Every finding on record at Parkdale Manor Health & Rehabilitation

Based on observation, interview and record review the facility failed to protect two residents (Resident #31 and #12) right to be free from physical and verbal abuse, when Resident #11, pushed resident #31 against a wall and when Resident #11 ran at Resident #12 with raised fists and threatened to kill him/her. This affected two of three sampled residents (Resident #31 and #12). The facility census was 33. Review of the facility's policy titled Abuse Prevent Program, dated December 2016, showed:-Residents had the right to be free from verbal and physical abuse;-The facility will protect residents from abuse;-The facility will implement policies and procedures to prevent abuse or mistreatment of residents. I think it would be best to move Resident #11's information to the top since this person was involved in both incidents. 1.Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 04/17/26, showed:-Severe cognitive impairment;-Supervision with ADLs-Diagnoses included: dementia and depression. Review of the resident's care plan dated 06/23/26 showed:-Assist of one for ADLs;-Dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits;-Impaired thought process that sometimes caused the resident to display behaviors of frustration;-Monitor for specific triggers that cause the resident to display behaviors and report findings;-The care plan did not identify specific triggers for the resident's behaviors or interventions to mitigate them.Review of the resident's nurse's notes showed:-On 02/12/26, the resident wandered the hallways, cussing at staff, threatening to kill you all. The resident attempted several times to go into other resident's rooms, walked up to another resident that was in the main area and started to yell at him/her. Staff attempted to redirect the resident several times. Resident became very upset yelling at staff when he/she was in his/her room.-On 02/21/26, the resident wandered into several residents' rooms, yelling and cussing at them. The resident threatened to hit and or kill the other residents; -On 03/2/26, the resident was up and down the hallways. The resident was agitated with another resident, yelling and arguing;-On 04/17/26, the resident had been pacing hallways all day. This continued into next shift. The resident said he/she wanted the resident next door to wipe his ass and entered the other resident's room. The resident continued with foul language, bared teeth and attempted to strike out at staff.-On 06/09/26. the resident was moved to the Memory Care Unit. -On 06/10/26, the resident was highly agitated, slamming his/her door aggressively and staff had been unable to reorient resident.-On 06/19/26 the resident had been having increased behaviors, and cussing at staff, and other residents.-On 06/17/26, the resident was agitated called the staff vulgar names and cursing at them. The resident said he/she needed to go to the store to buy cat food. The resident went to his/her room. The resident then came back out of his/her room. Resident #31 was out of his/her room. Resident #11 followed Resident #31 down to Resident #31's room and shoved Resident #31 into the wall.-On 06/24/26, the resident was agitated off and on through the evening. The resident was cursing and yelling at staff. The resident had pushed and hit staff. The resident threw books off the shelf in the dining room area. During an interview on 06/25/26 at 2:01 P.M., Certified Nurses Aide (CNA) B said:-He/She worked on the night Resident #11 pushed resident #31;-Resident #11 often pushed staff;-Resident #11 often yelled at resident #31;-Resident #11 hit CNA B in the face;-Resident #31 stood in the hall when resident #11 walked back to his/her room;-Resident #11 walked toward resident #31; -Resident #11 pushed resident #31 into the wall;-CNA B was the only staff member on the memory care unit when resident #11 pushed resident #31;-Resident #31 told CNA B he/she was afraid of resident #11;-CNA B was not instructed to do 5 minute checks;-No extra staff came to help him/her with care on the memory care unit that night;-Every time resident #31 saw resident #11, resident #11 went back to his/her room;-Resident #11 told resident #12 he/she would kill resident #12;-Resident #12 was moved back to the front hall;-He/She had told the DON and the Administer about how resident #31 felt about being around resident #11.-He/She did not know why resident #31 could not be moved farther away from resident #11;-Resident #11's room was across the hall from resident #31;-The interventions were medication changes;-No updated directives or care interventions were provided to staff following the incident.During an interview on 06/25/26 at 2:12 P.M., Registered Nurse (RN) said:-He/She worked the night Resident #11 pushed #31 into the wall;-No new training was provided after the incident:-No new resident specific triggers were identified to prevent resident #11 from having another behavior;-No new interventions were put into place.2. Review of Resident #31's MDS, dated [DATE], showed:-Severe cognitive impairment;-The resident used a cane;-Supervision with Activities of ADLs;-Diagnoses included: Post Traumatic Stress Disorder (PTSD), a condition that develops after experiencing or witnessing a life-threatening event, dementia and anxiety.Review of the resident's care plan dated 05/20/26, showed:-The resident was dependent on staff for meeting emotional, intellectual, physical and social needs;-The resident had a diagnosis of PTSD;-Staff to monitor for triggers that may be related to trauma on going;-The resident had a diagnosis of anxiety;-Monitor mood patterns for signs and symptoms of depression and anxiety;-The care plan did not address specific triggers related to trauma or interventions.Review of the resident's nurse's notes showed:-06/17/26, the resident went out of his/her room for coffee and was confronted by resident #11;-Resident #11 shoved Resident #31 into the wall causing Resident #11 to drop his/her cane;-The resident showed no physical injuries.Review of the facility's investigation dated 06/17/26 showed:-Two staff on the unit reported resident #11 had been agitated;-Resident #11 had pushed resident #31;-Resident #31 stumbled and fell into the wall and dropped his/her cane;-Resident #11 was verbally threatening resident #31.Observation on 06/23/26 at 7:43 P.M., showed:-One staff member on the memory care unit;-Resident #31 sat at the table in the dining room drinking a cup of coffee;-Resident #11 sat in a recliner in the dining room a few feet from resident #31;-Resident #11 got up from the recliner and walked toward the dining room table that resident #31 sat at;-Resident #31 got up from the dining room table, and walked back to his/her room as soon as resident #11 walked toward the dining room table;-Staff got up to assist resident #11.During an interview on 06/24/26 at 02:49 P.M., the resident's responsible party said:-He/She was notified the resident had been pushed by another resident in the memory care unit;-He/She expected the facility to keep resident #31 safe.During an interview on 06/25/26 at 9:16 A.M., CNA A said: -Resident #11 had frequent episodes of aggression before he/she was moved back to the memory care unit;-Resident #11 pushed resident #31 into a wall one night and started to go after resident #12; -Resident #11 tried to grab CNA A around the throat;-The definition of abuse is to intentionally hurt someone else;-When Resident #31 was pushed by Resident #11 that was abuse.3.Review of Resident #12's Quarterly MDS dated [DATE], showed:-Severe cognitive impairment;-Supervision with ADLs;-Diagnoses included: Alzheimer's Disease, depression and asthma.Review of the resident's care plan dated, 06/17/26 showed:-The resident will have physical and emotional needs met without increased emotional distress;-The resident had a mood problem related to dementia;-Monitor and report increased agitation and/or if the resident feels threatened by others.Review of nurse's notes for the resident dated 06/19/26 showed:-Resident #11 stood at the nurse's desk;-Resident #12 walked toward the smoke area with staff;-Resident #11 saw resident #12 and charged at Resident #12 with raised fists;-Resident #11 had his/her fists raised and yelled at resident #12 he/she was going to kill that son of a bitch;-Staff removed resident #12 from the memory care unit and moved him/her off the memory care unit.-Resident #11 remained on the memory care unit.During an interview on 06/24/26 at 03:12 P.M., the resident's family said:-He/She was notified the resident had moved off the memory care unit;-He/She was informed that the resident had been yelled at by another resident on the memory care unit;-He/She expected the facility to keep the resident safe.During an interview on 06/25/26 at 2:01 P.M., the DON said:-Abuse is on purpose and intended;-Resident #11 initially pushed resident #31 into the wall;-Resident #11 had medication changes as soon has he/she pushed resident #31;-A mental health professional had not assessed the resident;-Resident #12 was moved off the memory care unit after resident #11 charged at him/her;-Resident #31 cannot be moved off the memory care unit;-Resident #31 and resident #11 rooms across the hall from each other;-No room changes had been made on the memory care unit;-No changes have been made to staffing in the memory care unit;-The facility was responsible for keeping all residents safe. During an interview on 06/25/26 at 2:12 P.M., the Administrator said:-Abuse was whatever the Center's for Medicare and Medicaid Services (CMS) said it was;-Abuse was done on purpose and intended;-All residents have the right to feel and be safe.Intake 3046672

Based on interview and record review the facility failed to ensure sufficient number of nursing staff (including aides) to respond to residents call lights timely. This affected three (Resident #1, #2, and #3) of four sampled residents. The facility census was 30.Review of the facility Staffing policy, dated October 2017, included staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. The facility will provide enough staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.Review of the facility policy titled Answering the Call Light, dated March 2021, included: - The purpose of the procedure is to ensure timely response to the resident's requests and needs; -If the resident needs assistance, indicate the approximate time it will take for you to respond; If the resident request is something you can fulfill, complete the task within five minutes if possible; -If uncertain as the whether or not a request can be fulfilled or if you cannot fulfill the residents request, ask the nurse supervisor for assistance. Review of the facility's 802 form showed 19 of 30 residents required assistance with care.Review of the facility's staffing schedule, dated 3/6/26, showed: - The facility had one nurse working from 6:00 P.M. to 6:00 A.M.; - The Director of Nursing (DON) worked in the roll of a nurse aide from 6:00 P.M. to 6:00 A.M.Review of the facility's staffing schedule, dated 3/7/26, showed: - The facility had one nurse working from 6:00 P.M. to 6:00 A.M.; - The DON worked in the role of a nurse aide from 6:00 P.M. to 6:00 A.M. Review of the facility's staffing schedule, dated 3/8/26, showed: - One nurse working from 6:00 P.M. to 6:00 A.M.; - The DON worked in the role of a nurse aide from 6:00 P.M. to 2:00 A.M.; - When the DON left at 2:00 A.M. a nurse aide took over for the rest of the shift. Review of the facility's staffing schedule, dated 3/16/26, showed: - One nurse working from 6:00 P.M. to 6:00 A.M.; - One nurse aide working from 6:00 P.M. to 6:00 A.M.1.Review of Resident #1's care plan, dated 12/4/25, showed: -The resident required assistance with physical mobility but was very active mentally, with intact cognition; -The resident was continent of bowel and bladder and required a sit to stand to transfer to the toilet; -The resident had limited physical mobility related to cerebral palsy. Review of the facilities call light log dated 3/1/26 through 3/17/26 showed: -On 3/7/26 at 8:44 P.M. the resident turned on his/her call light staff turned off the call light 47 minutes and 51 seconds later; -On 3/8/26 at 4:14 P.M. the resident turned on his/her call light staff turned off the residents call light 46 minutes and 38 later; -On 3/16/26 at 6:04 P.M. the resident turned on his/her call light staff turned off the residents call light 35 minutes and 21 seconds later; During an Interview on 3/17/26 at 12:50 P.M. Resident #1 said: -There is not enough staff to take care of me; - Recently when he/she pressed the call light he/she waited a long period of time for staff to responded and when they did not, he/she wet the bed. -This made him/her feel frustrated and embarrassed since he/she was continent of urine. -He/she is able to use the bathroom if staff can get him/her to the bathroom in time; 2.Review of Resident #2's care plan, dated 5/30/25, showed: - He/she is cognitively intact; -He/she has limited physical mobility due to weakness and chronic obstructive pulmonary disorder(COPD); -He/she is at risk for falls; -He/she requires assistance from staff with activities of daily living; Review of the facilities call light log dated 3/1/26 through 3/17/26 showed: -On 3/1/26 at 10:52 A.M. the resident turned on his/her call light and staff turned off the call light 42 minutes and six seconds later; -On 3/1/26 at 7:44 P.M. the resident turned on his/her call light staff turned off the call light 42 minutes and five seconds later; -On 3/6/26 at 6:45 P.M. the resident turned on his/her call light and staff turned off the call light 54 minutes and 57 seconds later; -On 3/7/26 at 7:11 P.M. the resident turned on his/her call light and staff turned off the call light 45 minutes and 27 seconds later; -On 3/15/26 at 6:34 P.M. the resident turned on his/her call light and it took staff 99 minutes and 59 seconds to answer the resident's call light. During an Interview on 03/17/2026 at 11:30 A.M. the resident said: -There was not enough staff to take care of him/her and other residents; -Sometimes it would take one and a half to two hours before call lights would be answered; -He/she was frustrated because staff do not come and assist him/her when using the call light to ask for staff assistance with ADLS. -He/She cannot count on staff to answer his/her call light.3.Review of Resident #3's care plan, dated 1/12/26, showed: -The resident had multiple falls with no injury due to unsteady gait; -The resident was incontinent of urine due to impaired mobility. -Cognition was intact.Review of the call light log dated 3/1/26 through 3/17/26 showed: -On 3/1/6 at 5:27 A.M. the resident turned on his/her call light and staff turned off the call light 55 minutes and 54 seconds later; -On 3/7/26 at 9:00 P.M. the resident turned on his/her call light and staff turned off the call light 32 minutes and 10 seconds later.During an interview on 03/17/2026 at 4:00 P.M. the resident said: -The staff are busy all the time and not available when he/she needs help; -He/she had wet his/her pants due to having to wait for the call light to be answered, this made her feel angry and embarrassed. During an Interview on 03/17/2026 at 1:00 P.M. Certified Nursing Assistant (CNA) A said: -Some days there is not enough staff working in the facility. -The past two weeks staffing has been consistently short with not enough staff to cover the halls and demands of the call lights. - Several staff members quit due to having a heavy workload; -All staff try to answer call light as quickly as possible, however breakfast and lunch times were the busiest times for call lights and staff are busy with meal service. During an interview on 03/17/2026 at 1:20 P.M. Registered Nurse (RN) A said: -The previous administrator had tried to get agency staff to come into the building to ease the workload but cooperate did not allow this to occur; -Call lights had been answered slowly due to not having enough staff and this causes delays in resident's care.During an interview on 03/17/2026 Nursing Assistant (NA) A said: -There is not enough staff to answer call lights timely; - He/she felt like he/she was unable to keep up with the needs of the residents due to their not being enough staff. During an interview on 03/17/2026 at 3:00 P.M. an anonymous staff member said: -He/she had attempted to advocate to bring agency staff into the facility to ease the workload since it was difficult to get all shifts covered, but was unsuccessful; - He/she feels that it was a disservice to the resident's to not have enough staff to care for all of the residents.During an Interview on 03/17/2026 at 4:10 P.M. the Director of Nursing (DON) said: -She had to work frequently as a charge nurse or a nurse aide instead of performing DON duties due to low staffing; -The goal was to answer call lights within five to 15 minutes, but the current staffing is not able to meet that expectation currently. During an interview on 03/17/2026 at 4:14 P.M. the Regional Nurse said the goal was for residents call lights to be answered within 15 minutes but depending on how busy the day was it may take staff longer to respond.Intake 2797627

