LPN C found resident sitting on the floor at the foot of his/her bed with his/her walker tipped over. Staff assisted the resident up and into bed. The resident stated his/her legs gave out and he/she fell . LPN C notified the resident's guardian of the fall; he/she did not record an assessment of pain, if the resident complained of injury, or if he/she notified the physician. Vital signs: BP ,[DATE], P 74, R 18, T 97.4, O2 Sat 98%; staff did not record neurological (neuro) assessment. - 3:20 P.M.: LPN A recorded the resident complained of right anterior thigh cramping and he/she applied arthritis cream to the thigh. Staff did not record vital signs or neuro checks. - 3:25 P.M.: LPN A recorded the resident had full range of motion (ROM, the ability to move an extremity in all directions) to the right hip and knee; no redness or soreness upon touch. Monitor the resident. Staff did not record vital signs or neuro checks. - 4:00 P.M.: LPN A recorded the resident complained of pain in the right thigh. Tylenol 325 mg, two tablets administered. Continued to monitor. - 4:30 P.M.: LPN A recorded the resident complained of cramping of the thigh and pain in the thigh area. LPN A applied a hot pack (a moist, hot pack used to treat pain, ordered by the physician due to the possibility of burning a resident due to intense heat) to the resident's thigh. Continued to monitor. Staff did not record vital signs or neuro checks. - 5:00 P.M.: LPN A recorded the resident rested in bed, he/she removed the hot pack, and the resident was sleepy and the pain was better. Staff did not record neuro checks or vital signs. - 6:20 P.M.: LPN A recorded the resident stayed in bed and ate supper in bed; bruising noted to the resident's right eye; resident up in wheelchair in hallway related to right thigh soreness; continued to monitor. Alert to self. Vital signs: T 98.1, P 72, R 18, B/P ,[DATE], O2 Sat 96% - 6:50 P.M.: LPN B recorded the resident continued to complain of pain in the right thigh. The resident was upset and aggravated and made frequent movements in bed, complained of pain when staff straightened his/her right leg, and noted an area of redness to the right thigh described as a spider web pattern, two quarter-sized bruises noted to the right thigh and a large baseball sized bruise to the right shin. Call placed to On-call Physician (OCP) A. LPN B recorded OCP A did not answer, will call again, and awaited return call from OCP A. T 97.1, P 98, R 22, B/P ,[DATE], O2 Sat ,[DATE]%. Staff did not record Neuro checks. - 8:00 P.M.: LPN B recorded call placed to OCP A with no answer; no option to leave voicemail; will continue to try to call OCP A. No vital signs were recorded. Neuro checks were not recorded. - 8:20 P.M.: LPN B recorded area of redness decreased to right thigh, the resident "had calmed down," no longer cried, but still complained of pain; no return call from OCP A. Vital signs: O2 Sat 91%. Staff did not record neuro check. - 8:45 P.M.: LPN B contacted Family Nurse Practitioner (FNP) A and received an order to send the resident to the emergency room (ER) for evaluation of hip pain. (Eight hours and 50 minutes after the resident fell in his/her room and six hours after he/she first complained of pain in the right thigh). Staff did not record vital signs or neuro checks. - 9:10 P.M.: LPN A recorded ambulance staff transferred the resident to the local hospital for evaluation. - 10:00 P.M.: LPN E recorded the ER at the local hospital called and reported the resident suffered a fracture to his/her right hip and was admitted to the hospital. LPN E notified the resident's guardian. Review of the POS [REDACTED] - Recorded the time of the [DATE], fall as 1:20 P.M. - Pattern of falls: Increased restlessness, physical factors (shoes); - Contributing factor: Improper footwear. - Location: Resident room. - Un-witnessed fall. - Level of injury: Minor injury. - Description of incident: Found on floor, resident stated legs gave out and he/she went down. - Bed in low position, no bed rails. - Used walker. - Activity status: Ambulatory. - No medications were listed. - Health care status changed: Yes, fall signs and symptoms. - Safety measures in place prior to fall, interventions in the care plan, and interventions carried out as care planned. - The investigation report showed: If the fall was unwitnessed, or if the head was impacted (hit), were neuro checks done immediately and according to protocol and LPN C checked the NO box. - Staff initiated increased monitoring after the fall. - Staff continued to monitor the resident and had fall signs and symptoms. Review of the hospital ER notes, dated [DATE], at 10:00 P.M., showed the following: - The resident fell at the facility today and complained of pain in the right thigh with ambulation. - Also fell on [DATE], with old bruising to the face from that fall. - The fall today occurred six to 12 hours ago. Pain moderate and constant since the fall and prior injuries noted to the face from a previous fall on [DATE]. The resident showed mental [MEDICAL CONDITION] and could not answer most questions. - No obvious deformity or new bruising over the thigh where the resident pointed as painful, but old bruising noted to the face from a previous fall. - Pain with external (outward) rotation of the hip, mild TTP ([MEDICAL CONDITIONS] Purpura, blood clots forming in the small blood vessels) on the right hip. - Non-displaced intertrochanteric (femoral neck of the hip) fracture, admit for pain control and orthopedic consult in A.M. Review of the hospital history and physical (H&P), dated [DATE], at 10:40 A.M., showed the following: - Guardian helped resident in decision making process. - Previous fall on [DATE]. - Baseline mental [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. - Open reduction and internal fixation (repair) of right hip joint. During an interview on [DATE], at 1:45 P.M., the MDS Coordinator said the following: - The resident had several falls since admission. - She knew the resident fell on [DATE], but did not work that day. - She did work on [DATE], when the resident complained of foot, leg, and body pain. - The complaints the resident exhibited on [DATE], were more flu