Every finding on record at Pin Oaks Living Center

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, was free from misappropriation of medications when Registered Nurse (RN) A administered gabapentin (used to treat seizures and nerve pain) instead of the scheduled hydrocodone-acetaminophen (narcotic pain medication used for moderate to severe pain) to the resident. RN A documented he/she administered hydrocodone-acetaminophen on the resident's Medication Administration Record (MAR) and narcotic log, but RN A administered a gabapentin, not hydrocodone-acetaminophen as ordered. The facility census was 87. On 06/16/26 at 1:50 P.M., the Administrator was notified of the past noncompliance which occurred on 05/20/26. On 05/20/26, the Director of Nursing (DON) became aware RN A misappropriated Resident #1's hydrocodone-acetaminophen. Upon discovery, the DON and Licensed Practical Nurse (LPN) B interviewed RN A regarding administering gabapentin but documenting he/she administered hydrocodone-acetaminophen. The DON terminated RN A's employment, sent a self-report to the state survey agency, contacted the resident's physician regarding the incident, notified law enforcement, and notified the Missouri Board of Nursing. The DON and the Minimum Data Set (MDS) nurse counted all narcotic medications in all the medication carts to verify accuracy. The DON in-serviced all certified medication technicians (CMT) and licensed nurses on misappropriation of residents' belongings with emphasis on medication. The DON ran an as needed (PRN) medication report to see if RN A documented giving PRN medications to residents who no other staff had given or had given as frequently. Staff interviewed residents about concerns of missing medication with no further concerns identified. The facility replaced the resident's one tablet of hydrocodone-acetaminophen 10/325 mg. The deficiency was corrected on 05/21/26. Review of the facility's Tool: Abuse Prevention Policy and Procedure Checklist, undated, showed the following:-Each resident has the right to be free from misappropriation of property;-Misappropriation of resident property is defined as the deliberate misplacement, wrongful, temporary, or permanent use of a resident's belongings without the resident's consent. Review of Resident #1's undated face sheet showed the resident's diagnoses included low back pain, spinal stenosis (narrowing of the space surrounding the spinal cord, causing pressure and pain), fourth thoracic vertebra (break or collapse of the fourth bone down in the mid-back), first lumbar vertebra fracture (break in the bone at the very top of your lower back, where the mid-back meets the lower spine), second lumbar vertebra fracture, and third lumbar vertebra fracture. Review of the resident's Care Plan, updated 01/04/26, showed he/she received narcotic medication for treatment of chronic pain. Review of the resident's Physician Order Sheet (POS), dated May 2026, showed the following:-Gabapentin 600 mg, give one tablet twice a day between 6:00 A.M. and 10:00 A.M. and between 3:00 P.M. and 6:00 P.M. for fourth thoracic vertebra fracture (original order dated 1/21/26);-Hydrocodone-acetaminophen 10/325 mg, give on tablet every six hours at 06:00 A.M., 12:00 P.M., 06:00 P.M., and 12:00 A.M. for pain. Review of the resident's Medication Administration Record (MAR), dated 05/15/26 at 12:00 A.M., showed RN A documented he/she administered hydrocodone-acetaminophen 10/325 mg to the resident. During an interview on 06/16/26 at 11:45 A.M., the resident said the following:-On 05/15/26, he/she woke up at 3:00 A.M. in pain and realized the nurse had not brought his/her pain medication that was scheduled for 12:00 A.M.;-He/She asked the staff for his/her scheduled pain medication;-RN A brought in a tablet and said it was the pain medication. He/She did not look at the tablet in the cup;-He/She did not have enough water to swallow the pill and noticed the tablet had a terrible taste. His/Her pain medication (hydrocodone-acetaminophen) did not have a terrible taste;-He/She was in pain throughout the next morning, which was not normal because the pain medication (hydrocodone-acetaminophen) kept his/her pain tolerable;-He/She requested staff to allow him/her to taste his/her medication the next morning. The gabapentin had the same terrible taste as the medication RN A administered on 5/15/26. Review of the resident's MAR, dated 05/20/26 at 12:00 A.M., showed RN A documented he/she administered hydrocodone-acetaminophen 10/325 mg to the resident. During an interview on 06/16/26 at 11:45 A.M., the resident said the following:-On 05/20/26, he/she woke up at 1:15 A.M. and realized staff had not brought his/her pain medication, so he/she turned on the call light;-He/She asked Certified Nurse Assistant (CNA) C for some water and to tell the nurse he/she needed the scheduled pain medication. He/She asked CNA C to stay in the room when the nurse brought the medication into his/her room;-RN A handed him/her a medication cup with a tablet inside;-While RN A turned his/her back to get a cup of water, he/she spit the tablet out onto the bed without RN A noticing;-He/She took pictures of the front and back of the tablet and asked CNA C if he/she knew what the tablet was. CNA C said he/she did not know but would take it to a different charge nurse to find out;-The staff (unknown name) told him/her the medication was a gabapentin and not his/her pain medication (hydrocodone-acetaminophen). During an interview on 06/18/26 at 07:31 A.M., CNA C said the following:-The resident asked him/her to stay in the room while RN A brought in the medication;-RN A gave the resident a tablet in a medication cup, the resident put the cup to his/her mouth and held it between his/her lips and teeth instead of swallowing it;-The resident put the tablet on his/her bed without RN A noticing;-The resident asked for an identification of the tablet, but CNA C did not know what it was;-CNA C took the tablet to LPN B to determine if the tablet was correct and wrote a statement. Review CNA C's undated written statement, provided by the facility, showed the following:-The resident activated the call light around 1:10 A.M. on 05/20/26 to ask for his/her pain medication that was due at midnight;-He/She notified RN A about the resident's request for pain medication and returned to the resident's room with more ice water;-The resident asked CNA C to stay to make sure he/she received the correct medication as the resident reported last week RN A gave him/her something else;-RN A brought the medication to the resident;-The resident took the tablet from his/her lips and laid it next to him/her until RN A left to go back up the hall;-The resident asked what the medication was and if CNA C could find out;-CNA C took a picture on the resident's phone of the front and back of the tablet, then took it to Licensed Practical Nurse (LPN) B who put it in a medication bag. Observation on 06/16/26 at 12:05 P.M., showed the following:-The facility provided two pictures from the resident's phone of the medication RN A administered to the resident on 5/20/26; -The tablet was oval and white;-One side of the tablet was scored (manufactured with a shallow indentation or groove across it's surface for safely splitting the tablet in half) with the letter D on the right side and the number 24 on the left side of the tablet;-The other side was also scored but did not have any markings. Review of the website drugs.com showed an image of gabapentin 600 mg with an imprint of D 24 on the tablet, white in color, and oval in shape. (The image of the gabapentin 600 mg matched the photos of the tablet provided by facility from the resident's phone.) During an interview on 06/16/26 at 12:45 P.M., the Director of Nursing (DON) said the following:-She arrived at the facility around 5:30 A.M. on 05/20/26 and LPN B requested to talk about an incident;-LPN B provided a statement from CNA C and a tablet in a medication pouch. LPN B said RN A gave the resident a gabapentin in place of the hydrocodone-acetaminophen;-She called RN A into her office, handed RN A the gabapentin that was in the pouch, and asked RN A to explain what happened;-RN A said he/she must have been confused with the medications;-When she asked RN A if the narcotic count for the hydrocodone-acetaminophen would be over by one. RN A said, no; -She terminated RN A's employment;-She contacted the resident's physician, law enforcement, and the Missouri Board of Nursing regarding the incident;-The MDS nurse assisted with counting all narcotic medications in all the medication carts to verify accuracy;-She in-serviced all certified medication technicians (CMTs) and licensed nurses on misappropriation of residents' belongings with emphasis on medication;-She ran a PRN medication report to see if RN A documented giving PRN medication to residents who no other staff had given or had given as frequently;-The staff interviewed residents about concerns with missing medication with no further concerns identified;-The facility replaced the resident's of hydrocodone-acetaminophen 10/325 mg;-She expected staff to administer the correct medications when scheduled and not to divert any medications from a resident. During an interview on 06/16/26 at 1:50 P.M., the Administrator said she expected staff to administer medications per physician order and not divert the medication. 30193013020131

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of four residents (Resident #2, #3, #4 and #1) in a review of 10 sampled residents to answer call lights and check and change residents in a timely manner. Resident #2, normally continent of bowel and bladder, and requiring staff assistance to use the bathroom, turned on his/her call light and requested staff assist him/her out of bed as he/she needed to use the bathroom. Staff did not respond for three hours, and the resident was incontinent of bladder and bowel. The resident laid in urine and feces. The resident said staff not responding timely to his/her needs made him/her very upset and his/her feelings were hurt when staff treated him/her this way, and his/her skin was irritated and burned from being left soiled. Resident #4 said he/she would become incontinent while waiting for staff assistance and that made him/her feel ashamed and like a child. The facility census was 89.During an interview on 1/7/26 at 2:30 P.M. the Administrator said the facility did not have a policy specific to staffing, but she would expect the residents' needs to be met and the facility to follow regulatory requirements regarding staffing. Review of the Facility Assessment, dated September 2025, showed the following:-Average daily census was 87;-Resident