Based on interview and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program committee met on a quarterly basis to work on performance improvement projects (PIP) and track the performance of the PIP. This deficient practice had the potential to not identify or improve the care and services for 28 residents.The facility census is 28. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan revised April 2014 revealed, Policy Statement This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Policy Interpretation and Implementation The objectives of the QAPI Plan are to: 1. provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 2. Provide structure and processes to correct identified quarterly and/or safety deficiencies; 3. Establish and implement plans to measure performance and set goals 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5. Establish practices to systematically analyze underlying causes of deficiencies 6. Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program. Committee Membership 1. The Administrator shall appoint both committee members as designated below and shall appoint individuals to fill any vacancies occurring on the committee. 2. The following individuals will serve on the committee: a. Administrator; b. Director of Nursing Services; c. Medical Director; d. Dietary Representative; e. Social Services Representative; f. Activities Representative; g. Environmental Services Representative; h. Rehabilitative Services Representative; i. Business office. During an entrance conference on 03/11/25 at 9:34 AM, the Administrator was asked for a list of the QAPI committee members. A list was provided that included the Administrator, Director of Nursing (DON), the Medical Director, business office Manager (BOM), Minimum Data Set (MDS) Coordinator, Social Services, Activities, housekeeping, maintenance, therapy, dietician, pharmacy, Regional Nurse and the Director of Operations. During an interview on 03/14/25 at 12:12 PM, the Administrator was asked about the QAPI Program, and an example of a Performance Improvement Projects (PIP)that was in progress. The Administrator stated QA was not currently working on a PIP due to not having the staffing in place to perform QAPI activity. The Administrator stated that staff had been meeting but there was no documentation or evidence that a QAPI program was in place. The Administrator was asked how the facility identified issues and worked on improvements. The Administrator stated there were several different meetings such as risk, infection control or clinical in which topics were discussed and reviewed but there just had not been the staff for QAPI. The Administrator was asked about the list of committee members that had been provided when asked for. The Administrator stated that list is who the facility wants to have on the committee. The Administrator was asked to verify if the committee had met to discuss QAPI. The Administrator stated there had been a meeting on January 31 in which it was discussed about getting QAPI started. During an interview on 03/14/25 at 1:14 PM, the Medical Director was asked if she had participated in QAPI meetings since becoming the Medical Director. The Medical Director stated, No.

Based on interview and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program to identify, maintain, and evaluate concerns for effective resident care. This deficient practice had the potential to not identify issues and/or capture the efforts made in measuring the care and services for 28 residents.The facility census is 28. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised April 2014 revealed, Policy Statement The facility shall develop, implement, and maintain an ongoing, facility- wide Quality Assurance and performance Improvement (QAPI) program to actively pursue quality of care and quality of life goals. During an interview on 03/14/25 at 12:12 PM, the Administrator was asked about the QAPI Program, and an example of a Performance Improvement Projects (PIP) that was in progress. The Administrator stated they were not currently working on a PIP due to not having the staffing in place to perform QAPI activity. The Administrator was asked how the facility identified issues and worked on improvements. The Administrator stated there were several different meetings such as risk, infection control or clinical in which topics were discussed and reviewed but there had not been the staff for QAPI.

Based on policy review, record review, observations, and interviews, the facility failed to label and date enteral feedings for two of two residents (Residents (R) 27 and R29) who required enteral feedings out of a total sample of 18 residents. This failure increased the risk of nurses not knowing if the correct formula and rate was being provided and what date the formula was hung. The facility census is 28. Review of the policy titled Enteral Feeding via Continuous Pump revised November 2018 revealed . On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . 1.Review of R27's Face Sheet located in the Profile tab in the electronic medical record (EMR) revealed R27 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure and moderate protein-calorie malnutrition. Review of R27's Physician orders located in the Order tab in the EMR dated 08/15/24, revealed .NPO [nothing by mouth] diet . Review of R27's Physician orders located in the Order tab dated 12/11/24, revealed enteral feed every day and night shift for enternal feed of Jevity (protein and calorie liquid food) 1.5 at 65 ml (milliliter)/hour. Enteral feeding is provided through a tube that is surgically inserted through the abdomen into the stomach. Review of R27's care plan located in the Care Plan tab in the EMR dated 01/13/25, revealed R27 required tube feeding of Jevity 1.5. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/25, revealed R27 had a Brief Interview for Mental Status (BIMS) score of 99 indicating R27 could not participate in the assessment. R27 was totally dependent on enteral feeding from the nurses. Observation in R27's room on 03/11/25 at 11:04 AM, revealed the enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. Observation and interview in R27's room on 03/11/25 at 3:04 PM, revealed the enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. Licensed Practical Nurse (LPN) 4 confirmed R27's enteral feeding bag was not labeled. LPN 4 stated the night nurse were the ones to hang the bag and usually wrote the name of the formula, date time it was hung, and initials of who hung it. 2.Review of R29's Face Sheet located in the Profile tab in the electronic medical record (EMR) revealed R29 admitted to the facility on [DATE], with diagnoses which included gastrostomy (tube surgically placed through the abdomen and into the stomach for fluids, nutrition, and medications) status and dysphagia. Review of R29's physician orders located in the Orders tab and dated 03/07/25, revealed an enteral feed order every shift Jevity 1.5 at 45 ml continuous. Review of R29's care plan located in the Care Pla tab in the EMR dated 02/12/25, revealed .The resident has dehydration or potential fluid deficit r/t [related to] being NPO and receiving all nutrition enterally through J-tube. [named R29] also has a G-tube for gastric draining . Review of R29's admission MDS with an ARD of dated 02/17/25, revealed R29 had a BIMS score of 99 indicating R29 could not participate in the assessment. R29 was totally dependent on enteral feeding from the nurses. Observation in R29's room on 03/11/25 at 11:22 AM, revealed R29's enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. Observation and interview in R27's room on 03/11/25 at 3:01 PM, revealed the enteral feeding bag had formula and was running. The bag was unlabeled without the type of formula, the rate to run, the time it was hung, and which nurse hung the formula. LPN 4 confirmed R27's enteral feeding bag was not labeled. LPN 4 confirmed the nurses were supposed to label the enteral feeding bags with the date, time, name of formula, and who hung it. During an interview on 03/14/25 at 1:55 PM, the Director of Nursing stated the night nurses were responsible for hanging the enteral feeding for R27 and R29 and labeling the bags.

Based on record review, interview, and policy review, the facility failed to inform the Ombudsman of hospital transfers for two of four residents (Resident (R)8 and R27) reviewed for hospitalization out of a total sample of 18. The failure had the potential to cause the Ombudsman to not be aware of any trends or patterns of hospitalization of residents at the facility. The facility census was 28. 1.Review of the Census tab in the electronic medical record (EMR) revealed R8 was admitted on [DATE]. Review of the Discharge Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 located under the MDS tab in the EMR revealed R8 was discharged from the facility with an anticipated return from the hospital. Review of a nurse progress note dated 02/25/25 at 2:27 PM located under the Prog Note (Progress Notes) tab of the EMR revealed the nurse went to assess R8 and found him to be showing signs and symptoms of respiratory distress. The physician was in the facility at the time, assessed R8, and advised R8 be sent to the hospital. Review of the Parkdale Manor Health and Rehabilitation [NAME] HealthCare Group transfer form dated 02/25/25 and the Bed Hold Notice dated 02/25/25 provided by the Director of Nursing (DON) revealed all required information for the hospital transfer. An Ombudsman notice was asked for and not received. 2.Review of the Census tab in the EMR revealed R16 was admitted on [DATE]. Review of the Discharge Return Anticipated MDS with an ARD of 01/03/25 located under the MDS tab of the EMR revealed R16 was discharged from the facility with an anticipated return from the hospital. Review of a nurse progress note dated 01/03/25 at 6:35 PM located under the Prog Note tab of the EMR revealed R16 was assessed to have profuse bleeding from her vaginal area. Due to her history of a bladder tumor, the physician opted to have R16 sent to the hospital for treatment. The facility census is 28. Review of the Parkdale Manor Health and Rehabilitation [NAME] HealthCare Group transfer form dated 01/03/25 and the Bed Hold Notice dated 01/03/25 provided by the DON revealed all required information for the hospital transfer. An Ombudsman notice was asked for and not received. Review of the facility policy Transfer or Discharge Notice revised March 2021 revealed, a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. In an interview on 03/12/25 at 2:40 PM, the Administrator stated the Social Services (SS) staff did not realize the Ombudsman was to be notified when a resident was sent out. The Administrator stated the SS had a tracking system for monitoring hospital transfers but had not been sending the log monthly to the Ombudsman. In an interview on 03/14/25 at 10:15 AM, the SSD stated she was unaware the Ombudsman was to receive notice of resident transfers to the hospital. She stated she kept track of all transfers but had not sent a copy of the transfer list to the Ombudsman.

Based on interview, record review, and policy review, the facility failed to ensure residents were provided the Skilled Nursing Facility Advance Beneficiary Notice, form CMS-10055, or the Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for Medicare Part A Services when they were no longer covered or coverage was ending for two of three residents reviewed (Resident (R) 24, and R32) out of a total sample of 18 residents. This deficient practice had the potential for residents not to be provided the information about what services may not be covered by Medicare for residents to make an informed decision about receiving therapies.The facility census is 28. Review of the facility policy titled, Medicare Advance Beneficiary Notices dated April 2021 revealed, Policy Statement: Residents are informed in advance when changes will occur to their bills. Policy Interpretation and Implementation 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). a. The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers but may not pay for because the care is considered not medically reasonable and necessary, or custodial. b. The resident (or representative) may choose to continue receiving the skilled services that may not be covered and assume financial responsibility. 2. If the resident's Medicare Part A benefits are terminating for coverage reasons, the director of admissions or benefits coordinator issues the Notice of Medicare Non-Coverage (CMS form 10123) to the resident at least two calendar days before Medicare covered services end (for coverage reasons). a. The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review of service determination. b. The Notice of Medicare Non-Coverage is not indicated when the resident's Medicare covered days are exhausted; nor is it used to notify the resident of potential liability for payment. 1. Review of an undated document titled, SNF Beneficiary Notification Review for R24 indicated, .Medicare Part A Skilled Services Episode State date was: 10/06/24. The last covered day of Part A Services was 12/18/24. The form indicated, The facility-provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of the document indicated, Was an SNF/ABN, Form (CMS-10055) provided to the resident? It was marked, No. If no, explain why the form was not provided: The box Other was marked and the explanation was written Oversight. Review of R24's electronic medical record (EMR) revealed no documentation that communication took place between R24 and/or the representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services. 2. Review of an undated document titled, SNF Beneficiary Notification Review for R32 indicated, .Medicare Part A Skilled Services Episode State date was: 01/21/25. The last covered day of Part A Services was 01/27/25. The form indicated, Voluntary, i.e., self-initiated in consultation with physician, family, or AMA. Further review of the document indicated, Was an NOMNC, Form (CMS-10123) provided to the resident? It was marked, No. If no, explain why the form was not provided: The box Other was marked and the explanation was written Oversight. Review of R32's EMR revealed no documentation that communication took place between R32 and/or the representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services. During an interview on 03/14/25 at 9:24 AM, the Administrator stated the SNF ABN should have been provided for R24, and it was an oversight. The NOMNC was provided for R32, but it could not be located. During an interview on 03/14/25 at 10:14 AM, Social Services (SS) was asked about the forms not being provided to the residents. The SS stated she was not aware that the form had to be provided for R24. The SS was asked about the forms for R32 and the SS stated, They were completed, I can't locate them.

Based on record review and interview, the facility failed to initiate a new PASARR (Pre-Admission Screening and Resident Review) Level One for one of four residents (Resident (R) 21) reviewed for PASARR to reflect new psychiatric diagnoses out of a total sample of 18 residents. The failure to maintain a PASARR Level One that reflected the new diagnoses of R21 had the potential to delay or limit necessary assistance should R21 experience a psychiatric episode that disrupted her daily life. The facility census is 28. Review of the Census tab in the electronic medical record (EMR) revealed R21 was originally admitted on [DATE]. Review of the Level One Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition signed by the hospitalist on 11/30/21 prior to R21's admission to the facility and provided by the Administrator revealed the screening form contained the demographics fields to be complete, but the medical/psychiatric questions were unanswered, and the fields were blank. The pre-admission screening did not indicate whether the result was positive or negative for the need of a PASRR Level Two. Review of the Med Diag [Medical Diagnoses] tab of the EMR revealed R21 was diagnosed with major depressive disorder on 10/20/22 and bipolar two disorder on 02/07/23. Review of the Orders tab in the EMR revealed divalproex (anticonvulsant used for manic phase of depressive disorder) 125mg capsule twice a day related to major depressive disorder initiated on 10/18/22 and Cymbalta (antidepressant) 60mg capsules once daily related to major depressive disorder initiated on 12/11/22. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/23 under the MDS tab in the EMR revealed R21 had depression (other than bipolar) and bipolar disorder indicated as current diagnoses. Review of the Misc (Miscellaneous) tab in the EMR revealed several psychiatric notes related to R21's diagnoses and behaviors. In an interview on 03/14/25 at 9:20 AM, the Social Services (SSD) staff verified that there was no updated PASRR Level One to reflect R21's current diagnoses of major depressive disorder or bipolar II disorder. She confirmed a new screening should have been completed with each new diagnosis. A PASRR policy was requested for from the Administrator and SSD staff; no policy was provided.