like with an upset stomach, he/she hurt all over, not just the foot and the leg. - After his/her falls prior to [DATE], physical therapy screened the resident and determined he/she was not cognitively able to take instruction. - His/her family member died recently and he/she came to the facility to live. This caused a lot of stress for the resident, plus getting used to living at the facility contributed to his/her falls. - The physician ordered [MEDICATION NAME] (medication to control [MEDICAL CONDITION]) levels to assure the medication dose was sufficient since many of his/her falls happened when a [MEDICAL CONDITION] occurred. - After his/her fall on [DATE], his/her ambulation was different; he/she did not ambulate as much. During an interview on [DATE], at 1:55 P.M., LPN C said the following: - He/she heard the resident scream and found the resident sitting in the floor at the end of the bed on [DATE]. - The walker tipped over when he/she fell . - The resident said his/her leg gave out and he/she fell . - No problems noted with ROM, and staff assisted the resident back to bed. - LPN C did not call the physician because staff were not to call if there was no injury; he/she wrote an FYI (for your information) note and placed it on a clipboard in the DON's office for the physician to see the resident the next time he/she entered the building for rounds. - The resident complained of pain prior to the fall on [DATE], and he/she administered Tylenol to the resident. - LPN C notified the guardian of the fall. During an interview on [DATE], at 2:00 P.M., LPN B said the following: - LPN A reported to him/her that the resident fell earlier in the day now complained of pain, muscle cramping. - LPN A administered Tylenol with no relief. - The resident moved his/her leg up and down and had full ROM. - LPN A thought it was muscle cramping and used arthritis cream on the area, but it did not help. - LPN A then applied a hot pack which did not help the pain. - The resident "could not sit still" because of the pain. - The leg was red; the redness looked like spider veins on top of the leg. - LPN B called OCP A several times but he/she never returned the call. - LPN B finally called FNP A and received orders to send the resident to the hospital ER for evaluation. - Staff usually called another physician or FNP if the OCP did not respond within one hour. - LPN B started calling OCP A at 6:50 P.M. and did not contact FNP A until 8:45 P.M. During an interview on [DATE], at 6:30 P.M., LPN A said the following: - He/she knew about the fall on [DATE], but did not work that day. - He/she worked the evening shift after the resident fell on [DATE]. - LPN C (the day nurse) reported about the fall and said there was no injury. - A Certified Nurse's Aide (CNA) told him/her about the resident's complaint of pain and hesitancy to stand on [DATE], when LPN A first assessed the resident at 3:20 P.M. - LPN A asked the resident where the pain was located and he/she pointed to the top of his/her leg. - LPN A asked the resident if the pain felt like a muscle cramp and the resident said yes. - LPN A applied arthritis cream to the area, performed ROM, and gave the resident Tylenol. - The resident did not grimace with pain. - On [DATE], the resident was up and down the hall in the wheelchair; could not be still. - The resident used a walker prior to the fall and did not normally use a wheelchair for transportation. - The resident still complained of pain and LPN A placed a hot pack to the area, this was a nursing action; staff did not need a physician's orders [REDACTED]. - She did not contact the physician earlier in the shift because the resident had full ROM of the right leg, he/she was mildly retarded and could say where the pain was located, and he/she did not grimace with pain. - He/she talked to LPN B about the pain and LPN B assessed the resident and attempted to reach OCP A. - LPN A contacted the DON or the MDS Coordinator. During an interview on [DATE], at 11:00 A.M., the Medical Director for the facility said the following: - She expected staff to send a resident to the ER for evaluation if a fall occurred and a concern or change in condition was noted. - Staff should not delay care of a resident just because they cannot reach a physician; this could cause further problems for a resident. Staff could obtain an order to send the resident to the ER at a later time. - Staff should not have waited to send Resident #8 to the ER for evaluation because they could not reach the physician. - Staff should not have waited two hours after first trying and failing to contact the OCP before they contacted another physician or FNP. During an interview on [DATE], at 11:15 A.M., the DON said the following: - She expected staff to notify the physician if a resident had a change of condition or increased pain. - Staff did not think the resident's pain was severe enough earlier in the shift to send the resident to the hospital. During an interview on [DATE], at 1:00 P.M., the resident said the following: - He/she remembered falling in his/her room but did not remember how or why he/she fell . - His/her hip hurt and he/she went to the hospital. - He/she did not have pain now.

Based on observation, interview and record review the facility failed to notify two residents' (Resident #1 and #2) physicians of a change in condition. Staff failed to identify a risk of constipation for Resident #1 due to long-term use of scheduled and as needed (PRN) pain medications, failed to respond to the resident's request to receive medical treatment, failed to identify the resident's increased use of pain medication, increased pain, ongoing symptoms of a urinary tract infection [MEDICAL CONDITION], decreased appetite and decreased ability to participate in activities of daily living (ADLs) which resulted in the resident being sent to the emergency room (ER), where he/she had 3,700 milliliters (ml) of urine drained from the bladder and the eventual [DIAGNOSES REDACTED]. The facility census was 48. 