acuity levels in the facility range from low to high;-Special treatments and conditions included: -Respiratory treatment, oxygen therapy 15-20;-Mental health, behavioral health needs 15-20;-Intravenous medications 5-10;-Injections 10-20;-Dialysis 8-10;-Ostomy care 1-2;-Hospice or respite care 5-7;-Isolation or quarantine for active infectious disease 0-2;-Peg tube (delivers liquid nutrition through a tube into the stomach) management 0-2;-Urinary catheter (a tube inserted into the bladder to collect and drain urine from the body) 5-10;-Based on our resident population and their needs for care and support, our general approach to staffing is to ensure we have sufficient staff to meet the needs of the residents at any given time;-Direct care staff (nurse aide, Certified Nurse Assistant, Certified Medication Technician) was 8-10 per shift;-Staff assignments were made with consideration of continuity of care for residents;-Staff are assigned based on residents' acuity level as well as continuity of assignment. Review of the Resident Council Minutes, dated 11/17/25, showed the following:-The form directed staff to include old business and resolutions and new business and plan of action;-The residents said call light wait times were long;-The residents were waiting lengthy time periods to be changed and long wait times for showers;-The resident council minutes did not include a response to the residents' concerns. Review of the Resident Council Minutes, dated 12/18/25, showed the following:-Old business: listed for follow-up from last month minutes and staff identified as responsible: Call lights (there was no follow-up documented from last month or the staff identified as being responsible);-New business: Call lights;-Care concerns: Long call light times;-Other issues to address: The residents want to see more results from resident council;-The resident council minutes did not include a response to the resident concerns. Review of the Resident Mode of Transfer Form, completed by the Administrator on 1/7/26, showed the facility had 11 residents who consistently required transfer by a mechanical lift (a device used to transfer an individual with limited mobility, requiring two staff members). Two additional residents used a mechanical lift as needed for transfers. Review of the Facility Staffing Sheets, dated December 2025, showed the following:-On 12/24/25 day shift, (6:00 A.M. to 6:00 P.M.) CMT: 3 assigned for the medication pass and 6 nursing assistants were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment);-On 12/24/25 night shift, (6:00 P.M. to 6:00 A.M.) CMT: 1 assigned for the medication pass and 4 nursing assistants were assigned to provide direct care (four to six fewer direct care staff than identified as needed on the facility assessment);-On 12/26/25 night shift, CMT: 1 assigned for the medication pass and 6 nursing assistants were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment);-On 12/27/25 night shift, CMT: 1 assigned for the medication pass and 7 nursing assistants were assigned to provide direct care (one to three fewer direct care staff than identified as needed on the facility assessment);-On 12/28/25 night shift, CMT: 1 assigned for the medication pass and 7 were assigned to provide direct care (one to three fewer direct care staff than identified as needed on the facility assessment);-On 12/29/25 day shift, CMT: 2 assigned for the medication pass and 7 were assigned to provide direct care (one to three fewer direct care staff than identified as needed on the facility assessment);On 12/29/25 night shift, CMT: 1 assigned for the medication pass and 7 nursing assistants were assigned to provide direct care (one to three fewer direct care staff than identified as needed on the facility assessment);-On 12/31/25 night shift, CMT: 2 assigned for the medication pass and 6 nursing assistants were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment). Review of the Facility Staffing Sheets, dated January 2026, showed the following:-On 1/2/26 day shift, CMT: 2 assigned for the medication pass and 6 nursing assistants were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment);-On 1/3/26 day shift, CMT: 2 assigned for the medication pass and 6 nursing assistants were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment);-On 1/4/26 day shift: CMT: 2 assigned for the medication pass and 6 nursing assistants were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment);-On 1/5/26 night shift, CMT: 2 assigned for the medication pass and 4 nursing assistants were assigned to provide direct care (four to six fewer direct care staff than identified as needed on the facility assessment);-On 1/6/26 day shift, CMT: 3 assigned for the medication pass, and 6 nursing assistants worked 6:00 A.M. to 6:00 P.M. and were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment);On 1/6/26 night shift, CMT: 2 assigned for the medication pass, 5 nursing assistants were assigned to provide direct care (three to five fewer direct care staff than identified as needed on the facility assessment);-On 1/7/26 day shift, CMT: 2 assigned for the medication pass, 6 nursing assistants were assigned to provide direct care (two to four fewer direct care staff than identified as needed on the facility assessment). One nursing assistant was on light duty (passed ice and linens). 