Based on interview, record review, and policy review, the facility failed to ensure showers were provided per resident preference for one of 18 sampled residents (Resident (R)18). This deficient practice had the potential for residents dependent on staff to not maintain personal hygiene and not maintain participation in activities of daily living. The facility census is 28. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting revised March 2018, revealed, Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation l. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care) . Review of R18's Admission Record located in the electronic medical record (EMR) under the Profile tab indicated R18 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke) due to embolism of right middle cerebral artery, hemiplegia and hemiparesis of left non-dominant side, and major depression. Review of R18's EMR revealed a quarterly Minimum Data Set (MDS) assessment located under the MDS tab with an Assessment Reference Date (ARD) of 12/13/24 revealed a Basic Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. ADLs were assessed as maximal assistance of two staff. Review of the R18's EMR revealed a revised care plan dated 07/20/23, located under the Care Plan tab that indicated R18 had limited physical mobility and preferred showers. Review of the Daily Shower Schedule updated 02/14/25 located at the nurse's station revealed R18 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. During an interview on 03/11/25 at 1:33 PM, R18 stated he wanted showers three times a week and he had not showered in the last six days. When asked why he had not showered, he stated he did not know. Review of R18's showers sheet provided by the facility revealed in February 2025 no showers were provided on 02/11/25, 02/13/25 and 02/15 25. Review of March 2025 revealed no showers were provided on 03/06/25 and 03/08/25. The facility census is 28 During an interview on 03/12/25 at 2:03 PM, Certified Nursing Aide (CNA) 2 was asked about R18's showers. CNA 2 stated there was a list of when residents received their showers and R18 received them on Tuesday, Thursdays, and Saturdays. CNA 2 was asked how showers were assigned to staff. CNA2 stated usually someone will volunteer to give the showers and the rest of the staff will provide cares and answer lights so there is no set assignment. During an interview on 03/13/25 at 10:06 AM, Registered Nurse (RN)1 was asked about the showers. RN1 stated that a CNA is assigned to the showers and if a resident refuses then the CNA comes and tells the nurse and then the nurse is to talk with the resident and if the shower is still refused chart it. RN 1 was asked if there was documentation that R18 refused. RN 1 stated no. RN1 was asked how she follows up with staff to ensure showers are provided. RN 1 did not answer. During an interview on 03/14/25 at 9:27 AM, the Director of Nursing (DON) was asked about R18 not receiving showers. The DON stated R18 had told her that he had not received a shower in 6 days. The DON stated, I gave him a shower.

Based on the policy review, record review, and interview, the facility failed to follow the recommendations to obtain weekly weights for one of two residents (Resident (R) 27) reviewed for nutrition out of a total sample of 18 resident which caused inadequate tracking of weight loss or gain. The facility census is 28. Review of the facility's policy titled Weighing and Measuring revised March 2011 revealed .The purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and provide a baseline height in order to determine the ideal weight of the resident . Review of the Face Sheet located in the Profile tab in the electronic medical record (EMR) revealed R27 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date dated 02/27/25 revealed R27 had a Brief Interview for Mental Status (BIMS) score of 99 indicating R27 could not participate in the assessment. R27 was totally dependent on enteral feeding (tube feeding) from the nurses. Review of R27's Physician orders located in the Orders tab dated 08/15/24 revealed .NPO [nothing by mouth] diet . Review of the Request for Diet Changes dated 11/06/24 revealed .1. Monitor weekly wts [weights] . Review of R27's Physician orders located in the Orders tab dated 01/07/25 revealed .Monitor Weekly Weights . Review of the Request for Diet Changes dated 01/08/25 revealed .1. Obtain January wt. 2. Monitor weekly weights . Most recent weight in PCC [EMR] 8/24 . Review of the Request for Diet Changes dated 02/10/25 revealed .1. Obtain February weight . Review of the R27's weights found located in the vitals tab dated 08/16/24 150 lbs. (pounds), 01/15/25 162 lbs., 02/11/25 163.6 lbs., 02/20/25 160. 2 lbs., 03/10/25 162.4 lbs. which indicated a weight gain. Review R27's care plan found in the care plan tab in the EMR dated 02/10/25 revealed R27 was care planned to be NPO except mouth care. Interventions were to weigh R27 monthly and as ordered by the provider and to note any significant changes in R27's weight and to notify the provider. During a telephone interview on 03/13/25 at 12:38 PM, the Registered Dietician (RD) stated the nursing department oversaw making sure the weights were being completed. The RD made a request for the nursing department to monitor weekly weights indefinitely. The RD made this recommendation March 6, 2025, January 8, 2025, December 4, 2024, and November 6, 2024. The RD stated that she writes her recommendations and gives them the Director of Nursing (DON), Dietary Manager, and Administrator and expected the recommendations to be implemented within two weeks. The RD used the admission weight to make sure R27 was getting the correct calories and protein. When there was no weight in the EMR the RD asked the nursing department to obtain weights. The RD stated R27 weights should be obtained weekly. During an interview on 03/13/25 at 12:59 PM, the DON stated the Restorative Aide was responsible for obtaining all the residents' weights. The nurses were responsible for making sure weights were obtained as ordered. The DON stated the lift which was used to weigh R27 was broken, and she was just made aware of it. The DON did not know how long the lift had been broken. During an interview on 03/13/25 at 1:11 PM, the Restorative Aide stated she was responsible for obtaining weights for all residents The Restorative Aide stated she was not told R27 was supposed to be on weekly weights. During an interview on 03/13/25 at 1:23 PM, the Registered Nurse (RN)1 stated whoever was the charge nurse made sure the residents' weights were completed and added to the EMR. During a telephone interview on 03/14/25 at 1:06 PM, the Medical Director stated she did not remember whether she saw the recommendations or not but would have done whatever the Registered Dietician recommended. The RD usually left a form, and the Medical Director would sign off on it. Further interview revealed the Medical Director was not aware the lift used to weigh R27 was not working. The Medical Director stated, If I sign an order, I expect them (nursing staff) to follow the order to weigh the patient. During an interview on 03/14/25 at 1:45 PM, the Administrator stated she did not know there was an issue with the facility getting consistent weights for R27. The Administrator noticed in her report the RD had made recommendations regarding R27 weights. The Administrator's expectations were that if the RD made recommendations, it should be sent to the primary care physicians. The Administrator was made aware of the lift was not working.

Based on record review, interview, and policy review, the facility failed to provide a PASARR (Pre-Admission Screening and Resident Review) Level One for one of four residents (Resident (R)21) reviewed for PASARR to reflect a positive or negative screen result out of 18 sample residents. The failure to maintain a PASARR Level One that reflected either a positive or negative screen result had the potential to limit or delay the assistance needed for R21 should R21 experience a psychiatric episode. The facility census is 28. Review of the Census tab in the electronic medical record (EMR) revealed R21 was originally admitted on [DATE]. Review of the Med Diag (Medical Diagnoses) tab of the EMR revealed that R21 was diagnosed with morbid obesity and dysphagia. There was no reference to a psychiatric diagnosis. Review of the Level One Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition signed by the hospitalist on 11/30/21 prior to R21's admission to the facility on [DATE] and provided by the Administrator revealed the screening form contained the demographics fields to be complete, but the medical/psychiatric questions were unanswered, and the fields were blank. The pre-admission screening did not indicate whether the result was positive or negative for the need for a PASRR Level Two. In an interview on 03/14/25 at 9:20 AM the Social Services (SSD) staff, verified the provided PASRR form from 11/30/21 did not show any psychiatric questions answered nor did the form state if the PASRR screen produced a positive or negative result. The SSD staff stated the point tally indicated on the first page is used for purposes of determining if the person can be admitted to a nursing facility. The SSD staff confirmed the PASRR Level One in R21's chart was incomplete. Review of the facility policy Admission Criteria revised March 2019 provided by the Administrator revealed, all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) Process.

Based on observation, interview, record review, and policy review, the facility failed to ensure the oxygen (O2) concentrators had dust free filters on the inlet where the air came into the machine for one of two residents (Resident (R) 25) reviewed for oxygen usage out of a total sample of 18 residents. This deficient practice had the potential for increased chance of infection and unnecessary respiratory treatment. The facility census is 28. Review of the facility's policy titled, Departmental (Respiratory Therapy)- Prevention of Infection revised November 2011, revealed, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure Infection control considerations Related to oxygen Administration. 9.Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 1. Review of R25's undated Face Sheet located in R25's electronic medical record (EMR) under the Profile tab, indicated diagnoses to include solitary pulmonary nodule, chronic respiratory failure with hypercapnia (increased carbon dioxide), and asthma. Review of Physician Orders, dated 01/07/25 and located in R25's EMR under the Orders tab, indicated Oxygen 3LPM [liters per minute] via nasal cannula continuously. During an observation on 03/11/25 at 10:16 AM, R25's oxygen concentrator located in R25's room and was observed to have a black oxygen filter on both sides of the concentrator. Both filters were observed to be full of a buildup of a large amount of white lint and heavy debris and were observed to be very dirty. During an observation on 03/12/25 AM, R25's oxygen concentrator filters were observed to be full of a large buildup of white lint and heavy debris and were observed to be very dirty During observation and interview on 03/13/25 at 9:45 AM, Registered Nurse (RN)1 was shown the filters. RN1 stated no the filters should not look like this. The RN added it should be everyone's responsibility to look at them, but ultimately the nurse was responsible. During an observation and interview on 03/13/25 at 10:25 AM, the Director of Nursing (DON) was shown the filters. The DON stated, They are not clean. The DON was asked who should be cleaning them. The DON stated the night nurse on Sunday nights should be cleaning them weekly.

Based on observation, interviews and record reviews, the facility failed to assure staff followed acceptable standards of practice for one (1) of the five (5) sampled residents, (Resident #1), when staff failed to follow provider orders, remove a resident's surgical staples in a timely manner, and charted that the surgical staples had been removed per provider orders and were not actually removed. The facility census was 24. The facility did not provide policies and procedures relating to physician orders and weekly skin assessments. Review of the facility's policy for Wound Care, revised October, 2010, showed: - The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; - Verify that there is a physician's order for this procedure; - Review the resident's care plan to assess for any special needs of the resident; - The following information should be recorded in the resident's medical record: - (1.) The type of wound care given. - (2.) The date and time the wound care was given. - (4.) The name and title of the individual performing the wound care. - (6.) All assessment data obtained when inspecting the wound. - Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #1's medical record showed: - The resident was admitted to the facility on [DATE] following surgery to correct broken bones in both legs; - The resident's surgical incisions on both legs had been closed using surgical staples; - Provider orders for staple removal read: Start Date: 10/22/2024 Remove staples one time only for staple removal for one day; - The resident's treatment record shows staple removal charted as completed on 10/22/2024; - A mobile x-ray of the resident's legs was ordered by the provider on 10/24/2024. The facility failed to include any indication the x-ray was completed or resulted in the resident's medical record; - Weekly skin assessments were charted in the resident's treatment record as complete on 10/27/2024, 11/03/2024, and 11/10/2024; - Neither of the two users who documented performing a complete skin assessment on the resident recognized, reported, or intervened to ensure the resident's healing was not delayed by staples still in the resident's skin; - The resident was scheduled for a follow-up appointment on 11/06/2024 which was missed and had to be rescheduled for 11/11/2024; - The resident's surgical staples were removed on 11/13/2024, five weeks after surgery; - The resident was alert and oriented and capable of making decisions and verbalizing needs with a Brief Interview for Mental Status (BIMS)score of 15, indicating the resident was cognitively intact. During an interview on 12/04/2024 at 10:15 A.M., Resident #1 said: - He/She was incredibly upset about how long it took the facility to remove his/her surgical staples and he/she was so fed up with the situation. During an interview on 12/04/2024 at 2:23 P.M., the facility administrator said: - Resident #1's original follow-up appointment had been scheduled by the hospital prior to the resident's admission to the facility. The follow-up appointment had been titled virtual and did not contain any provider contact information, which led facility staff to believe this was not an in-person appointment and this is the reason the first appointment was missed; - He/She had attempted to call the hospital that had made the appointment for clarification but did not receive a call back for two (2) days and by the time the return call was received, the resident had already missed the appointment; - The x-ray the provider ordered on 10/24/24 was a mobile x-ray and the result summary was sent directly to the resident's orthopedic (bone doctor) provider. The provider required the resulting x-ray to be sent to him on a disc which the mobile x-ray company was unable to accomplish so a second x-ray was ordered out of the facility. The results of this x-ray were sent directly to the orthopedic provider and were never seen by facility nursing staff. - Facility administration was not aware that the resident's surgical staples had not been removed until 11/10/2024. When administration became aware of the staples still being in place, it was discovered the facility did not have any staple removal kits. The kits were ordered but the resident's family presented to the facility with kits they had purchased themselves. The facility nursing staff used these kits to remove the resident's staples on 11/13/24. - Usually, the facility social services director would schedule and confirm follow-up appointments are scheduled for residents, but that at the time he/she was serving as both the facility administrator and the social services director due to staffing complications. - Nursing staff is expected to chart tasks as completed only after they are finished. MO245146