1. Review of the facility's Pain Management Policy, dated 2/15/10, showed: - The facility is committed to the management of pain for all residents; - Improve the well being of our resident's and to increase comfort and reduce depression and anxiety; - Optimize the resident's ability to perform activities of daily living and participate in activities; - Screen promptly and assess and diagnose pain; - Monitor for effectiveness of treatment and reassess as appropriate for all residents' pain; - Monitor for side effects related to pain management, including constipation. Review of the facility's undated Physician Notification Policy showed: - The facility will immediately notify the physician and consult with the physician, if appropriate, when changes occur; - If known, the facility will notify the resident's legal representative and/or the interested family member for a need to alter a resident's treatment significantly and of any significant change in the resident's physical, mental or psychosocial status, such as a determination in health, mental, or psychosocial status, in life threatening condition or clinical complications. Review of the facility's Bowel Movement (BM) Policy, dated 7/12/10, showed: - Nurse aides (NA) are responsible to document BM results in the care tracker system; - Charge nurse is responsible to enter the BM results in the BM book, which is used for a backup; - Cognitive residents need to be asked if they had a BM both by charge nurse and NA daily; - The nurse on 2:00 P.M., shift is responsible to check the care tracker report for (residents who have) no BM's or small BM's in the last nine shifts; - If the resident has not had a BM in the last nine shifts, then check for a PRN order to treat constipation and administer accordingly; - All interventions will be documented on the care tracker report; - If there are still no results after an intervention, the nurse is expected to do an assessment of the resident's abdomen; - Unless contraindicated, the nurse is expected to do a rectal exam and remove the hard stool, if indicated, manually; - The resident's physician is to be notified of the interventions and the resident's condition; - Residents must have at least a medium sized BM or two small BM's in order for them to not need an intervention. The facility did not provide, after requested, their policy for urine output without a urinary catheter or UTI's. 2. Review of Resident #1's nurses notes, dated 4/3/13, showed: - Arrived at the facility by van; - Alert and oriented to person, place and time; - Pleasant and cooperative; - Continent of bowel and bladder, urinates small amounts at a time; - Bowel sounds positive in all four abdominal quadrants; - No [MEDICAL CONDITION] present. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] 5/325 milligrams (mg) by mouth every six hours as needed for pain; - [MEDICATION NAME] 17 grams (gm) daily as needed for constipation; - [MEDICATION NAME] 25 micrograms (mcg) [MEDICATION NAME] topically every 72 hours for pain; - Tylenol 500 mg, two tabs as needed for pain every six hours. Review of the website www.[MEDICATION NAME].com, administered by the manufacturer of [MEDICATION NAME]es showed: - A strong pain medication which contains an opioid (a narcotic) used to treat moderate to severe around-the-clock pain in people who are already regularly using opioid pain medications. - Possible side effects listed constipation and abdominal pain. Review of the website www.dailymed.nlh.gov, administered by the National Institutes of Health and Human Services showed: - A [MEDICATION NAME] is an opioid used to treat moderate to moderately severe pain and should be used with caution in the elderly; - Adverse reactions to this medication included constipation and [MEDICAL CONDITION]. Review of the nurses' notes showed: - 4/4/13, On an antibiotic for a UTI; Up to the bathroom several times through the shift and denied complaints of pain during urination; Complained of urgency and frequency with urination; Staff continued antibiotic and monitoring related to UTI. - 4/5/13, Received an order for [REDACTED]. - 4/6/13 Resident up to the bathroom frequently and denied complaints of painful urination; urine clear yellow and without odor; continued antibiotic for UTI; Resident complained of constipation and staff received an order for [REDACTED]. - 4/7/13, Resident used the bathroom frequently and denied complaints of pain with urination but said he/she never felt empty; reported vomiting through the night and complained of nausea, refused breakfast or snacks; unable to void through the night and expressed urgency to urinate; fluids encouraged by staff, abdomen not distended or tender; resident complained of constipation and staff gave [MEDICATION NAME]. - 4/8/13, Resident complained of upset stomach, staff gave Tums (antacid used for indigestion); resident stated Tums helped a little but not much; resident complained of abdominal pain in right upper quadrant, belching, felt more bloated than normal and had not had a bowel movement in two days, right upper abdominal quadrant was tender to the touch; rated pain at an eight on a pain scale of zero through 10; physician called with condition report and new orders received for STAT (immediately) x-ray of the abdomen; resident's daughter notified of new orders and the resident's condition; [MEDICATION NAME] applied and Milk of Magnesia (MOM) for constipation given; received orders for [MEDICATION NAME] 17 gm at supper daily scheduled; two medium bowel movements and reported his/her pain was a lot better; right upper abdominal quadrant continued to be distended and tender; distention had decreased. Review of the Minimum Data Set (MDS) Admission Assessment, a federally mandated assessment instrument completed by facility staff, dated 4/9/13, showed: - Brief interview for mental status (BIMS) score of 15, which indicated the resident as cognitively intact; did not have behavior problems; - Limited staff assistance with transfers and use of the toilet; - Continent of bowel and bladder; did not have constipation; - [DIAGNOSES REDACTED]. - No as needed pain medication; scheduled pain medication; occasionally had pain, but did not limit day-to-day activity and did not interfere with sleep; rated pain a four on a scale of zero to 10. Review of the nurses' notes showed: - 4/9/13, X-ray report showed no