1. Review of Resident #2's undated Face Sheet showed the following:-The resident readmitted to the facility on [DATE];-Diagnoses included acquired absence below the knee on the right and left leg and osteomyelitis (infection in the bone). Review of the resident's Care Plan, dated 1/4/26, showed the following:-Assist the resident to bathroom before and after meals, at bedtime and as needed;-The resident was continent of bowel and bladder. Review of the PPS 5-day Minimum Data Set (MDS) a federally mandated assessment instrument required to be completed by facility staff, dated 1/4/26, showed the following:-Cognitive skills for daily decision making was independent;-The resident makes self-understood and understands others;-Speech was clear;-The resident was dependent on toilet transfer;-The resident was incontinent of bowel frequently and occasionally incontinent of urine;-The resident required substantial to maximum assistance with lower body dressing. During an interview on 1/7/26 at 9:48 A.M., the resident said the following:-He/She was out of bed before 6:00 A.M. that morning and had not been to the bathroom since then. He/She liked to get up early and needed two staff members to get back to bed;-He/She turned on his/her call light around 8:00 A.M. as he/she needed to have a bowel movement. A staff member came in and said they would be back as they needed two staff members to transfer him/her;-He/She turned his/her call light on a second time, and staff turned the call light off again; he/she was still waiting for staff to assist him/her to the bathroom. He/She had now been incontinent of urine and feces while waiting for staff assistance. His/Her skin was irritated;-The facility was short staffed early mornings and at night; Observation on 1/7/26 at 10:00 A.M. showed the resident remained in his/her wheelchair waiting for staff to assist her with changing his/her brief. Observation on 1/7/26 at 11:00 A.M. showed the resident remained in his/her wheelchair waiting to be changed. The resident requested the surveyor notify staff as his/her skin was very irritated. Observation on 1/7/26 at 11:02 A.M. showed the following:- Certified Medication Technician (CMT) A and CMT B (after being notified by the surveyor the resident was still waiting for assistance) used a mechanical lift to transfer the resident back to bed;-Both staff verified the resident was saturated with urine through the incontinence brief to his/her sweatpants. The wheelchair seat was also wet with urine;-Soft [NAME] feces the resident's front and back perineal area and lower back area. The resident's skin was bright red where the brief had been. The resident said his/her skin burned as staff cleaned urine and feces from his/her skin. During a telephone interview on 1/14/26 at 1:30 P.M. the resident said the following:-He/She was still in bed as staff had not assisted him/her out of bed yet for the day;-He/She turned on his/her call light a couple of times and had requested staff assist him/her out of bed and to get cleaned up. Staff came in and turned off his/her call light and had not returned;-He/She was incontinent of both urine and feces in his/her bed and had laid in it for hours; -His/Her skin was raw and irritated;-He/She had pulled off his/her soiled brief and was able to get wet wipes off his/her bedside table and clean up the best he/she could;-The soiled wipes and brief were beside him/her in bed. He/She could smell urine and feces in the bed;-The facility was short staffed. Weekends were very short staffed with only a couple aides on the floor;-He/She went hours waiting for assistance from staff;-He/She was very upset, and his/her feelings were hurt by how he/she was being treated. 2. Review of Resident #3's undated Face Sheet showed diagnoses included Alzheimer's disease, diabetes and dementia. Review of the resident's Care Plan, dated 11/14/25, showed the resident was incontinent of bowel and bladder, wore a brief for dignity and needed assistance from staff with toileting hygiene. Observation on 1/7/26 at 9:55 A.M. showed the following:-CMT C (assigned to work the floor as direct care staff) removed the resident's brief and said the resident was incontinent of bladder and bowel;- The resident had dried fecal material to the front and back perineal area. The resident's skin was red and there were creases to the skin where the brief had been;-CMT A said the resident was just assisted back to bed and was a mechanical lift transfer;-The resident was last checked and changed approximately three hours prior. 3. Review of Resident #4's undated Face Sheet showed diagnoses included end stage renal disease, hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the non-dominant side. Review of the resident's quarterly MDS dated [DATE] showed the following:-The resident was cognitively intact;-Functional limitation in range of motion to one side of the body involving both the upper and lower extremity;-Dependent on toilet hygiene and on chair/bed-to-chair transfer. Review of the resident's Care Plan, dated 11/14/25, showed the following:-The resident was incontinent of bowel and bladder. The resident wore briefs for dignity;-The resident needed help with personal hygiene;-The resident transferred with one to two staff assistance with a gait belt (a device placed around a resident's waist to help caregivers safely assist with walking, standing or transferring). During an interview on 1/7/26 at 3:30 P.M. the resident said the following:-He/She attended the resident council meetings routinely;-There was an ongoing issue with staff not answering call lights in a timely manner;-He/She had accidents (incontinence) while waiting for staff assistance. That made him/her feel ashamed and like a child;-He/She had to wait long periods for staff assistance to get back to bed or to get out of bed;-The facility was short staffed on weekends and evenings. 