Based on interview, observation, and record review, the facility failed to ensure that seven of 12 sampled residents (Residents #1, #20, #12, #2, #16 #19, #23), who required staff assistance, were provided with adequate assistance for activities of daily living (ADL's: tasks completed to care for oneself daily such as bathing, dressing, moving from a chair to bed, and personal hygiene), as well as failed to provide proper incontinence care for Residents #16, #23, The facility census was 22. Review of the facility ADL policy dated March 2018, showed: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks) and communication (speech, language, and any functional communication systems). 1. Review of Resident # 1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 7/24/23 showed: - Brief interview of mental status (BIMS) score of 13, which indicates intact cognition; - Requires supervision with setup help only for bed mobility and transfer; - Independent with no setup help for locomotion on and off unit, toilet use, and personal hygiene; - Limited assistance with one person physical assist for dressing; - Independent with setup help only for eating; - One person physical assist in reference to physical help for bathing; - Occasionally incontinent of urine; - Diagnoses of bipolar disorder, and non-Alzheimer's dementia. Review of the resident's care plan, revised 6/27/23 showed: - Resident requires assistance with ADL's, mobility, medication administration, and meal prep; - Bathing preference of showers, two times a week; - Resident has limited physical mobility; - Resident has bladder incontinence related to Dementia. During an interview on 8/1/23 at 2:22 P.M., Resident #1 said: - He/she has not been receiving showers two times a week; - His/her showers have been missed multiple times, and missed showers occur monthly; - He/she is upset and does not like to feel unclean; - That showers were missed due to staff being busy. Review of undated facility shower schedule showed: - Resident #1 was scheduled to receive showers on Mondays and Fridays. Review of facility bathing task follow up report dated 4/1/23 to 7/31/23 (35 scheduled shower dates) showed: - Resident received showers on 4/14/23 (Friday), 4/29/23 (Saturday), 5/12/23 (Friday), 5/15/23 (Monday), 6/2/23 (Friday), 6/5/23 (Monday), and 6/23/23 (Friday); - The day of 6/20/23 showed Not applicable; - The dates of 4/27/23 (Thursday) and 5/24/23 (Wednesday) showed no shower received. 2. Review of Resident # 20's quarterly Minimum Data Set (MDS), dated [DATE] showed: - BIMS score of 15, which indicates intact cognition; - Independent requiring setup help only for bed mobility and eating; - Independent with no setup help for transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene; - One person physical assist in reference to physical help with bathing; - Occasionally incontinent of urine; -Diagnoses of a stroke, and hypertension. Review of the resident's care plan, revised 7/20/23 showed: - The resident is unable to return to the community and requires assistance with ADL's, mobility, medication administration, and meal prep; - Bathing preference of showers, two times a week; - Resident has limited physical mobility. During an interview on 8/1/23 at 12:45 P.M., Resident #20 said: - He/she does not get showers when he/she is supposed to; - He/she did not receive one of his/her showers as scheduled the week prior; - He/she feels dirty and upset about his/her showers being missed. Review of undated facility shower schedule showed: - Resident #20 was scheduled to receive showers on Tuesdays and Fridays. Review of facility bathing task follow up report dated 4/1/23 to 7/31/23 (35 scheduled shower dates) showed: - Resident received showers on 4/18/23 (Tuesday), 4/21/23 (Friday), 6/6/23 (Tuesday), 6/20/23 (Tuesday), 6/27/23 (Tuesday), 7/4/23 (Tuesday), 7/8/23 (Saturday), 7/11/23 (Tuesday); - The date of 5/24/23 (Wednesday) showed no shower received. 3. Review of Resident # 12's quarterly Minimum Data Set (MDS), dated [DATE] showed: - BIMS score of 15, which indicates intact cognition; - Independent with no setup help for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene; - Independent requiring setup help only for eating; - One person physical assist in reference to physical help for bathing; - Diagnoses of type 1 diabetes mellitus, (a metabolic disease, involving inappropriately elevated blood glucose levels),with diabetic neuropathy, (A type of nerve damage that can occur with diabetes), hypertension, dementia, and depression. Review of the resident's care plan, revised 7/20/23 showed: - The Resident is unable to return to the community and requires assistance with ADL's, mobility, medication administration, and meal prep; - Bathing preference of showers; - Resident is at risk for limited physical mobility; - Resident may have occasional balder incontinence and may need assistance with toileting and bathing. During an interview on 8/1/23 at 10:46 A.M., Resident #12 said: - He/she did not receive one of his/her showers the week prior; - His/her showers have been skipped a few times in the past; - He/she is frustrated over less employees to help. Review of undated facility shower schedule showed: - Resident #20 was scheduled to receive showers on Tuesdays and Fridays. Review of facility bathing task follow up report dated 4/1/23 to 7/31/23 (35 scheduled shower dates) showed: - Resident received showers on 4/7/23 (Friday), 4/14/23 (Friday), 4/28/23 (Friday), 5/15/23 (Monday), 5/29/23 (Monday), 6/5/23 (Monday), 6/12/23 (Monday), 6/17/23 (Saturday), 6/23/23 (Friday), 7/7/23 (Friday); - The day of 6/20/23 showed Not applicable; - The date of 5/24/23(Wednesday) showed no shower received. During an interview on 8/4/23 at 7:23 A.M. LPN C said: - He/she does not give showers; - Certified Nursing Assistants (CNA's) are responsible for providing showers to residents. During an interview on 8/4/23 at 7:49 A.M., CNA A said: - He/she has heard complaints from resident's not receiving their showers; - He/she feel's bad, but staff can get busy assisting residents, so showers get missed. During an interview on 8/4/23 at 12:23 P.M., the DON said: - He/she would expect residents to receive two showers a week or documentation showing they had refused. 46706 Review of the facility's Perineal Care policy, revised, February 2018, showed: -Wash and dry hands; -Female residents: wash the perineal area from front to back, separate all skin folds, using a new wipe/clean wash cloth for each cleaning; -Male residents: wash the perineal area from the urethral opening working outward, using a new wipe/clean cloth for each cleaning. Review of the facilty's Hand washing/Hand Hygiene Policy, revised, August 2019, showed: -Hand hygiene is the primary means of prevention of the spread of infections; -Wash hands when they become visibly soiled; -Gloves should be worn when anticipating contact with body fluids; -Wash hands with soap and warm water for 15 seconds; -Rinse and dry hands; -Use clean paper towel to turn off faucet. The facility did not provide a policy on shaving. 4. Review of Resident #2's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Required assistance of one staff for bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Uses a wheel chair for mobility; -Independent with eating; -Diagnoses included, orthostatic hypotension (low blood pressure upon standing), dementia and anxiety. Review of the resident's undated care plan showed: -ADL self care deficit related to dementia; -Dependent on staff of two for bed mobility; -Requires assistance of two staff with dressing; -Requires assistance of two staff for personal hygiene. Observation and interview on 8/01/23, at 10:12 A.M., showed: -The resident setting in his/her room in a recliner; -The resident had facial hair on his/her chin and under his/her lip; -The resident said he/she does not get regular showers; -The resident said he/she said would like to be shaved at least two or three times a week; -The resident said he/she said he/she needs help with shaving; -The resident said he/she said it makes him/her fell embarrassed to have facial hair; -The resident said he/she used to get showers on Tuesdays and Thursdays and now just once a week, if at all. During observation and interview on 08/02/23, at 8:07 A.M. showed: -The resident in his/her room setting in a recliner; -The resident still had facial hair on his/her chin and under his/her lip; -The resident said he/she still did not get a shower. During observation and interview on 08/04/23 at 8:15 A.M., showed: -The resident laying in bed talking to the staff; -The resident still had facial hair on his/her chin and under his/her lip. Review of Resident #2's bathing documentation in point click care (PCC, cloud-based electronic health records used by the facility), dated 4/10/2023 through 7/21/23 showed the resident had showers on the following days: - 6/2/23; -7/11/23; -7/20/23; -No other bathing documentation was found; -No documentation that the resident's facial hair had been shaved. 5. Review of Resident #19's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Uses a wheel chair for mobility; -Independent with eating; -The resident is on oxygen therapy; -Diagnoses included, high blood pressure, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 7/20/23, showed: -The resident has limited physical mobility due to weakness and COPD; -The staff will accommodate the resident's shower preference; -Independent with dressing and personal hygiene. Observation and interview on 8/01/23, at 10:36 A.M., showed: -The resident laying in bed in in his/her room; -The resident's hair was oily with debris in it; -The resident's glasses had dirt and debris on them; -The resident said he/she does not get regular showers; -The resident said he/she said would like to have at least two showers a week; -The resident said he/she said he/she needs help getting the water to the right temperature; -He/she needs help from the staff to washer his/her hair and his/her back; -The resident said he/she said it makes him/her feel unclean not having two showers a week. During observation and interview on 08/02/23, at 7:14 P.M., showed: -The resident in his/her room setting in a wheelchair; -The resident's hair was still oily with debris in it; -The resident's glasses still had dirt and debris on them; -The resident said he/she still did not get a shower. Review of Resident 19's bathing documentation in PCC, dated 4/5/2023 through 7/26/23 showed the resident had showers on the following days: - 4/12/23; -6/30/23; -7/26/23; -No other bathing documentation was found; -No documentation that the resident's hair had been washed. During an interview on 08/02/23 at 8:10 P.M., NA A said: -The residents should receive a shower on the days and times they choose; -The residents should be shaved when they choose; -The staff should clean the residents' glasses before they put them on; -Residents should have a shower at least once a week; -Sometimes showers do not get done because we don't have enough help. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -Residents should have a shower as often as they choose, at least once or twice a week; -The residents should be shaved when they choose; -The staff ensure residents' glasses are clean; -Sometimes he/she is busy and does not have time to get the showers done. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Residents should receive a shower on the days and times they choose; -Residents should be shaved whenever they choose; -Staff should clean and make sure resident are wearing glasses and/or hearing aides; -Residents should have a shower at least once a week; -If a resident refuses a shower it is documented and the staff try at another time. 6. Review of Resident #23's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Extensive assistance of two staff with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Receiving Hospice services; -Diagnoses included, dementia, high blood pressure, kidney disease and diabetes ( too much sugar in the blood). Review of the resident's care plan, revised 1/25/23, showed: -ADL self care deficit related to dementia; -Total dependence of staff with dressing, personal hygiene, and transfers. During an observation on 08/02/23, at 07:34 P.M., showed: -CNA B and NA A entered the residents room; -CNA B and NA applied gloves; -CNA B and NA A are both wiping feces off the bottom of the resident; -CNA B and NA A position the resident on his/her back; -CNA B wiped feces off of his/her gloves and cleaned the front of the resident; -NA A did not change gloves and cleaned the front of the resident; -CNA B and NA A did not wash their hands before putting on gloves to start perineal care; -CNA B did not change gloves and wash hands before wiped the front of the resident; -NA A did not change gloves, wash hands and apply clean gloves before cleaning the front of the resident; -CNA B did not separate and clean all areas of the front skin folds where urine had touched. During an interview on 08/02/23 at 8:10 P.M., NA A said: -He/she should have washed his/her hands before applying gloves before starting perineal care; -He/she should have took off his/her dirty gloves after cleaning feces's off the resident, washed his/her hands and applied clean gloves; -He/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -He/she should have washed his/her hands before applying gloves before starting perineal care; -He/she should have took off his/her soiled gloves after cleaning feces off the residnet, washed his/her hands and applied clean gloves; -He/she should not wipe soiled gloves off with a wipe; -He/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Hand washing should be preformed and clean gloves applied to start perineal care; -He/she should not wipe soiled gloves off with a wipe; -Gloves should be changed after being soiled -He/she should not wipe soiled gloves off with a wipe; -He/she should have separated and cleaned all areas of the skin where urine had touched. 7. During an observation on 08/03/23, at 08:35 A.M., showed: -CNA A and CMT A entered the resident's room with the mechanical lift; -CNA A and CMT A washed their hands and applied gloves; -CNA A and CMT A removed the resident's wet incontinent brief; -CMT A used a wiped and wiped down the left groin and CNA A gave CMT A a clean wipe; -CMT A wiped down the right groin and wiped the front skin folds; -CMT A did not separate and clean all areas of the front skin folds where urine had touched. During an interview on 08/02/23 at 8:55 A.M., CMT A said he/she should have separated and cleaned all areas of the skin where urine had touched. During an interview on 08/02/23 at 8:56 A.M., CNA A said all skin folds and areas of the skin that have touched urine should be separated and cleaned. During an interview on 8/3/23 at 9:46 A.M., Licensed Practical Nurse (LPN) A said: -Hand washing should be performed and clean gloves applied to start perineal care; -He/she should not wipe soiled gloves off with a wipe; -Gloves should be changed after being soiled -He/she should have separated and cleaned all areas of the skin where urine had touched. 31102 8. Review of Resident #16's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers and toilet use; - Dependent on the assistance of one staff for dressing and personal hygiene; - Required extensive assistance of one staff for bathing; - Upper extremity impaired on one side; - Lower extremities impaired on both sides; - Occasionally incontinent of urine; - Always incontinent of bowel; - Diagnoses included stroke, chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 7/2023 showed: - The resident had occasional bladder incontinence related to impaired mobility; resident is incontinent of bowel; - Check frequently and as required for incontinence. Wash, rinse and dry peri area. Observation and interview on 8/1/23 at 2:34 P.M., showed: - CNA B and Nurse Aide (NA) A entered the resident's room and the resident said he/she accidentally dumped the urinal in his/her lap and he/she was sitting in urine; - CNA B and NA A used the mechanical lift and transferred the resident from his/her electric wheelchair to the bed; - CNA B and NA A removed the lift pad, the resident's wet incontinent brief and wet pants and covered the resident with a blanket; - The resident repeated again that he/she had dumped the urinal in his/her lap and was sitting in urine; - CNA B and NA A said they didn't hear him/her say anything about sitting in urine and both uncovered the resident; - CNA B used a wiped and wiped down the skin folds, folded the same wipe and wiped down one side of the groin; - NA A used the same area of the wipe and wiped down the skin folds then up the other side of the groin; - CNA B and NA A did not separate and clean all areas of the front skin folds where urine had touched; - NA A and CNA B turned the resident on his/her side; - NA A used the same area of the wipe and cleaned different areas of the buttocks; - NA A and CNA B turned the resident onto his/her back and covered the resident. During an interview on 8/4/23 at 11:30 A.M., NA A said: - He/she should not use the same area of the wipe to clean different areas of the skin; - He/she should have separated and cleaned all areas of the skin where urine had touched; - He/she should not have folded the wipe. During an interview on 8/4/23 at 12:03 P.M., CNA B said: - He/she should have separated and cleaned all areas of the skin where urine had touched; - He/she should not fold the wipe, it should be one wipe per swipe; - He/she should not use the same area of the wipe to clean different areas of the skin. 9. Review of Resident #16's bathing documentation in point click care (PCC, cloud-based electronic health records used by the facility), dated April, 2023 showed: - 4/25/23- the resident had a shower. Review of the resident's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers and toilet use; - Dependent on the assistance of one staff for dressing and personal hygiene; - Required extensive assistance of one staff for bathing; - Upper extremity impaired on one side; - Lower extremities impaired on both sides; - Occasionally incontinent of urine; - Always incontinent of bowel; - Diagnoses included stroke, COPD and hemiparesis The facility did not provide any shower sheets or documentation for May, 2023. Review of the resident's bathing documentation in PCC dated June, 2023 showed: - 6/4/23- the resident had a shower; - 6/25/23- the resident had a shower. Review of the resident's bathing documentation in PCC dated July, 2023 showed: - 7/11/23- the resident had a shower; - 7/13/23- the resident had a shower; - 7/20/23- the resident had a shower. Review of the Resident's care plan, revised 7/20/23 showed;- Personalized care- the resident preferred showers. Observation and interview on 8/1/23 at 10:28 A.M., showed; - The resident sat in bed with an excess amount of dry flaky skin on the resident's face, shoulders and the front of his/her shirt;- The resident said he/she has only had about four showers in a month; - He/she would prefer to have at least two showers a week; - It made him/her feel frustrated and he/she asked who would want to feel like a giant ball of disgustedness? During an interview on 8/4/23 at 8:49 A.M., CNA A said: - The residents do not always get two showers a week; - The showers do not always get done because there's not enough staff. During an interview on 8/4/23 at 11:30 A.M., Nurse Aide (NA) A said: - The showers do not always get completed because he/she may be the only aide on the floor. During an interview on 8/4/23 at 12:23 P.M., the DON said: - She would expect the residents to get two showers a week or documentation which showed the resident had refused; - The staff should document the showers in the computer or on a shower sheet.