masses, obstruction or calcification; stated he/she feels better; resident reported his/her abdomen as sore and he/she felt more pressure rather the sharp pain he/she felt earlier; received his/her last dose of antibiotic for a UTI. - 4/12/13 Orders received for [MEDICATION NAME] gel (medication for nausea) and repeat urinalysis and culture and sensitivity, if needed. - 4/13/13, Resident complained of a headache and rated pain at an eight on a pain scale of zero to ten and Tylenol 500 mg two tabs given; - 4/16/13, Lab results from urinalysis faxed to the physician and no new orders received. Review of the urinalysis dated 4/16/13, showed: - Urinalysis negative for infection; microscopy and culture not indicated. Review of the care plan dated 4/16/13, showed: - Weak and confused at times, needed assist with activities of daily living; - History of UTI's and does not always empty his/her bladder; - Notify the physician of signs and symptoms of a UTI and obtain a urinalysis (UA); - Signs and symptoms included back pain, fever and confusion; - [MEDICATION NAME] for pain, change every three days; - Rate pain on a scale of zero to 10. Review of the nurses' notes showed: - 4/18/13, Received a physician order [REDACTED]. - 4/23/13, Resident complained of back pain and rated pain at a seven on a pain scale of zero to ten; Tylenol 500 mg two tabs given and relief from the pain medication not noted; - 4/24/13, Resident complained of back pain and rated pain at an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given and relief noted; - 4/25/13, Resident complained of back pain and rated pain at an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given and relief noted; - 4/26/13, Resident complained of back pain and rated pain at an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given and relief noted. Review of the bowel and bladder report for 4/13, showed: - Resident had 25 medium to small BMs; - Four large BMs; - Staff did not document a consistency any of the bowel movements. - Incontinent of urine one day, all other days continent of urine. Review of the MAR, for 4/13, showed: - Staff administered [MEDICATION NAME] 17 gm for constipation 20 days during the month; - Staff documented the resident refused to take the [MEDICATION NAME] eight times during the month; - Staff documented they administered Tylenol four times during the month; - Staff did not document they administered any pain medication, other than the Tylenol; - Staff documented they administered [MEDICATION NAME] one time during the month; - Staff documented they applied [MEDICATION NAME] 25 mcg [MEDICATION NAME] every 72 hours. Review of the nurse's notes showed: - 5/3/13, Resident complained of back pain, rated pain at an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given and relief noted; - 5/5/13, Resident complained of arm pain and rated pain at a six on a pain scale of zero to ten; Tylenol 500 mg two tablets given and relief noted; - 5/6/13, Resident complained of pain all over and rated pain at an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given and relief noted; - 5/7/13, Resident complained of back pain and rated pain at a seven to an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given and relief noted; - 5/9/13, Resident with three plus [MEDICAL CONDITION] (swelling from a build-up of fluid which causes indention in the skin when touched) in lower extremities bilaterally; For your information note sent (FYI) to the physician and labs, [MEDICATION NAME] (medication given to reduce swelling) 40 mg daily by mouth and potassium (medication used with [MEDICATION NAME] to prevent low blood levels of potassium) 10 micro equivalents (meq) one tablet by mouth for four days ordered; did not indicate they notified the resident's interested family. - 5/11/13, 12:15 A.M., Resident complained of pain all over and rated pain at an eight on a pain scale of zero to 10; Tylenol 500 mg two tabs given, relief noted; - 5/12/12, Resident stated he/she felt nauseated while using the toilet; he/she threw head back and became unresponsive for minutes; when he/she became responsive, he/she complained of blurred vision and felt light headed; skin and face slightly pale, vital signs included blood pressure 122/68, pulse 79, respirations 24, temperature 97.4 and blood oxygen 98%; physician called, new lab orders received, staff to monitor resident's symptoms; send the resident to the emergency room if symptoms became worse; - 5/13/13, at 12:15 A.M., Resident complained of pain all over and rated pain at an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given to the resident; staff did not document they followed up with the resident to see if the pain medications were effective. - 5/13/13, at 4:55 P.M., resident found in room on floor with walker flipped over, resident reported he/she tripped and denied hitting head; family member notified of incident; staff did not document they notified the physician; - 5/13/13, at 5:30 P.M., nurse called to the resident's room by the certified nurses' aide (CNA); resident slumped over in wheelchair, unresponsive with blank look on face; [MEDICAL CONDITION] activity observed for five to six minutes; physician called with orders to send the resident to the ER. Review of the physician order [REDACTED]. - [MEDICATION NAME] 17 gm given daily prior to going to the hospital; - Order for [MEDICATION NAME] 17 gm daily discontinued; - New order for [MEDICATION NAME] 17 gm daily as needed for constipation. Review of the nurses' notes showed: - 5/16/13, Resident returned from the hospital to the facility; complained of torso pain and Tylenol 500 mg two tabs given to the resident; staff did not document where the resident's pain rated, but documented relief; - 5/19/13, Resident complained of constipation, [MEDICATION NAME] 17 gm given. - 5/27/13, Resident complained of back pain and rated at a seven on a pain scale of zero to 10; Tylenol 500 mg two tabs given to the resident; staff did not document if the medication relieved the resident's pain. Review of the FYI sent to the physician on 5/27/13, showed: - Resident had one plus [MEDICAL CONDITION] in bilateral ankles and lower legs; - Staff asked if the