4. Review of Resident #1's undated Face Sheet showed diagnoses included mild dementia with agitation. Review of the resident's Care Plan, dated 9/23/25, showed the following:-The resident had mixed incontinence (stress and urge incontinence) and wore a brief for dignity and need assistance with toileting hygiene;-The resident needed assistance of one to two staff members with dressing;-The resident required assistance of one staff for transfers and used a wheelchair for mobility. Observation on 1/7/26 at 9:25 A.M. showed the following:-The resident was in his/her wheelchair in the hallway and a strong odor of urine permeated the hall;-CMT A (assigned to work the floor as direct care staff) pushed the resident in his/her wheelchair into the hall bathroom and said he/she was going to change the resident, as the resident was wet;- CMT A assisted the resident to the toilet and removed the resident's incontinence brief which was saturated with urine. The resident's inner legs and front and back perineal area were red with creases noted to the skin from the urine-soaked incontinence brief. The resident's pants and wheelchair cushion were saturated with urine. A strong odor of urine permeated the bathroom. 5. During an interview on 1/7/26 at 9:30 A.M. and 10:00 A.M. CMT A said the following:-Resident #1 was already out of bed when he/she arrived to work that morning at 6:00 A.M.; CMT A was assigned the resident's hall, and he/she had not checked the resident for incontinence or changed the resident since arriving to work because of short staffing;-CMT A was not sure when night shift assisted the resident out of bed;-He/She was not sure who answered Resident #2's call light, staff were working as fast as they could to assist the residents;-Resident #3 was last changed around 7:00 A.M. and assisted out of bed, the resident had not been checked and changed for approximately three hours;- The hall had a lot of heavy care residents, including multiple residents that required the mechanical lift for transfers. It was hard to get residents checked and changed every couple of hours;-It was common for the facility to be short staffed. He/She did the best he/she could. During an interview on 1/8/26 at 10:30 A.M. Certified Nurse Aide (CNA) F said the following:-The facility was short staffed;-Some staff completed mechanical lifts with only one person because they were short staffed;-The night shift staff were instructed by administration to get a minimum of two residents up per aide before the end of the night shift and those residents needed to be residents who required assistance with meals and were also a mechanical lift transfer. During an interview on 1/8/26 at 1045 A.M. CNA E said the following:-The facility was short staffed and staff members were unable to meet all the needs of the residents;-Call lights may go unanswered for 45 minutes or longer because staff were helping other residents;-Staff were not able to check and change residents every two hours because of short staffing. During interview on 1/7/26 at 11:02 A.M. CMT B said the facility was short staffed that day and it was difficult to assure residents were checked and changed in a timely manner. The facility was often short staffed. During an interview on 1/7/26 at 3:25 P.M. CMT D said the following:-The facility was short staffed and because of this, staff members were unable to check and change the residents every two hours;-Staff was not able to answer call in a timely manner due to being short staffed;-CMT D tried to help on the floor, but was too busy completing his/her medication pass responsibilities when assigned to the complete the medication pass;-On 1/6/26 Resident #2 waited for over an hour for his/her call light to be answered because staff were short staffed and helping other residents;-Many of the residents were incontinent while waiting for staff assistance to the bathroom. During an interview on 1/7/26 at 3:00 P.M. Licensed Practical Nurse (LPN) G said the following:-The facility was short staffed on some shifts;-Staff did not check and change the residents every two hours, it was probably closer to every three hours. During an interview on 1/8/26 at 3:48 P.M. Registered Nurse (RN) I said the following:-He/She worked the night shift. The facility was short staffed;-From 6:00 P.M. to 10:00 P.M. staff were busy trying to get residents changed and to bed;-Many residents were up until after 10:00 P.M. waiting for staff assistance back to bed;- Staff were not getting residents checked and changed every two hours and residents went long periods waiting for staff assistance while wet with urine. As a result, many of the residents had red skin related to waiting for staff assistance for long periods to be changed;-The facility had a lot of call ins. The facility did not have a consistent schedule. Staff