During an interview and record review, the facility failed to maintain a Department of Health and Senior Services (DHSS) approved surety bond that was equal or greater than one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive months from July 2022 through June 2023. This has the potential to affect all residents who had money in the trust account. The facility census was 22. Review of the facility policy, Surety Bond, dated March 2021, showed: -Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility; -A surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of resident's funds that the facility holds, accounts for, safeguards, and manages; -This facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents; -All funds entrusted to the facility for a resident are covered by the surety bond; -The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents' funds; -Inquiries concerning the financial security of personal funds managed by the facility should be referred to the administrator. Review of the facility's current bond, dated 7/1/23, was $20,000. Review of DHSS bond records showed the facility's current bond was $20,000. Review of the bond worksheet, completed on 8/2/23, showed: -An average monthly balance of $15,264.27 (determined by using the total of each ending balance for the last 12 months bank statements and divided by 12 months); -A required bond amount of at least $22,500. During an interview on 08/02/23 at 2:12 P.M., the Business Office Manager (BOM) said: -He/She did not know who monitored the bond; -He/She did not know the bond amount was not sufficient; -He/She had been the BOM since September 2021. During an interview on 08/02/23 at 2:22 P.M., the Administrator said: -He/She did not know who made sure the bond amount was sufficient; -He/She expected the BOM would monitor and notify if the bond needed increased; -He/She did not monitor the bond amount and was not aware that the bond was insufficient. The administrator later provided additional information of a surety bond that was effective July 1, 2023 in the amount of $30,000; however, it had not received DHSS approval.

Based on observations, interviews and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not offer evening (HS) snacks to all residents. This affected eight of 12 sampled residents, (#1,#2, #4, #9, #12 and #16) and other residents who attended the resident group interview. The facility census was 22. Review of the facility's policy for serving snacks between meal and bedtime, revised September 2010, showed, in part: - The purpose of this procedure is to provide the resident with adequate nutrition; - Review the resident's care plan and provide for any special needs of the resident; - The person performing this procedure should record the following information in the resident's medical record: the date and time the snack was served; the amount of snack eaten by the resident; if the resident refused the snack, the reasons why and the intervention taken. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/23 showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Required set up with eating; - Upper and lower extremity impaired on both sides; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), dementia and anxiety. Review of the resident's care plan, revised 7/20/23 showed: - Personalized care: having snacks between meals was very important. During an interview on 8/1/23 at 12:37 P.M., the resident said: - The staff do not come to his/her room every night and offer him/her a snack at bedtime; - He/she would take a snack at bedtime if it was offered. 2. Review of Resident #16's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Required set up with eating; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Diagnoses included stroke, COPD, and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 7/20/23 showed: - Personalized care: having snacks available between meals was very important. During an interview on 8/1/23 at 10:11 A.M. the resident said: - The staff do not come to his/her room each night and offer him/her a bedtime snack; - He/she would take a snack if it was offered. 3. Review of the resident council meeting notes showed: - May 2023; New business or concerns: better snack options on snack cart and passed out more often; - June 2023: New business or concerns: snacks are still not always being passed; - July 2023: New business or concerns: snacks are still not always being passed. 4. During the resident group interview on 8/2/23 at 10:04 A.M., the residents said: - The staff do not come to their room every night and offer them a snack at bedtime; - Four of the five residents said they would take a snack if it was offered to them. During an interview on 8/2/23 at 7:01 P.M., Licensed Practical Nurse (LPN) A said: - They have a little basket with snacks in them; - The staff pass the snacks out at the beginning of the 2:00 P.M. -10:00 P.M. shift but do not pass them out at bedtime unless a resident would ask for something. During an interview on 8/4/23 at 8:49 A.M., Certified Nurse Aide (CNA) A said: - He/she tried to pass the snacks at bedtime if they were not super busy, which seemed to be all the time now; - The snacks do not always get passed at bedtime; - If he/she had time to pass them, he/she did not go room to room and ask each resident, it's mainly if a resident asked for something to eat; - The new company has asked the staff to document meals and snacks. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: - She would expect the staff to go to each residents room and offer them a snack after dinner and document in point of care. 46706 5. Review of Resident #2's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Required assistance of one staff with ADL's; -Occasionally incontinent of bladder; -Diagnoses included, high blood pressure, dementia and anxiety disorder. Review of the resident's care plan dated, 7/20/23, showed: -The resident has an ADL self care performance due to dementia; -Having snacks available in between meals is very important to the resident. During an interview on 8/1/23, at 4:29 P.M., the resident said: -He/she likes to have a snack at bedtime; -The staff does not pass snacks before bedtime. During a observation and interview on 8/2/23, at 7:03 P.M., showed: -No staff was passing snacks; -No snacks observed in his/her room; -The resident said he/she had not been offered a snack; -The resident said he/she would take one if it was offered. 6. Review of Resident #4's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Independent with ADL's; -Occasionally incontinent of bladder; -Diagnoses included, hypothyroidism (the thyroid gland does not produce enough thyroid hormone), arthritis and anemia (the blood does not have enough healthy red blood cells) and dementia. Review of the resident's care plan dated, 7/20/23, showed: -The resident has an ADL self care performance due to dementia; -Having snacks available in between meals is very important to the resident. During an interview on 8/1/23, at 9:15 A.M., the resident said: -He/she likes to have a snack at bedtime; -The staff do not pass snacks before bedtime; -If he/she wants a snack he/she has to ask for it; -The staff don't have time to pass the snacks. An observation on 8/2/23, at 7:51 P.M., showed: -No staff was passing snacks; -The resident rang his/her call light; -The resident asked Nurses Aide (NA) to bring him/her a snack; -NA A brought a basket to the resident's room and the resident chose a snack from the basket; -The resident closed his/her door. During an interview on 08/02/23 at 8:10 P.M., NA A said: -He/she works the 2:00 P.M. to 10:00 P.M. shift and he/she passes snacks when she gets here at 2:00 P.M.; -2:00 P.M. is the only time he/she passes snacks during the whole shift; -He/she said there is a place to chart snacks but sometimes he/she does not get the snacks charted because he/she is busy. During an interview on 08/02/23 at 8:17 P.M., CNA B said: -He/she passes snacks if he/she has time; -There was no designated person to make sure snacks got passed; -If the resident wants a snack they can ask the staff. 48727 7. Review of Resident # 1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff., dated 7/24/23 showed: - Brief interview of mental status (BIMS) score of 13, which indicates intact cognition; - Requires supervision with setup help only for bed mobility and transfer; - Independent with no setup help for locomotion on and off unit, toilet use, and personal hygiene; - Limited assistance with one person physical assist for dressing; - Independent with setup help only for eating; - One person physical assist in reference to physical help for bathing; - Occasionally incontinent of urine; - Diagnoses of bipolar disorder, hypertension, non-Alzheimer's dementia, Review of the resident's care plan, revised 6/27/23 showed: - Resident requires assistance with ADL'S, mobility, medication administration, and meal prep; - Having snacks available between meals is very important to the resident; - Resident has unplanned/unexpected weight loss related to diuretic use. Review of resident's physician order sheet, dated 7/20/22 showed: - An order for a regular diet; - An order for a high calorie snack twice a day. During an interview on 8/1/23 at 2:15 P.M., the resident said: - Staff does not offer him/her snacks at night; - Staff rarely offer snacks to him/her; - He/she would like to be offered snacks. During an interview with on 8/3/23 at 8:21 A.M., the resident said: - No snacks were provided to him/her in the evening of 8/2/23. 8. Review of Resident # 12's quarterly MDS., dated 5/31/23 showed: - BIMS score of 15, which indicates intact cognition; - Independent with no setup help for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene; - Independent requiring setup help only for eating; - One person physical assist in reference to physical help for bathing; - Diagnoses of type 1 diabetes, dementia, and depression. Review of the resident's care plan, revised 7/20/23 showed: - The resident is unable to return to the community and requires assistance with ADL'S, mobility, medication administration, and meal prep; - Having snacks available between meals is very important to the resident; - The resident is at risk for limited physical mobility; - An intervention of offering between meal and bedtime snacks for fluctuating blood sugars related to diabetes. Review of resident's physician order sheet, dated 10/29/22 showed: - An order for a regular diet; - An order for a protein snack at hour of sleep. During an interview on 8/2/23 at 7:43 P.M., Resident #12 said: - He/she had not received a snack; - He/she was not feeling well and would like a snack; - Staff commonly do not pass evening snacks. During an interview on 8/3/23 at 10:05 A.M. the Dietary Manager said: - Kitchen staff do not hand out evening snacks; - Snacks are supplied to nursing to hand out to residents; - Evening cook places stocked snack basket on shelf outside of kitchen in the evening for nursing; - Snacks consist of cookies, apple sauce, yogurt, puddings, chips, and peanut butter and jelly sandwiches, if requested; - Daytime snacks are provided if requested; - Does not know exact time evening snacks are passed. During an interview on 8/4/23 at 12:23 P.M., the Director of Nursing (DON) said: -She would expect the staff to go to each residents room and offer them a snack after dinner and document in point of care.

Based on record review and interview, the facility failed to ensure they utilized the correct Skilled Nursing Facility Advance Beneficiary Notice of non- coverage (SNFABN) form (a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility), for two of three residents sampled for beneficiary notifications (Residents #5 and #12). The facility census was 22. Review of the facility policy, Medicare Advance Beneficiary Notice, dated April 2021, did not address the utilization of the correct 2020 dated ABN form. Review of Resident #5's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 2/28/23. The resident signed the form on 2/16/23. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #12's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 2/28/23. The residents' representative signed the form on 2/21/23. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. During an interview on 08/02/23 at 11:30 A.M., the Administrator said: -Staff should use the correct 2020 form; -He/She was not aware the ABN form was wrong. During an interview on 08/02/23 at 1:22 P.M., the Social Services Director said: -He/She completed the ABN forms with residents; -He/She was not aware of an updated form dated 2020; -He/She had been given the 2018 form.