physician would consider putting the resident on a low dose of a diuretic to decrease the swelling episodes. Review of the nurses' notes, dated 5/28/13, showed: - 7:05 A.M., Resident complained of back pain, rated at a seven on a pain scale of zero to ten, Tylenol 500 mg two tablets by mouth given; - 10:25 A.M. Nurse followed up with pain relief and documented the resident continued to have pain, rated pain at a six on a pain scale of zero to 10; staff did not document any interventions, a description of the pain or any follow-up he/she did; received physician's orders [REDACTED]. Nurses notes did not show the physician was notified of the resident's increased/continued pain. Review of the bowel and bladder report for 5/13, showed: - Resident had 12 medium to small BMs; - Three large BMs - Staff did not document a consistency of the BMs. - Continent of urine the entire month. Review of the MAR for 5/13, showed: - Staff documented they administered [MEDICATION NAME] 17 times during the month. - Staff documented the resident refused the [MEDICATION NAME] two times; - On 5/16/13, staff changed the [MEDICATION NAME] order from 17 gm scheduled daily to daily as needed; - Did not administer any [MEDICATION NAME] 5/325 mg every six hours as needed for pain; - Staff documented they applied the [MEDICATION NAME] 25 mcg [MEDICATION NAME] every 72 hours; - Tylenol 500 mg, two tabs given eight times; - Staff did not administer any [MEDICATION NAME] 0.5 mg two times daily as needed for anxiety. Review of the nurses' notes showed: - 6/2/13, Resident requested to have compression stockings removed because they felt too tight and made him/her weak; stockings removed; - 6/4/13, Resident complained of bilateral lower leg pain and knee pain with one plus [MEDICAL CONDITION] noted in bilateral lower legs; [MEDICATION NAME] 5/325 mg (pain medication) one tablet given and [MEDICATION NAME] 0.5 mg one tablet by mouth for anxiety and anger outburst; staff did not document the number the resident rated his/her pain on a pain scale, a description of the resident's pain or if they followed up with the resident on his/her pain. Review of an FYI note sent to the physician on 6/5/13, showed staff reported the following: - Resident up frequently to the restroom, about every fifteen minutes; - Denied pain or discomfort with urination; - Requested the physician order [REDACTED]. - Informed the physician the resident did have an order for [REDACTED]. - The physician responded with an order for [REDACTED]. Facility FYI did not show the physician was notified of the resident's increased/continued pain. Review of the nurses' notes showed: - 6/5/13, Resident up to the bathroom about every fifteen minutes, denied pain or discomfort; FYI note sent to the physician, orders received for MOM 30 ml as needed for constipation, and [MEDICATION NAME] 5 mg by mouth two times daily. - 6/10/13, at 5:30 P.M., Resident requested pain medication and anxiety medication to help him/her sleep; administered [MEDICATION NAME] and [MEDICATION NAME] per as needed order; staff did not document a description of the pain, the location of or the intensity of the resident's pain; - 6/11/13, at 7:30 A.M., complained of leg pain, rated pain at six on a scale of zero to ten; Tylenol 500 mg, two tabs by mouth given and staff noted pain relieved; - 6/11/13, at 5:40 P.M., [MEDICATION NAME] given for increased anxiety, [MEDICATION NAME] per as needed order for generalized discomfort; staff did not document a description of the resident's pain or where the resident rated the pain on a pain scale; - 6/12/13, at 5:00 P.M., [MEDICATION NAME] given for increased anxiety, [MEDICATION NAME] per as needed order for generalized discomfort; staff did not document a description of the resident's pain or where the resident rated the pain on a pain scale; - 6/13/13, at 5:10 P.M., Resident complained of left arm pain, rated at nine on a pain scale of zero to 10; [MEDICATION NAME] 5/325 mg given; staff did note the pain as relieved; 7:45 P.M., resident complained of increased anxiety, [MEDICATION NAME] given and staff documented the resident experienced relief from the anxiety medication; - 6/14/13, at 5:25 P.M., Resident complained of generalized discomfort and anxiety; [MEDICATION NAME] and [MEDICATION NAME] given; staff did not document a description of or the intensity of the resident's pain; staff documented the resident experienced relief from the anxiety and pain; - 6/15/13, at 4:45 P.M., resident complained of leg pain and rated pain at an eight on a pain scale of zero to 10; [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 5/325 mg given with relief from pain noted; resident had not had a BM in three days, MOM 30 ml given. - 6/16/13, Resident requested MOM due to not having had a BM. Review of the bowel and bladder report for 6/13, showed: - Resident had 22 medium to small Bowel Movements; - Six large BM's - Staff did not document a consistency of the BM's. - Continent of urine the entire month. Review of the MAR for 6/13, showed: - Staff documented they administered [MEDICATION NAME] three times during the month; - Documented they administered MOM two times during the month; - They documented they gave [MEDICATION NAME] 5/325 nine times during the month; - Staff documented they applied the [MEDICATION NAME]es every 72 hours; - Documented they gave Tylenol one time during the month; - Staff documented they administered [MEDICATION NAME] 0.5 mg 10 times during the month. Review of the nurses' notes showed: - 7/6/13, Resident complained of back pain, rated at an eight on a pain scale of zero to 10; Tylenol given; staff did not document if the resident experienced pain relief. - 7/8/13, Resident complained of a stomach ache, [MEDICATION NAME] (medication used for upset stomach) given and noted relief. Review of the quarterly MDS, dated [DATE], showed: - BIMS score of 11, which indicated the resident as moderately cognitively impaired; - No behavior problems; - Resident highly involved in ADLs, staff provided guided maneuvering of limbs or other non-weight bearing assist with transfers and use of the toilet; - Frequently incontinent of bowel; occasionally incontinent of bladder; - Received