were not marked off appropriately on the daily staffing sheet, so it was difficult to know who was working or not;-He/She had night shift staff get up four to five residents to help the day shift staff. He/She knew at least those residents would be changed, up for breakfast and would not have to lay in bed all day due to being short staffed. During an interview on 1/12/26 at 3:45 P.M. RN J said the following:-The direct care staff were short staffed around 75 percent of the time;-Incontinent residents were usually checked and changed every three hours. It was impossible for staff to change them every two hours;-Staff did not answer call lights in a timely manner;-The CMT was usually busy with the medication pass and it was difficult for them to help on the floor with direct care. During an interview on 1/7/26 the Director of Nursing said the following:-She was not aware that resident council minutes showed the residents were having issues with call lights not being answered timely;-Staff should answer call lights timely;-The facility recently had an increase in call ins, and it was difficult to get all the shifts covered;-Staff should check and change incontinent residents as needed, every two hours;-She would expect staff to meet resident needs. During an interview on 1/7/26 at 2:00 P.M. and 5:46 P.M. and 1/12/26 at 10:00 A.M. the Administrator said the following:-The CMT's assigned to the medication pass could also help some on the floor during their shifts;-She would expect for staff to check and change incontinent residents every two hours as needed, and call lights be answered timely;-Residents should not be saturated with urine. If residents were saturated with urine staff were not getting them changed quickly enough;-The facility had call ins, but she felt the shifts were usually covered;-She would expect staff to meet the resident needs;-The facility had changed from 8-hour shifts to 12-hour shifts and some staff quit due to the shift change;-The schedule was on an online app for staff to view, and the facility had a hard copy on each hall currently that was being updated. The two were not matching and too many staff were trying to update the schedule, and it was not getting updated appropriately. The facility had been short staffed on some shifts;-She had not put a system in place to ensure staff were answering resident call lights timely. 2692203

Based on interview and record review, the facility failed to follow physician orders for surgical wound care for one resident (Resident #11), of nine sampled residents. The facility failed to change the resident's wound vacuum assisted closure (vac) dressing (a specialized sealed foam bandage connected to a portable pump that applies gentle, constant suction to the wound) biweekly per the physician's order. As a result, the wound vac sponge adhered to the wound bed and the sternum (breastbone) requiring surgery for urgent wound debridement (the process of removing dead or damaged tissue from a wound) and omental flap mobilization and skin grafting (a reconstructive surgery technique used to cover large, complex or infected tissue defects, particularly on the chest wall using fatty tissue from the abdomen) for final wound closure. The resident required an extended hospital stay and required a behavioral health consult after the resident made statements of wanting to end his/her life due to his/her current situation. The facility census was 85.During an interview on 02/0/26 at 1:00 P.M., the Administrator said the facility did not have a policy specific to wound vacs. Review of the facility policy, Physician Orders, undated, showed the following:-A current list of orders must be maintained in the clinical record of each resident to avoid confusion and errors;-Treatment Orders: specify what is to be done, location, and frequency and duration of the treatment. Review of the facility policy, Dressing Change, undated, showed to complete dressings as ordered. 1. Review of Resident #11's undated face sheet showed the following:-The resident was admitted to the facility on [DATE];-Diagnoses included infection following a procedure, deep incisional surgical site (primary admission due to cardiac surgery), methicillin susceptible staphylococcus aureus infection (MSSA, an infection caused by bacteria) atherosclerosis of coronary bypass graft (plaque built up in bypass grafts), acute and subacute endocarditis (a slow progressive infection of the heart lining or valves). Review of the resident's hospital Discharge summary, dated [DATE], showed the following:-Diagnoses included coronary artery disease and sternal wound infection;-Continue with biweekly wound vac changes at the facility, remove the old wound vac sponge, place sterile gauze soaked with Vashe solution (wound cleanser) in wound bed for 5-10 minutes. Cleanse surrounding skin with Vashe solution. Once dry, apply Cavilon (advanced skin protectant) to intact skin surrounding wound. Apply new wound vac sponge, and keep wound vac at 125 millimeters of mercury (mmHg, unit of measurement used to quantify the level of negative pressure/suction applied to the wound) suction continuously;-General: alert and oriented. Conversational. Cooperative but with poor medical insight;-Return on Monday (12/15/25) to wound clinic for wound check. Review of the resident's hospital discharge orders, dated 