Based on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to: properly clean resident room floors, properly strip and re-wax to maintain tiles around the base of resident toilets. Additionally, the facility failed to repair damaged base boards in resident room [ROOM NUMBER], fix a dragging door to restroom in room [ROOM NUMBER], and repair a damaged circular metal floor plate in the 500 hall; As well as failure to maintain the entrance to the facility by not removing spider webs, and a bird's nest from above main entry doors. This effected the quality of life for all residents in the facility. The facility census was 22. Review of the facility policy on floor cleaning and maintenance dated December of 2009, showed: - Floors shall be maintained in a clean, safe, and sanitary manner; - All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures; - Floor cleaning procedures are maintained by the environmental services director; - No information on polishing or stripping waxed tile flooring. Review of the facility policy on cleaning and disinfecting residents' rooms dated August 2013, showed: - The purpose of the procedure is to provide guidelines for cleaning and disinfecting residents' rooms; - Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled; - No information on polishing or stripping waxed tile flooring. Observations on 8/1/23 at 8:19 A.M., showed: - Area above main entry doors blanketed with cobwebs and spider webs; - Area above main entry doors had bird nests on top of exposed fire suppression water line. Observations on 8/1/23 at 2:45 P.M., showed: - Floor tile around base of toilet in room [ROOM NUMBER] stained with a dark rust color and damaged; - Baseboard near sink in room [ROOM NUMBER] is torn off the wall, exposing damaged drywall and exposed glue; - Tile near corners of entry door into room [ROOM NUMBER] is dirty with dark, grimy, and unpolished coating. Observation on 8/2/23 at 7:15 P.M. showed: - Circular floor steel drain plate near the end the 500 hall was loosely secured to floor with duct tape. Observations on 8/3/23 at 8:00 A.M., showed: - Floor tile near corners of entry door into room [ROOM NUMBER] is dirty with dark, grimy, and unpolished coating; - Floor tile in room [ROOM NUMBER] has small scratches where the restroom door drags and scrapes the floor. During an interview on 8/3/23 at 8:09 A.M., Housekeeper A said: - Resident rooms and bathrooms are cleaned daily; - The buildup is because the tile has not been stripped and re-waxed; - Maintenance is in charge of stripping and re-waxing tile flooring; - Tile around toilets should not be stained; - Spider and cobwebs should be clean up when found; - Damaged or torn off baseboards should be fixed by maintenance after receiving a request. During an interview on 8/3/23 at 8:40 A.M., the Housekeeping Supervisor said: - Staff is aware of the grimy buildup around the toilets and doors; - Buildup is caused by wax not being properly stripped in the past; - Maintenance is responsible for stripping and re-waxing the tile flooring; - The discoloration and buildup around toilets and doors is not acceptable or homelike. During an interview on 8/4/23 at 11:37 A.M., the Maintenance Manager said: - The polish on the tile is getting old around some doors and areas of flooring; - Maintenance is responsible for stripping and re-polishing the floors; - Work orders should have been put in for damaged baseboards if he is not already notified of the damages; - He has not had the machine to properly strip the floor wax until one week prior to survey; - Residents deserve a homelike environment; - Torn running boards and dirty flooring is not homelike.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive plan of care which included measurable objectives and timeframe's for two sampled resident, (Resident #24 and Resident #9). Staff failed to implement a comprehensive person-centered plan of care that addressed hearing issues for Resident #9 and develop a plan of care to address Resident #24's diagnosis of a Post Traumatic Stress Disorder (PTSD, a disorder that develops in some people who have experienced a shocking, scary or dangerous event). The facility census was 22. 31102 Review of the facility's Comprehensive, Person-Centered Care Plan Policy, revised December 2016, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The comprehensive, person-centered care plan will include: o Measurable time tables o Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being; o Include the resident's stated goals upon admission and desired outcomes; o Identify problem areas; o Reflect the resident's expressed wishes regarding care; o Aid in preventing or reducing a decline in the resident's functional status; o Assessments of residents are ongoing and revised as needed. 1. Review of Resident 24's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with bed mobility, transfers, dressing and personal hygiene; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), stroke, dementia, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), and post traumatic stress disorder (PTSD, a disorder that develops in some people who have experienced a shocking, scary or dangerous event). Review of the resident's care plan, revised 7/20/23 showed it did not address the resident's diagnosis of PTSD. 2. Review of Resident #9's quarterly MDS dated [DATE] showed: - Cognitive skills intact; - Had minimal difficulty with hearing; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Upper and lower extremity impaired on both sides; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), dementia and anxiety. Review of the resident's care plan, revised 7/20/23 showed it did not address the resident's hearing issues. During a telephone interview on 8/3/23 at 3:41 P.M., the MDS/Care Plan Coordinator said the care plans should be resident centered and should address any issues a resident was having with their hearing. During an interview on 8/4/23 at 12:23 P.M., the DON said the residents care plans should address PTSD and the resident's hearing issues.

Based on record review and interview, the facility failed to complete a discharge summary for two residents out of the two sampled closed resident records (Resident #15 and Resident #28). The facility census was 22. The facility did not provide a policy addressing discharge summaries. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/28/23 showed: - No cognitive impairment; - Assistance of one staff for Activities of Daily Living (ADL's); - Diagnosis included, high blood pressure and depression; - Resident planned to return to the community. Review of the resident's care plan, dated 4/21/23 showed: -The resident is a full code; -The resident would like to return home following his/her rehabilitation stay. Review of the nurses' notes dated 5/5/23 at 9:16 A.M. showed the resident left the facilty with a friend. Review the of resident's medical record did not show a discharge summary. During an interview on 8/3/23 at 5:40 P.M., the Director of Nursing (DON) said: -The resident did not have a discharge summary. There was a discharge nurses' note but no summary. Staff should complete a discharge summary after residents are discharged . 31102 2. Review of Resident #28's admission MDS, dated [DATE] showed; - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility and transfers; -Required extensive assistance of one staff for dressing and toilet use; - Always incontinent of urine; - Always continent of bowel; - Diagnoses included high blood pressure, diabetes mellitus and repeated falls. Review of the resident's care plan, revised 5/31/23 showed: - The resident wanted to return home following their rehab stay. Review of the resident's medical record showed it did not contain a recapitulation of the resident's stay from admission on 5/3/23 until discharge on [DATE]. During an interview on 8/4/23 at 12:23 P.M., the DON said: - There should be a recapitulation in the resident's chart when a resident is discharged from the facility; - Social Services or nursing should make sure it's completed.

Based in observations, interviews, and record reviews the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of ten sampled residents (Resident #6) when the facility failed to notify the resident's primary care and/or hospice physician in a timely manner after the resident fell , sustained a possible [MEDICAL CONDITION], expressed signs and symptoms of significant pain, and after the resident developed a fever and lowered oxygen saturation. This had the potential to affect any resident with a significant change in condition. The facility census was 40. 1. Review of the undated facility policy on fall prevention, showed: - Staff should be aware of a resident's mental and physical changes; - Staff should request a physical therapy evaluation for a resident at risk for falls; - Staff should make interventions for any resident at risk for falls. Review of the undated facility policy on accident/incident reporting showed staff should not move a resident if the resident's injuries might require transfer to the hospital. Review of the undated facility policy on transfers showed staff should: - Not move a fallen resident; - Assess the resident; - Notify the resident's physicians; - Call the family regarding transfer to the emergency department for further care; - Call administrative staff for further guidance. Review of the undated facility notice posted at both nurse's stations on resident change in condition, showed staff should: - Notify the resident's physicians; - Notify the resident's family; - Send the resident to the emergency department, if any doubt about the resident's condition. Review of the undated hospice notice in the resident's chart showed staff should notify hospice for any change in resident condition. Review of the resident's care plan, initiated on [DATE], showed: - Poor balance; - History of falls; - Needed assistance with toileting; - Required low bed with mats; - Received diuretics (medications used to remove excess fluid from the body resulting increased urination). Addendums to care plan, initiated on [DATE], under Falls Prevention, showed : - Staff found the resident kneeling at his/her bedside, on [DATE], and no additional interventions were provided. - Staff found the resident kneeling at his/her bedside, on [DATE], and no additional interventions were provided. - Staff found the resident kneeling at his/her bedside, on [DATE], and no additional interventions were provided; - No addendum's were placed on the resident's care plan when the resident was placed on hospice care; - No addendum's were placed on the resident's care plan regarding care for a possible, untreated, [MEDICAL CONDITION]. Review of the resident's fall risk assessment, dated [DATE], showed a fall risk of 14, greater than or equal to ten means the resident was at high risk for falls. Review of the resident's nurse's notes, dated [DATE], showed the family did not want the resident placed on hospice at that time. Review of the resident's nurse's notes, dated [DATE], showed staff: - Found the resident on the floor; - No apparent injuries; - Sent a fax to the resident's physician regarding finding the resident on the floor. Review of the resident's nurse's notes, dated [DATE], showed: - The resident's oxygen saturation (SaO2) was 91% (normal SaO2 should be greater than 96%); - The resident's hands were [MEDICAL CONDITION] (swollen); - The resident was lethargic and could not take his/her medications; - No notation of the physician being notified of the resident's condition. Review of the resident's quarterly Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated [DATE]. showed: - Cognitively intact; - Transferred independently; - Always continent of bowel and bladder; - Walked in room with limited assistance; - Prognosis showed the resident did not have a condition or chronic disease that might have resulted in a life expectancy of less than six months; - Not receiving hospice care; - The resident participated in the assessment process; - The resident's family did not participate in the assessment process; - [DIAGNOSES REDACTED]. Review of the hospice consent form, dated [DATE], showed: - The consent was signed by Family Member (FM) A, the resident's Durable Power of Attorney (DPOA); - The resident did not sign the form. Review of the nurse's notes, dated [DATE], showed no mention of the resident receiving hospice services. Review of Licensed Practical Nurse (LPN) D's nurse's notes, dated [DATE] at 9:15 P.M., showed: - Staff found the resident lying on the floor; - The resident complained of bilateral elbow and right hip pain; - Review of a fax showed staff notified the resident's physician to be viewed the next morning; - Notified the hospice nurse on-call about the resident's fall; - Staff did not note the condition of the resident's hip; - Hospice Nurse (HN) A notified the resident's DPOA; - Per HN A the DPOA requested the resident not be transferred to the emergency department for definitive treatment. Review of LPN D's nurse's note's, dated [DATE] at 9:25 P.M., showed: - Gave the resident a pain medication that had been ordered to give as needed; - Placed a gait belt (a device placed around the resident's waist to assist with transferring when the resident can bear weight) on the resident; - Transferred the resident to a recliner with the assistance of three staff; - No mention of notifying facility administrative staff for further guidance. Review of LPN D's nurse's notes, dated [DATE] at 10:00 P.M., showed: - HN A arrived at the facility; - Resident transferred