scheduled and as needed pain medication; pain assessment interview showed the resident did not have pain in the last five days. Review of the nursing notes, dated 7/14/13, showed staff documented: - The resident called the nurse to his/her room to look at his/her legs; - One plus bilateral [MEDICAL CONDITION] around ankles noted; - Continued to use restroom frequently without relief, resident dribbled when urinating, will refax FYI to the physician. Review of the care plan, updated 7/15/13, showed: - History of UTI's; - Monitor the resident for signs and symptoms of back pain, foul smelling urine, fever and confusion; - Notify the physician with signs and symptoms of a UTI and obtain a urine culture (urine collected to test for a UTI); - Encourage to drink lots of fluids; - History of anxiety; - Talk to the resident and ask the resident about his/her feelings; - Chronic pain due to [MEDICAL CONDITION]; - [MEDICATION NAME] for pain; - Have resident rate pain on a scale of zero to 10; - Administer [MEDICATION NAME] as needed for pain and check for effectiveness; - Continent of bowel and bladder and independent with peri care; - No interventions to deal with the resident's constipation; - Assist of one staff member and a gait belt with transfers. Review of the summary of a care plan conference, attended by the director of nursing (DON), social service director (SSD), MDS coordinator and the resident's family member, dated 7/11/13, showed: - Discussed constipation, back pain and UTI with the resident's family member at the care conference; - Did not document plan or intervention for the resident's constipation. Review of the nursing notes showed: - 7/15/13, Received orders from physician for amitriptaline (anti-depressant) 25 mg one time daily, obtain urinalysis and culture and sensitivity, if indicated, compression stocking on in the A.M., and off in the P.M.; - 7/16/13, Urinalysis obtained, amber in color and sediment (matter that settles at the bottom of liquid) noted, sent to the lab; physician orders [REDACTED]. Review of the urinalysis report, dated 7/16/13, showed: - Abnormal results; - The physician wrote if not on any antibiotic [MEDICATION NAME] mg by mouth two times daily for 10 days. Review of the urine culture test, dated 7/18/13, showed: - Colony count over 100,000, (indicating an infection); - Antibiotic susceptibility not completed with the culture. Review of the nurses' notes showed: - 7/20/13, Resident continued to have frequency with urination; normal for this resident; - 7/21/13, Temperature 96, resident continued to have frequency with going to the bathroom, agitation noted; - 7/21/13, Frequency not improved, denied pain with urination; per resident, frequency normal because of a prolapsed uterus years ago; - 7/26/13, Resident continued with frequent trips to the bathroom, needed extra help with toileting; resident upset while on the toilet, heard crying from the hallway; asked the resident what was wrong? Resident said he/she would just like to get off the toilet and didn't know there was a certain amount of times he/she was allowed to use the toilet; resident had an incontinent episode and told staff if "If knew what I was doing I would change it." Review of the nurses' notes showed: - 7/30/13, Resident complained of bilateral back pain, rated pain at an eight on a pain scale of zero to 10; [MEDICATION NAME] given to the resident; staff did not document a description of the resident's pain; staff documented the resident experienced relief from the pain. Review of the meal intake report showed: - 7/31/13, Resident ate 100% of breakfast, 50% of lunch, 75% of dinner and consumed 170 ml of fluid. Review of the MAR for 7/13, showed staff did not administer MOM or [MEDICATION NAME] during the entire month. Staff documented they administered the resident's scheduled [MEDICATION NAME] 25 mcg the entire month; administered Tylenol 500 mg two tabs as needed every six hours, one time; administered [MEDICATION NAME] 5/325 mg as needed every six hours, two times. Review of the bowel and bladder report for 7/13, showed staff documented: - Resident had 30 medium to small BMs; - Three large BMs; - Staff did not document a consistency of the BMs. - Incontinent of urine two days, all other days continent of urine. During an interview on 8/29/13, at 4:15 P.M., CNA B said: - The resident always had problems going to the bathroom. - The resident had increased frequency with urine in 7/13. - The resident's bowel movements were soft but he/she was going. Review of the nurses' notes showed: - 8/1/13, at 5:30 P.M., resident complained of back pain rated at a nine on a pain scale of zero to ten; [MEDICATION NAME] 5/325 given, at 6:30 P.M., resident reported pain had decreased to a five on a pain scale of zero to ten; at 10:00 P.M., resident complained of back pain and rates pain at an eight on a pain scale of zero to 10; Tylenol 500 mg two tabs given at 10:00 P.M., and relief documented at 11:00 P.M.; - 8/2/13, at 4:40 A.M., resident complained of left hip socket pain and rated pain at an eight on a pain scale of zero to 10, [MEDICATION NAME] 5/325 given and results documented; staff did not document a description of the resident's pain. - 8/3/13, at 12:20 A.M., resident complained of low back pain and Tylenol given per order; staff did not document the description of the pain or where the resident rated in on the pain scale, but noted the resident had relief; at 11:30 A.M., resident complained of back pain and rated at an eight on a pain scale of zero to ten; Tylenol 500 mg two tablets given to the resident; staff did not document the description of the pain, but noted the resident had relief; at 5:55 P.M., resident complained of back pain and rated pain at an eight on a pain scale of zero to ten; [MEDICATION NAME] 5/325 mg given to the resident; staff did not document the description of the pain. Review of the meal intake report showed: - Prior to 8/3/13, staff documented the resident ate between 50% to 100% of every meal; - 8/3/13, Resident refused lunch and dinner and consumed 380 ml of fluid. Review of the nurses' notes for 8/4/13, showed: - At 12:00 A.M., resident complained of back pain and rated