12/10/25, showed the wound vac dressing change was to be completed biweekly. Review of the resident's Physician Order Sheet (POS), dated December 2025, showed change wound vac twice a day on Monday and Thursday. Remove the old wound vac dressing, place sterile gauze soaked with Vashe solution in wound bed for 5-10 minutes. Cleanse surrounding skin with Vashe solution. Once dry, apply Cavilon skin protectant to intact skin surrounding wound. Apply new wound vac sponge, keep wound vac at 125 mmHg suction, continuously. Review of the resident's Treatment Administration Record (TAR), dated December 2025, showed the following:-Change wound vac twice a day on Monday and Thursday. Remove the old wound vac dressing, place sterile gauze soaked with Vashe solution in wound bed for 5-10 minutes. Cleanse surrounding skin with Vashe solution. Once dry, apply Cavilon to intact skin surrounding wound. Apply new wound vac sponge, keep wound vac at 125 mmHg suction, continuously;-On 12/11/25 staff documented completing the dressing change;-On 12/15/25 at 7:46 P.M., staff documented late administration, dressing changed at the physician's office. During an interview on 02/04/26 at 1:30 P.M., Registered Nurse (RN) A/wound nurse said the dressing was ordered to be changed twice a week on Monday and Thursday and not twice a day on Monday and Thursday. The order was transcribed incorrectly. RN A said staff knew from the resident's hospital discharge orders it was bi-weekly, but never changed it on the POS or TAR. He/She said the dressing was never changed twice a day. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument, completed by the facility staff), dated 12/16/25, showed the following:-Cognitively intact;-The resident had no signs or symptoms of feeling down, depressed or hopeless;-The resident required substantial/maximum assistance with toileting, showering and upper and lower body dressing;-The resident had a surgical wound and surgical wound dressings. Review of the resident's Treatment Administration Record (TAR), dated December 2025, showed the following:-On 12/18/25 staff documented completing the dressing change;-On 12/22/25 at 9:08 A.M., staff documented the dressing will be changed tomorrow at the wound clinic;-On 12/25/25 at 8:32 A.M., staff documented the resident refused the dressing change and it was just changed at the wound clinic;-On 12/29/25 staff documented completing the dressing change. Review of the resident's Progress Note, dated 12/31/25 at 11:23 A.M., showed the following:-New updated orders from the wound care clinic regarding wound vac;-Wound vac orders, do not replace until Monday (01/05/26) due to wound vac being changed today. Review of the resident's Care Plan, updated 01/01/26, showed the following:-The resident plans to be here short term, regain his/her strength to be as independent as possible prior to discharge;-The resident required enhance barrier precautions secondary to his/her peripherally inserted central catheter (PICC, a long thin flexible, soft plastic tube inserted int a large vein in the upper arm and threaded to just above the heart which is used to deliver intravenous medications) and open wound to his/her chest.-The care plan did not address the wound vac dressing changes or care of the wound vac. Review of the resident's TAR, dated January 2026, showed the following:-Change wound vac twice a day on Monday and Thursday. Remove the old wound vac dressing, place sterile gauze soaked with Vashe solution in the wound bed for 5-10 minutes. Cleanse surrounding skin with Vashe solution. Once dry, apply skin protectant to intact skin surrounding wound. Apply new wound vac sponge, keep wound vac at 125 mmHg suction, continuously;-On 01/01/26 at 8:41 A.M., RN B documented not administered. Comment: changed yesterday at appointment. Review of the Wound Management Detail Report dated 01/05/26, showed on 01/05/26 at 4:49 A.M., observation of surgical incision completed. The length was 20 centimeters (cm), and the width 5 cm. Skin surrounding incision normal, incision drainage sanguineous (reddish, thin and watery), wound healing status was stable. Wound vac remains in place. Review of the resident's TAR, dated January 2025, showed the following:-On 01/05/26 at 10:28 A.M., RN B documented the resident refused the dressing change, dressing to be changed tomorrow at appointment. -On 01/08/26 at 1:00 P.M., RN B documented the resident refused the dressing change and wanted it done tomorrow (01/09/26);-On 01/12/26 the TAR was blank. During an interview on 02/05/26 at 12:45 P.M., RN/Wound Nurse/Educator A said he/she changed the resident's wound vac dressing on 01/05/26 at 4:49 A.M. RN B was not aware the dressing change was completed as this was documented under wound management and it should have been documented on the TAR. There was no evidence in the medical record staff changed the dressing on 01/06/26 or 01/09/26. Review of the resident's Progress Note dated 01/13/26 at 9:52 A.M., showed RN B spoke with the physician assistant at the cardiothoracic surgery clinic and he/she wanted to see the resident as soon as possible today, transport to take the resident after 10:00 A.M. today. Review of the resident's Progress Note, dated 01/13/26 at 2:01 P.M., showed the resident admitted to the hospital. Review of the resident's hospital records, dated 01/13/26 at 4:04 P.M., showed the following:-Chief complaint: My wound vac is stuck.