from the recliner to the bed, no mention of method of transfer or number of staff required to assist with the transfer; - After transferring the resident to bed, resident complained of hip pain; - Right hip was slightly rotated (a sign of a possible [MEDICAL CONDITION]); - There was no notation of the resident's physician or family being notified about the extent of the resident's injuries and pain. Review of LPN D's nurse's notes, dated [DATE] at 10:30 P.M., showed the resident received an additional pain medication. Review of the nurse's notes, dated [DATE] at 1:00 A.M., showed: - The resident showed no signs or symptoms of pain when at rest; - The resident grimaced when moved from side to side. Review of LPN A's nurse's, dated [DATE] at 7:30 A.M., showed: - The resident was moaning and groaning; - LPN A, with assist of two staff, transferred the resident from bed to wheelchair; - The resident refused to eat and staff returned the resident to bed; - No mention of discussing with the family the benefits versus the risks of getting the resident out of bed. Review of nurse's notes, dated [DATE], showed: - At 8:00 A.M., the staff got resident up for breakfast but the resident refused to eat; - At 1:00 P.M., the resident refused to eat and moaned when being turned; - At 3:30 P.M., the resident grimaced with movement of right hip; - At 9:00 P.M., "exaggerated rotation" of right lower extremity; - No notation of staff notifying the resident's physician or hospice provider regarding pain with movement and extremity rotation. Review of the nurse's notes, dated [DATE] at 00:35 A.M., showed: - Resident incontinent of urine; - Resident moans with any movement; - Pain medication given. Review of the nurse's notes, dated [DATE] at 1:00 A.M. showed the resident cringed during staff assessment. Review of the nurse's notes,, dated [DATE] at 7:45 A.M., showed: - Staff got the resident out of bed for breakfast; - Did not show how the resident was transferred; - Was given medication for right hip pain. Review of LPN E's nurse's notes, dated [DATE] at 3:30 P.M., showed: - The resident grimacing and moaning; - Pain medication given. - Temperature 100.3 Fahrenheit (F); - Did not show staff notified the resident's physician about the resident's fever. Review of LPN E's nurse's notes, dated [DATE] at 8:00 P.M. showed: - Notified on-call hospice nurse that the resident had a temperature of 100.3 F; - No documentation the resident's physician was notified; - Received a phone order for Tylenol as needed from the on-call hospice nurse; - Administered the Tylenol and pain medication. Review of LPN E's nurse's notes, dated [DATE] at 1:00 A.M., showed: - The resident was incontinent of urine and received incontinent care; - Resident's temperature was 101 F; - No notation regarding staff notifying the resident's physician regarding the resident's continued fever. Review of the nurse's notes, dated [DATE] at 3:30 P.M., showed: - Temperature of 101 F and SaO2 89% while on oxygen; - No notation regarding staff notifying the resident's physician regarding the resident's fever and decreased SaO2. Review of the nurse's notes, dated [DATE] at 9:30 A.M., showed: - Temperature of 100.3 F and SaO2 86% on oxygen; - No notation regarding staff notifying the resident's physician regarding the resident's fever and decreased SaO2. Observation, on [DATE] at 11:30, showed: - The resident in bed lying on his/her back asleep; - Certified Nurse Aide (CNA) A brought the resident his/her lunch tray; - CNA A attempted unsuccessfully to awaken the resident. During an interview, on [DATE] at 2:23 P.M., FM B said: - Was not the resident's DPOA; - Visited two to three times a week; - The resident made his/her own decisions until about one month ago; - The resident fell frequently; - The facility put a bed alarm on the resident; - The resident disabled the bed alarms; - He/she was unaware of any other fall prevention strategies the facility implemented; - Two days after the resident was placed on hospice, the resident fell and injured his/her hip; - The resident had to urinate very quickly or he/she would have an accident; - Since the resident fell , staff did not keep the resident pain free; - On [DATE], FM B told staff the resident's pain was not relieved; - Staff told FM B that it was too soon for further medication; - FM B then called the hospice nurse who came in and assess the resident; - Asked the staff to place the resident in a brief at all times to minimize moving the resident when staff provided incontinent care but the staff did not place the resident in a brief. Review of the nurse's notes, dated [DATE] at 00:30 A.M., showed: - Temperature of 100.7 and SaO2 84% on oxygen; - No notation regarding staff notifying the resident's physician regarding the resident's fever and decreased SaO2. Review of LPN F's nurse's notes, dated [DATE] at 6:55 A.M., showed the resident expired. Review of the resident's significant change MDS, dated [DATE] (not yet transmitted to Center for Medicare/Medicaid Services but copied by the facility for surveyor use) showed: - Severe cognitive impairment; - Unable to walk in room; - Transferred independently; - Always incontinent of bowel and bladder; - Prognosis the resident did not have a condition or chronic disease that might have resulted in a life expectancy of less than six months; - Received hospice care; - [DIAGNOSES REDACTED]. During an interview, on [DATE] at 2:45 P.M., LPN C said: - Gave the resident pain medication around 7:45 P.M. on [DATE]; - Around 10:00 P.M., FM B said the resident's pain was unrelieved; - The hospice physician ordered pain medication to be given every four hours as needed; - He/she could not give the resident another dose of pain medication until 11:45 P.M.; - The DON instructed staff to contact the hospice nurse on-call, rather than the resident's physician, for resident needs; - LPN C planned to call the hospice nurse on call due to the resident's unrelieved pain when he/she had time to make the call; - Hospice notified FM A after the resident fell and injured his/her hip on [DATE]; - The facility did not obtain any orders, other than pain medications, for providing care to the resident with a possible [MEDICAL CONDITION]; - The facility did not care plan for the resident's possible [MEDICAL CONDITION]. During an interview, on [DATE] at 3:10 P.M., the DON said: - Staff discussed resident falls weekly; - Staff should investigate recurring falls and find new fall prevention strategies; - Should have care planned for the resident's possible [MEDICAL CONDITION]; - Staff should have notified the resident's primary care physician when the resident sustained [REDACTED]. - Staff should have notified the resident's primary care physician when the resident ran a fever; - Staff should have notified the resident's primary care physician when the resident's SaO2 decreased. During an interview, on [DATE] at 3:40 P.M., LPN D said: - Was the charge nurse when the resident fell on [DATE]; - Was notified, by an unnamed CNA that the resident was on the floor; - Assessed the resident and found he/she had bilateral elbow and right hip pain; - With the assistance of three other staff members, used a gait belt to stand and transfer the resident to a recliner; - Should not have used a gait belt to stand and transfer a resident with hip pain because it could cause further injury and pain; - Notified the hospice nurse; - The HN A and LPN D assessed the resident; - The resident experienced intense pain when transferred by standing using a gait belt; - LPN D sent a fax to the resident's primary care physician's office to be viewed by the physician in the morning; -LPN D did not work the next morning, so was unaware of any physician response to the fax; - He/she would have sent the resident to the emergency department (ED) but HN A told him/her not to send the resident to the ED per family request; - Did not know if HN A contacted the resident's physicians regarding his/her fall; - The resident was not wearing any type of personal alarm when he/she fell ; - Should have contacted the resident's physician, irregardless of the time, when the resident fell and had pain; - The resident could turn off his/her personal alarms; - The facility had not provided a fall prevention program for the resident. During an interview, on [DATE] at 4:20 P.M., HN A said: - Received the call that the resident fell and was in pain on [DATE]; - Assisted the staff to stand the resident using a gait belt and placed the resident in a recliner; - The resident had pain with movement; - He/she and staff attempted to stand the resident but the resident could not stand; - HN A and the staff pivoted the resident from recliner to bed; - Called FM A and gave options of transporting the resident to the ED, having mobile X-ray in the morning, or waiting until the morning to provide further care; - FM A requested the resident receive care in the morning; - Did not call the resident's hospice or primary care physicians; - Used hospice standing orders for pain; - Did not notify the hospice physician that the resident required pain medication; - Did not give the facility any orders or guidance for incontinent care or positioning of the resident after a possible [MEDICAL CONDITION]. During an interview, on [DATE] at 5:30 P.M., HN C said: - He/she was the resident's case manager; - Was not on call the night the resident fell ; - Saw the resident the day after the fall; - Spoke with Physician (Dr) A, the hospice physician, regarding the resident's fall and family request on [DATE]; - Dr. A said to provide comfort care per family request; - Felt the resident had a fractured right hip because the resident's right leg was rotated and the resident experienced pain when the leg/hip was moved; - The family wanted the resident to get out of bed for meals even though HN C told the family that getting out of bed would be painful for the resident; - HN C felt he/she should support the family's decision to get the resident out of bed for meals even though getting the resident out of bed caused the resident a lot of pain; - HN C "had to do what the family requested"; - HN C did not suggest the facility staff use a mechanical lift to transfer there resident; - Facility staff should have contacted the resident's primary care physician for care related to the resident's possible [MEDICAL CONDITION]; - Hospice was not responsible for care of a possible [MEDICAL CONDITION] because the resident received hospice care for [MEDICAL CONDITION]. During an interview, on [DATE] at 9:15 A.M., the administrator (ADM) and social services designee (SSD) said: - Hospice physicians provided care for residents receiving hospice benefit; - The resident's primary physician, Dr. B, defers care of his/her residents receiving hospice care to the hospice physician. During an interview, on [DATE] at 11:00 A.M., Dr. A said: - He/she was the hospice physician for the resident; - Learned that the resident fell and had a possible [MEDICAL CONDITION] at the hospice weekly meeting (the day after the resident fell [DATE]); - Family requested no care for the possible fracture; - Gave no orders for resident positioning or ambulatory status; - Ordered a physical therapy evaluation but the resident died before the physical therapy evaluation could be done; - According to HN C, the family wanted the resident to get out of bed; - Did not think it was in the resident's best interest to get him/her out of bed since the resident had a possible [MEDICAL CONDITION]; - Had not met or talked with the resident's family; - According to intake information, provided by hospice staff, the resident had severe cognitive impairment; - Was unaware the resident had febrile (fever) episodes. - Was never contacted by facility staff regarding the resident's decreased SaO2. During an interview, on [DATE] at 12:05 P.M., HN C and HN D said: - FM B called the on-call hospice nurse because he/she felt the facility was not adequately managing the resident's pain; - HN C and HN D did not feel the facility should have gotten the resident out of bed after he/she had a possible [MEDICAL CONDITION]; - Family insisted the facility get the resident out of bed even though he/she had a possible [MEDICAL CONDITION]; - The facility staff did not notify the hospice physician when the resident ran a fever; - Facility staff should notify the hospice physician immediately for a change in condition or or decline; - Facility staff should have notified the physician if the resident had a fever; - The facility was responsible for positioning of the resident and any resident needs when hospice not in the facility. During an interview, on [DATE] at 2:40 P.M., Dr. B's nurse said: - He/she was returning the call for Dr. B and had reviewed the resident's medical record; - The resident was placed on hospice due to [MEDICAL CONDITION]; - The resident's [MEDICAL CONDITION] could have contributed to his/her fall due to shortness of breath; - Had no records indicating physician notification of the resident's fall; - Had no records indicating the resident had been running a fever; - Dr. B always deferred care of his residents to the hospice physician. - The resident was placed on hospice care due to physical decline rather than cognitive decline. During an interview, on [DATE] at 12:00 P.M., Registered Nurse (RN) A said: - Worked in the facility as a charge nurse; - Staff should use a mechanical lift to transfer a resident after a fall; - If a resident had an obvious or possible fracture, staff should call the emergency medical transport system for further care.