pain at a seven on a pain scale of zero to ten; [MEDICATION NAME] given and pain relief noted; staff did not document the description of the pain. - At 6:45 A.M., resident complained of sciatic pain and rated pain at an eight on a pain scale of zero to 10; [MEDICATION NAME] 5/325 given, staff did not document the description of the pain. - At 8:00 A.M., resident up to the bathroom, nurse just walked out of the room and the resident turned his/her light back on; reminded the resident he/she just went to the bathroom. Assisted the resident back to the bathroom and the resident did not void at all. - At 7:50 A.M., resident had increased anxiety and tearful, staff gave [MEDICATION NAME] 0.5 mg for anxiety. - At 8:30 A.M., resident up to the bathroom and rated his/her pain at a six. Very anxious, worried his/her pain would come back. -At 8:45 A.M., resident crying and anxious, expressed concerns because his/her pain was bad. Resident requested an x-ray and wanted an intramuscular (IM) shot. Nurse sat with the resident, provided reassurance, education to wait and see if the medications would work. Told the resident he/she had not given the medications enough time to work, encouraged the resident to stay in bed off feet to relieve back pain. - At 9:00 A.M., Tylenol 500 mg tabs given for back pain. Staff did not document where the resident rated his/her pain or a description of the pain. Anxious, encouraged to rest and be calm. - At 9:15 A.M., resident seemed more quiet and calm, respirations 18, pulse 68 and lying relaxed in bed. - At 9:20 A.M., resident jerked awake and said he/she had to go to the bathroom. Encouraged the resident to rest and the resident refused. Assisted the resident to the bathroom and the resident did nothing, assisted the resident back to bed. - At 10:15 A.M., resident awake and encouraged to stay in bed as long as he/she could. Resident got up to the bathroom and said he/she voided a few drops, staff did not hear any urine expressed. - At 10:55 A.M. resident back up to the bathroom and denied painful urination or burning; recent UTI; finished antibiotic last week; - At 5:40 P.M., resident came out for meal and left quickly related to back pain; [MEDICATION NAME] given and staff to monitor. Review of the meal intake report showed: - 8/4/13, Resident refused breakfast, ate 25% of lunch and 10% of dinner and consumed 600 ml of fluid; - 8/5/13, Resident ate 75% of breakfast, 10% of lunch and 50% of dinner and consumed 780 ml of fluid. Review of the nurses' notes dated 8/5/13, showed: - At 9:40 A.M., resident with three plus bilateral lower extremity [MEDICAL CONDITION], abdomen distended with bowel sounds in all four abdominal quadrants, lung sounds clear in upper lung lobes bilaterally, lower lobes with inspiratory (taking a breath in) crackles bilaterally. Resident needed increased assistance with ADLs. Resident up and down to the bathroom multiple times. FYI note sent to the physician; - At 5:30 P.M., resident complained of back pain and rated at an eight on a pain scale of zero to ten; [MEDICATION NAME] given to the resident; staff did not document a description of the resident's pain. - At 6:30 P.M., notified the family nurse practitioner (FNP) of the resident's condition who planned to look at the resident's chart the following day; - At 7:30 P.M., pain relieved, continued to need increased assistance with ADLs, three plus [MEDICAL CONDITION] in lower extremities. Review of the FYI faxed to the physician on 8/5/13, showed: - Resident had three plus [MEDICAL CONDITION] in bilateral lower extremities; - Abdomen distended with bowel sounds in all four quadrants; - Lung sounds clear in upper lobes with inspiratory crackles in both lower lobes; - Needed increased assistance with ADLs, due to [MEDICAL CONDITION]; - Resident had panic and anxiety episodes over the weekend; - Resident up and down to the bathroom multiple times; - Staff asked the physician if he/she had any new orders; - Staff did not include the resident's increased levels of pain in the note to the physician. Review of the meal intake report, dated 8/6/13, showed the resident refused to eat breakfast and lunch and consumed 240 ml of fluid. Review of the nurses' notes dated 8/6/13, showed: - FNP visited the facility to see the resident, bilateral lower extremity [MEDICAL CONDITION], abdominal distention worse than yesterday. Face flushed. Temperature 99.3, pulse 100, respirations 20, blood pressure 112/70, blood oxygen 95%; - Resident denied pain and bowel sounds hypoactive in all four abdominal quadrants; - Order received to send the resident to the emergency room ; - Resident's family notified and planned to meet the resident at the emergency room . Review of the bowel and bladder report for 8/1/13 through 8/6/13, showed: - The resident had six medium to small BM's; - Incontinent of urine two days, all other days continent of urine; - Staff did not document a consistency of these BM's. Review of the MAR for 8/13, showed staff did not administer MOM or [MEDICATION NAME] to the resident during the first six days of the month. Staff documented they applied the resident's scheduled [MEDICATION NAME] 25 mcg every 72 hours as ordered. During an interview on 8/28/13, at 1:36 P.M., CNA D said: - Resident #1 used the bathroom a lot prior to going to the hospital. - Staff took turns taking the resident to the bathroom because the resident went so much. - The resident would just get to the dining room and have to go back to his/her room to use the bathroom. - The resident barely sat his/her bottom on the toilet before he/she said "I can't go." - The resident went to the bathroom at least fifteen times on the day shift and he/she knew the resident did not empty his/her bladder. - He/she reported the issue to at least two different nurses in July when it went on for several days. - The resident complained of pain in abdomen at times but mainly complained of back pain; - Staff had to provide more assistance to the resident with activities of daily living; - The resident could hardly walk or do anything for him/herself. - The resident could do everything for him/herself since he/she returned from the hospital.

Based on observation, interviews and record review, the facility failed to assure staff notified the attending physician of the resident's change of condition, affecting one of nine sampled residents (Resident #2). The facility census was 38. 1. Review of the resident's nurses notes showed on 11/18-20/11, no complaints of pain. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/11, showed: - No cognitive impairment. - As needed pain medication. - Occasional moderate pain rated 6 on 1-10 pain scale. Review of the resident's nurses notes showed: - 11/23/11, at 6:50 A.M., License Practical Nurse (LPN) A documented the resident complained of left lower leg pain, able to wiggle toes and foot, skin warm and dry, unable to rate pain, furrowed brow, [MEDICATION NAME] (pain medication) 50 milligram (mg) given, will monitor. - 6:15 P.M. the resident complained of left lower leg pain rated 8 on 1-10 pain scale, [MEDICATION NAME] 50 mg given, will continue to monitor. - 8:30 P.M. LPN B documented the resident complained of left lower leg pain rated 10 on pain scale, unable to administer [MEDICATION NAME] due to time limit between [MEDICATION NAME] doses, gave [MEDICATION NAME] 200 mg two tablets, the resident stated he/she could not feel his/her foot, unable to wiggle toes, pedal pulse (pulse located in the foot) present but faint, will continue to monitor. - 9:30 P.M. the resident continues to complain of pain, unable to give pain medication due to [MEDICATION NAME] time limit. - 11/24/11, 3:00 A.M., LPN D documented the resident complained of left lower leg pain, rated 10 on pain scale, the resident's crying heard from the nurses station. - 4:00 A.M. [MEDICATION NAME] 400 mg, resident continues to complain of left lower leg pain, will continue to monitor. - 4:30 A.M. resident tearful an irritable, said he/she could not stand the pain, leg cold to touch and dark in color around the leg wound area, will continue to monitor. - 5:30 P.M. LPN C documented resident in bed crying, complained of left lower leg pain, 10 on pain scale, [MEDICATION NAME] 50 mg given, will continue to monitor. - 6:10 P.M. LPN C received physician order [REDACTED]. - 9:00 P.M. LPN E documented the resident complained of left lower leg pain, rated 10 on pain scale, [MEDICATION NAME] 50 mg given, will monitor. - 9:30 P.M. the resident's moaning heard from the hallway, resident continued to complain of left lower leg pain, rated 10 on pain scale, LPN E gave the resident [MEDICATION NAME] (narcotic pain medication)7.5/500 mg for pain, will monitor. - 11/25/11, 9:00 P.M., resident in bed crying, complained of left lower leg pain rated 10 on pain scale, [MEDICATION NAME] 50 mg given, will monitor. - 11/26/11, 3:30 P.M., LPN C documented resident complained of left lower leg pain rated 10 on pain scale, [MEDICATION NAME] 50 mg given, will monitor. - 4:45 P.M., resident reported no relief, will continue to monitor. - 11/27/11, 6:30 P.M., LPN E documented resident complained of left lower pain rated 10 on pain scale, [MEDICATION NAME] 50 mg given, will monitor. - 11/28/11, 11:00 A.M., LPN A documented resident complained of left lower leg pain, grimacing, left lower leg purple and red around the leg above the ankle, resident unable to wiggle toes or foot, notified the Family Nurse Practitioner and received orders to transfer the resident to the hospital for Doppler study for blood clot. Review of the hospital physician's history and physical showed the resident had an acute occlusion (clot) of the left common femoral artery, required surgical intervention. During an interview on 12/7/11, at 3:50 P.M., LPN B said: - The resident's pain did not seem severe and when he/she left the room (on 11/23) the resident became quiet. - He/she gave the resident pain medication and the resident said the pain medication helped with the pain but the resident asked for another pain pill and it was not time to give another pill. - The resident's foot was not warm but not cold, the left leg maybe was a little darker than the right leg. - He/she did not call the physician and did not think it might be a blood clot. During an interview on 12/7/11, at 4:00 P.M., LPN C said: - He/she gave the [MEDICATION NAME] pain medication. - Contacted the physician 11/24/11, informed him of the pain and received an order for [REDACTED]. - The resident said he/she could feel her touching the leg, the leg was cool not cold. - Did not think it might be a blood clot. During an interview on 12/8/11, at 6:55 A.M., LPN D said: - The resident complained of severe pain in the left foot (on 11/24). - Gave the resident [MEDICATION NAME] pain medication, he/she thought it helped with the pain. - The resident's leg was not warm, it was a normal temperature, no other signs except severe pain. - He/she did not contact the physician of the pain. - Did not think of possibility of blood clot. During an interview on 12/8/11, at 8:50 A.M., LPN A said: - He/she went into the resident's room (on 11/28) to do the treatment to the wound on the resident's leg, When he/she touched the leg the resident moaned or cried out with pain. - The resident's left leg was red/purple band above the ankle and the leg looked normal, the foot was cool. - He/she contacted the director of nurses (DON) and discussed getting a Doppler study thinking possible blood clot. - Contacted the Family Nurse Practitioner (FNP) associated with the resident's attending physician, received orders to transport to the hospital for doppler study. During an interview on 12/8/11, at 10:15 A.M., the FNP said: - He/she was in the facility 11/25/11, and was not informed of the resident having severe pain and no feeling of the foot. - The resident's physician and he/she would expect staff to notify the physician or him/herself of the severe pain and not feeling the foot. - Staff should have picked up on the possibility of blood clot. - Would expect the staff to get on top of the pain and identify the problem. During an interview on 12/8/11, at 10:45 A.M., the DON said: - Staff should notify the physician of a change in condition or pain. - Staff did contact the physician and obtained an order for [REDACTED]. - Staff should have informed the FNP the resident was having severe pain.