Observation, interview, and record review showed the facility failed to notify a physician in a prompt manner after staff assessed and documented a change in condition affecting one of nine sampled residents (Resident #7). Staff documented on 5/26/12, that the resident exhibited signs and symptoms consistent with a [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke) but did not notify the physician until 5/29/12. A physician did not see the resident until 6/5/12, and at that time documented the resident had a recent stroke which resulted in Hospice care. The facility census was 39. Review of the facility's Change in a Resident's Condition or Status policy revised October, 2010 showed: - Staff shall promptly notify the resident's attending physician of changes in the resident's medical/mental condition; - The nurse supervisor/charge nurse will notify the resident's attending physician or the on-call physician when there has been a reaction to medication, a significant change in the resident's physical/emotional/mental condition, a need to transfer the resident to a hospital/treatment center; - A significant change of condition is a decline in the resident's status that will not normally resolve itself without intervention, and that impacts more than one area of the resident's health status; -In medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Review of www.MayoClinic.com showed the signs and symptoms of a stroke may include trouble with walking, loss of balance or coordination, trouble with speaking and understanding, confusion, slurred speech, paralysis or numbness to one side of the body or face. It is advised that a person exhibiting any of these symptoms seek immediate medical attention. Complications involve paralysis on one side of the body, difficulty in talking and swallowing, memory loss or trouble understanding, and pain sensation in parts of the body affected by the stroke. Stroke damage to brain tissue on the left side may affect movement on the right side; this damage may also cause speech and language disorders. Seek immediate medical attention by calling the local emergency number. The longer a stroke goes untreated, the greater the potential for brain damage and disability. Seek emergency treatment with clot-busting drugs (TPA) must start with 4.5 hours and is used for ischemic [MEDICAL CONDITION], the most common type of stroke. 1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/26/12, showed: - [DIAGNOSES REDACTED]. - Minimum difficulty in ability to hear; - Clear speech; - Makes self understood; - Clear comprehension; - Vision adequate; - Resident participated in his/her goal planning; - Brief Interview for Mental Status (BIMS) score 11, or moderately impaired cognitive ability; - Mood severity score 6, or mild depression; - Independent in bed mobility; - Limited assistance with walking, toileting, personal hygiene; - Independent to move between locations; - Independent with eating; - Physical assistance of one person for bathing; - No swallowing difficulties; - Not at risk for developing pressure ulcers; - Regular diet - No impairment in range of motion of extremities; - Occasionally incontinent of urine. - [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Review of physician's progress note dated 4/18/12, said the resident has a history of a stroke, but he/she has completely recovered from it. Review of the nursing monthly summary dated April, 2012 showed the resident was independent in bed mobility, adequate hearing, clear speech, usually understood and occasionally incontinent. Review of the physician order [REDACTED]. No order for oxygen noted. Review of nurses' notes showed: - 5/11/12, at 2:00 P.M., vital signs within normal limits; oxygen saturation level 91% on room air, blood pressure 118/68, pulse 89, respirations 18. - 5/11/12, at 4:00 P.M., in wheelchair wandering independently in the corridors and in good spirits. - 5/18/12, new order for [MEDICATION NAME] increase to 12.5 mg A.M., noon and P.M.; - 5/20/12, resident continues making sexual aggressive comments; - 5/24/12, resident saying "I love you honey", called and left message with mental health nurse for Physician C. Resident resting in recliner, vital signs within normal limits, weekly blood pressure 122/48. - 5/25/12, Family here, not wanting medication for resident's behaviors. Physician C called and gave order to discontinue A.M. and noon [MEDICATION NAME] (antipsychotic). -5/26/12, at 1:00 P.M., Licensed Practical Nurse (LPN) D documented resident sitting in wheelchair, right arm drooping from chair, staff lifted resident's arm and placed it in his/her lap; resident was unable to grip the nurse's hand with his/her right hand, his/her speech was slurred and left side of mouth slightly drooped; vital signs showed temperature 98.5, oxygen saturation 90% on room air, pulse 76 and irregular, respirations 18 and shallow, blood pressure 148/78; nurse will continue to monitor. During an interview on 6/14/11, at 4:00 P.M., LPN D said the following about what occurred during his/her shift on 5/26/12: - He/she was off work on 5/23 - 5/25/12, and returned on 5/26/12, (Saturday). - The resident was normal looking the last time he/she worked, but on 5/26/12, the resident looked different, his/her mouth was drooping, and he/she was drooling and mumbling; - The off-going nurse said nothing in report about the resident's change in condition; - The resident could not swallow his pills, so LPN D crushed them, this was another change in condition he/she noticed; - He/she asked the CNAs what had happened to the resident and was told that they noticed the changes in condition two days before; - He/she questioned Family Member A who was visiting, about the stroke-like changes in the resident and was told the resident had been like that since Thursday night (5/24/12). - LPN D thought the resident might have had a mini stroke; - He/she did not know if the physician had been notified. - LPN D did not notify the physician. During an interview on 6/19/12, at 2:10 P.M., Certified Nurse Aide (CNA) I said on 5/25 or 5/26/12, he/she observed the resident's arm was limp and reported it to LPN D. During an interview on 6/19/12, at 2:15 P.M., CNA E said he/she observed the following on 5/25 or 5/26/12: - The resident's arm was flopping, was not capable of movement, it would just flop; - The resident was sleeping and slobbering; - Reported these new changes to LPN D During an interview on 6/19/12, at 2:30 P.M., Restorative Aide M said he/she observed the following around May 26th, unable to remember exact date: - Been off two days and when he/she returned realized something was very wrong with the resident; - Resident's face drooping, speech garbled, arm limp; - I had no doubt something was wrong, I thought the resident had a stroke; -Told a nurse about all these changes, I don't remember who, and I don't know if the nurse did anything or not. Continued review of nursing notes showed: - 5/26/12, at 3:30 P.M., sitting in recliner, feet elevated, skin pale, left corner of mouth dropping, right hand extremely weak, left hand grip firm, speech slurred; blood pressure 138/76, pulse 68, respirations 20, temperature 98.2, oxygen saturation 92% on room air; nurse will continue to monitor. - No nurses notes on 5/27/12. - 5/28/12, at 8:30 A.M., could not open mouth to take medications; mumbling and not making any sense, will not open eyes. - 5/28/12, at 9:30 A.M., Family Member A said the resident's right wrist is swollen and is coughing. Nurse will fax physician. Review of fax to Physician A written by LPN B on 5/28/12, but not faxed to Physician A until 5/29/12, then re-faxed on 5/30/12, at 2:00 A.M., showed the resident: - Continues to be lethargic at times, mumbling, not making any sense; - Right sided weakness to body; - Right wrist swollen, red and warm to touch; - Moist crackles to lung fields; - Family concerned resident has had a stroke; - [MEDICATION NAME] 12.5 mg am and noon discontinued; - Still taking [MEDICATION NAME] 25 mg at bedtime; - Request order to discharge from restorative; - Request order for chest x-ray and right wrist x-ray; - Physician A did not respond to fax until 6/5/12, with order to discharge the resident from restorative. No other symptoms addressed. During an interview on 6/19/12, at 2:40 P.M., the MDS nurse said she noticed on 5/26/12, or 5/27/12, (unsure of date) the resident's arm was swollen and flaccid. She read documentation in the nurses notes the resident was drooling. Further review of nursing notes showed: - 5/28/12, at 9:45 A.M., right wrist red, warm to touch and slightly swollen, resident complains of pain, moist crackles to lungs fields, temperature 98.2; telephone order for chest x-ray and right wrist x-ray. - 5/28/12, at 12:15 P.M., mobile x-ray at facility. - 5/28/12, at 2:15 P.M., temperature 99.5, resident resting quietly with eyes closed; chest x-ray showed mild cardiomegalia (an enlarged heart), hiatal hernia, no abnormalities of the chest; wrist x-ray showed no fracture. - 5/28/12, at 7:00 P.M., not very alert, needed encouragement and instruction to swallow. -5/28/12, at 10:30 P.M., not swallowing, unable to give P.M. Tylenol tab by mouth; the resident groaned in pain when right arm moved; changed urine-soaked linens by rolling resident to left side; right arm propped on pillow; lungs congested in upper lobes bilaterally; oral care given. Review of nurse progress notes completed by MDS nurse showed: -5/28/12, (no time written on this progress note ) significant change in mood, behaviors, and in functional ability. Questionable stroke, slurred speech, weakness on right side, drooping mouth. No documentation physcian was notified. - 5/28/12, Registered dietician recommended ground meat, no spicy foods. Resident is being fed by staff. Review of Registered Dietician's nutritional assessment dated [DATE], showed the resident has had a decline in status recently possibly due to a new stroke and recommended ground meats to help with chewing. Discussed with family foods to avoid due to recent hiatal hernia. Further review of nursing notes showed: -5/29/12, at 12:15 A.M., vital signs are blood pressure 146/82, temperature 98.5, pulse 88, respirations 16, oxygen saturation 81% on room air; oxygen applied at 2 liters per nasal cannula; resident is resistant, moaning and mumbling, grabbing at nurses' hands; right arm flaccid, elevated on pillow, complains of discomfort by moaning when arm is touched or moved; neck hyper-extended, tried to adjust pillow, but resident became combative; lung sounds congested in upper lobes, breath sounds diminished in lower lung lobes; nursing continues to observe. - 5/29/12, at 6:04 A.M., fax sent to Physician A requesting order for Milk of Magnesia 30cc by mouth as needed for three days if resident does not have a bowel movement. No mention of decline or other symptoms. - No nurses notes on 5/30/12. - 5/31/12, at 12:45 A.M., resting quietly; oxygen saturation is 86% on room air; oxygen applied with nasal cannula; resident trying to speak but words are garbled. - 5/31/12, at 5:45 A.M., resident is resistant with cares, hitting staff when trying to change linens due to incontinence; resident re-directed with some success. - 5/31/12, at 6:30 A.M., faxed to primary care physician requesting oxygen as needed for decreased oxygen saturation levels. - 5/31/12, at 9:30 A.M., Physician A's nurse called regarding the resident's current status; staff informed Physician A's nurse about medication changes and decline; Physician A to come and see resident on 6/6/12, in the afternoon. During an interview on 6/14/12, at 4:15 P.M., Physician A's nurse said: -The resident's family member came to Physician A's office on 5/30/12, and said the resident had a change in status. - Family member stated the resident wasn't using one of his arms as well, and had to be fed. The family member did not mention anything about a stroke. -When family member came in on 5/30/12, it was the first time we had heard about the resident's change in status. - He/she called the facility and asked about the resident's condition. The facility nurse said there was a change in condition, but nothing about a stroke. Physician A said the family could bring the resident in to the office that day or he/she would come to see the resident on Wednesday, 6/6/12. - If the facility or the family member would have described stroke symptoms, I would have told them to get the resident to the emergency room immediately. During an interview on 6/14/12, at 9:30 A.M., Registered Nurse (RN) A said Physician A's nurse called the facility on 5/31/12, sometime during the morning to check on resident. RN A read parts of the chart regarding the resident's behaviors and the symptoms that began on 5/26/12, right sided weakness, drooping mouth and vital signs. RN A said Physician A's nurse said it sounded like a stroke and he/she would get in touch with Physician A and call the facility back . He/she called back between 11:30 A.M and 12:30 P.M. and said family could bring the resident in to see Physician A that day or Physician A would come to the facility to see the resident the on June 6th. RN A said the family decided to change physicians. Family changed the resident's primary care physician to Physician B. RN A said she had not notified the physician of the resident's change in condition prior to this conversation on 5/31/12. Continued review of nursing notes showed: - 5/31/12, at 2:00 P.M., care plan meeting with family; family wishes to change primary care physician from Physician A to Physician B because Physician A said he/she would come to see the resident and has not; family wants Hospice to assist in end of life care; Physician A notified of family wishes, and Physician B notified of new client; hospice notified of family's request. - 5/31/12, at 6:00 P.M., blood pressure 118/60, pulse 74, temperature 98, oxygen saturation 98% on oxygen at two liters with nasal canula; resident aroused with verbal and touch stimulation, opens eyes then closes them. Review of the nursing monthly summary dated May, 2012 showed the resident was totally dependent in bed mobility, minimal difficulty with hearing, unclear speech, rarely understood, altered level of consciousness, poor appetite, little energy, and always incontinent. Review of physician's orders [REDACTED]. Order requested for oxygen as needed due to decreased oxygen saturation levels. Requested that supplemental oxygen will be given in order to keep oxygen levels be kept above 90%. Review of the resident's significant change MDS, dated [DATE], showed: - Moderate difficulty in ability to hear; - Unclear, slurred/mumbled speech; - Rarely/never understands; - Vision moderately impaired; - Resident unable to participate in his/her goal planning; - Unable to interview for mental status, resident rarely/never understood; - Mood severity score 19, moderately severe depression; - Total dependence for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, and bathing; - Toileting and walking did not occur; - At risk for developing pressure ulcers; - Holds food in mouth, on therapeutic mechanically altered diet; - Impairment on one side of upper extremity and both sides of lower extremities; - Always incontinent of urine; - On oxygen therapy; - On Hospice care. -[MEDICAL CONDITION] marked. Review of the resident's care plan dated 6/1/12, showed: - One staff assist with wheelchair locomotion. Must have both foot rests on wheelchair, resident cannot hold feet up; - Swallowing problem, pureed diet with nectar consistency fluids; - Resident has to be fed by staff; - Lay resident down between meals to rest. - Two assist with Hoyer lift for all transfers; - Two assist with dressing; - Must be fed at all meals; - Pureed diet with nectar thickened liquids; - Turn and reposition on rounds, prop with pillows as needed; - Elevate lower extremities on pillow when in bed to suspend heels off surface; - Heel/elbow protectors when in bed; - One assist with wheelchair to/from all meals. Review of the current staff care card showed the resident required: - Two staff to assist with turning in bed, transfer with mechanical lift and dressing. - Resident has to be fed by staff; - On oxygen therapy and Hospice; - Always incontinent; - Hearing poor; - Severely impaired in decision making; - Rarely able to understand others; - Rarely able to express self; - No tendency to wander; - Does not walk and is not toileted; - Hospice care. Review of Activity Director's progress notes dated 6/1/12, said: - Resident had a significant decline in health; - Speech unclear; - Requires full assistance with everything; - Is now on Hospice; - Most of time spent in room; - Will start activities one on one in resident's room one time a week. Review of nursing notes from 6/1/12 to 6/5/12, showed staff did not contact any physician about the resident's status. Review of physicians orders dated 6/4/12, showed diet changed to pureed with pudding consistency thickened liquids due to swallowing problems. Review of Physician B's initial in-person assessment dated [DATE], showed: - Abnormal muscle weakness; - "[MEDICAL CONDITION] family made decision for hospice;" - admitted to hospice for [MEDICAL CONDITION]. During observation on 6/11/12, at 10:30 A.M., showed the resident slumped to right side, sitting in wheelchair in his/her room. During observation on 6/11/12, at 11:35 A.M., the resident attempted to talk to Resident #6 but his/her speech was garbled. Resident #6 turned to his wife and said he could not understand the resident and asked if she could understand. She said she also could not understand what the resident was saying. The resident was completely dependent on staff for eating and drinking. Staff fed the resident pureed food and thickened liquids. During an interview on 6/12/12, at 5:30 P.M., Family Member B said the resident now mumbles and requires a mechanical lift and a bedpan, but before the stroke the resident had clear speech and walked to the bathroom. He/she said before the stroke that was about 2 weeks ago on a Friday (5/25/12), the resident walked independently in his/her room, but now the resident is unable to get up and do anything independently. He/she thinks the side effects of [MEDICATION NAME] had a lot to do with the resident's stroke. No one in the facility said that the resident had a stroke, it was just something he/she thought. During an interview on 6/13/12, at 10:35 A.M., Family Member A said on 5/25/12, he/she noticed the resident was mumbling and could not eat and his mouth was twisted and his face was sunk in on the right side and he could not move his right arm or leg and she reported it to an unknown nurse, but was told that the resident was okay and had days like this. He/she thought these symptoms indicated a stroke and thought it was probably caused by the [MEDICATION NAME]. He/she felt if the [MEDICATION NAME] was discontinued that the resident would get better, so he/she went to Physician A's office on 5/30/12, and told them he/she wanted the [MEDICATION NAME] discontinued. The facility never acknowledged to him/her or anyone else in her family that the resident had a stroke. But he/she believes the resident had a stroke on 5/25/12. During an interview on 6/19/12, at 2:00 P.M., CNA J said near the end of May, 2012: - The resident's right side was flaccid and his/her speech was slurred; - He/she asked the nurse if the resident had a stroke and did not get a straight answer. Nurse said she would check on it. - CNA J was working with CNA I who did not know what had happened to the resident either, but we both noticed a big change. During an interview on 6/19/12, at 2:20 P.M., CNA K said he/she observed the following around sometime around Memorial Day: - The resident's speech was garbled; - The resident's whole side was weak, could not use it; - The resident was leaning; - He/she told the nurse he/she thought the resident had a mini stroke. During an interview on 6/14/12, at 6:45 A.M., LPN A said the resident had a recent significant change and she observed the following changes: - Right side of mouth drooped; - Speech incoherent, slurred; - Right side weakness - Right wrist swollen. - He/she did not notify the physician. During an interview on 6/14/12, at 10:40 A.M., LPN B observed the following changes in the resident on 5/28/12: - Drooling; - Mouth drooping; - Flaccid right arm, LPN thought it was "asleep"; - Significant weakness on the right side, LPN B thought it was a side effect from the [MEDICATION NAME] medication; -Swallowing difficulty; - LPN B said she did not notify the physician, but should have. Observation on 6/14/12, at 11:00 A.M., showed the resident sitting in his/her room in a recliner, leaning to right side, drooling, eyes closed. During an interview on 6/14/12, at 11:00 A.M., the Assistant Director of Nursing (ADON) said she noticed the stroke like symptoms that the resident exhibited and thought the physician had been notified. The ADON said she was working as the weekend supervisor on May 26th and 27th, but there was no discussion about sending the resident out. The ADON said the physician should have been notified because there was a significant change in condition and the facility should have sent the resident out to the emergency room . She had been off two days, when she returned to work she saw the change of stroke-like symptoms, but thought the physician had been notified. This is the reason she did not notify the physician. During an interview on 6/14/12, at 11:30 A.M., LPN E said: - A few weeks ago, the resident was unable to swallow his medications, it was as if his/her tongue was not working right. LPN E removed the pill from the resident's mouth and crushed it, added applesauce and verbally instructed the resident how to swallow, but the resident still had significant difficulty swallowing. - He/she had not previously observed the resident having swallowing difficulty; this was a change in condition. -The nurse on duty prior to LPN E said the resident wasn't doing well, but I guess I was the first to notice that the resident could not swallow. I should have notified the physician. During an interview on 6/14/12, at 4:15 P.M., Physician B said: - The resident had weakness of the right arm. - "The [DIAGNOSES REDACTED]." - The family chose to have hospice for comfort measures. On 6/14/12 at 4:30 P.M., the surveyor attempted to contact Physician B's office for additional information. The physician was not in and left message to return call. During an interview on 6/28/12 at 2:00 P.M., Physician B said: - He/ she would expect staff to contact a physician with a resident's change of condition such as muscle weakness, drooling, slurred speech, and facial drooping. -Elderly people (over [AGE] years of age) require treatment within the first three hours of the event to attempt to reverse symptoms. During an interview on 6/14/12, at 6:00 P.M., the Director of Nursing said she would expect staff to notify the family and physician if there was a change in condition. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level, "J". Based on record review and interviews completed during the onsite visit, it was determined the facility had implemented corrective actions to address and lower the violation at the time. During the onsite visit, the Department of Health and Senior Services (DHSS) surveyors determined the facility immediately re-educated their nursing staff currently on timely notification of the physician of any change in resident condition. All staff had been re-educated on this policy and procedure prior to working their next shift. This addressed the signs and symptoms of various acute conditions including stroke and directed staff to contact the physician immediately, or if unable to make contact, send the resident to the hospital. The facility has scheduled an in-service for all licensed nursing staff about notification in case of a significant change. They will also re-educate certified staff to report any changes in condition to the charge staff. Interviews and record review confirmed the administrator and DON completed this staff re-education for each staff person currently on duty and will re-educate all other staff prior to working their next shift. Facility staff will monitor to assure interventions are effective and appropriate. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of th exit, the severity of the deficiency was lowered to the "D" level. the facility had completed inservicing, but had not had sufficient time to monitor interventions to assure staff adequately, and in a timely manner, notified the physician or hospital if a change in a resident's condition occurred. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be to address Class I violation(s).