-Our office was contacted by the facility this morning regarding the resident's wound vac. They attempted to remove the wound vac today and they were unable to remove the sponge. The resident was ordered to have biweekly wound vac changes; the facility did not perform wound vac change last week because they thought the resident's wound vac was changed at the clinic. The wound was not assessed at the clinic. The resident was here for a transesophageal echocardiogram (TEE, a specialized heart imaging test);-During evaluation, the sponge was severely adhered to the wound bed and sternum. Manual debridement was undertaken but the resident was unable to tolerate all the needed debridement. The resident refuses to return to the facility and was admitted for urgent wound debridement and omental flap mobilization (with general surgery) and skin grafting mobilization for final wound closure tomorrow. During an interview on 02/05/26 at 8:10 A.M., the resident said the following:-He/She was to be in the facility a short time for wound care;-He/She did not refuse any of his/her dressing changes while at the facility;-The facility waited too long to complete the wound vac dressing changes;-The nurses tried to put off completing the dressing until another day which caused the sponge to stick more when they finally changed the dressing;-Some of the nurses did not know how to change the dressing;-The dressing was to be changed twice a week;-He/She had to have surgery to cut the sponge out of his/her chest because staff waited too long to change the dressing;-He/She had additional pain, surgery and had to be readmitted to another skilled nursing facility;-He/She just wanted to return home. During an interview on 02/05/26 at 9:56 A.M., the resident's emergency contact said the following:-The resident was to be at the facility only a short time for wound care;-The resident was not receiving wound care as ordered;-The resident had very specific orders for wound care so the wound would heal like it was supposed to;-The resident called him/her on more than one occasion, scared because staff failed to complete the dressing change as ordered, or put it off to the next day;-On 01/12/26 the resident called him/her and said the facility could not remove the sponge from the wound and said it was adhered to the tissue;-He/She called and notified the cardiothoracic clinic right away;-On 01/13/26 the cardiothoracic clinic directed the facility to transport the resident to the hospital for evaluation of the wound;-The resident required surgery to remove the wound vac sponge because the facility had not changed the dressing for a week;-The resident refused to return to the facility and admitted to another facility after his/her surgery. During interviews on 02/04/26 at 3:45 P.M. and 02/05/26 at 12:45 P.M., RN /Wound Nurse/Educator A said the following:-She was not aware the facility was not getting any correspondence from the wound clinic after each appointment;-The charge nurse should clarify if a dressing change was completed at an appointment;-Staff should follow physician orders;-If a dressing change was not completed on the scheduled day it was ordered, staff should document why in the note and/or obtain physician orders as needed to change it on another day. During an interview on 02/05/26 at 2:45 P.M., the Director of Nursing said the following:-She would expect physician orders be followed for wound care and dressing changes;-The facility sends a referral sheet with each resident to their appointments where new orders or changes could be written;-If the referral paperwork was not completed staff should follow-up up with the physician's office after the appointment to see if any new orders or changes were made;-She was not aware the resident was refusing his/her wound vac dressing changes;-She would expect staff to notify the physician if that occurred frequently. During an interview on 02/04/26 at 3:50 P.M., the Administrator said the following:-She would expect staff to follow physician's orders regarding the wound vac and dressing changes;-The facility should follow the facility policies on physician orders. During an interview on 02/06/26 at 5:45 P.M., the resident's Physician Assistant said the following:-He/She was very familiar with the resident;-He/She was present during the resident's surgeries and followed the resident when he/she had appointments at the cardiothoracic clinic;-He/She completed wound vac dressing changes at each of the resident's appointments at the wound clinic;-On 12/31/25 at a clinic appointment, the resident reported concerns about his/her dressing changes. The resident said one of the nurses had difficulty with getting the old sponge out after a recent dressing change;-The resident said staff often passed the dressing change off to the next shift and it was left in place too long;-On 12/31/25, the Physician's Assistant contacted the facility by phone and explained the importance of dressing changes being provided as ordered twice a week;-The resident did not have an appointment at the wound clinic on 01/06/26;-On 01/12/26 the resident's emergency contact called the hospital upset and said the facility could not get the wound vac sponge out of the wound;-On 01/13/26 the Physician's Assistant called the facility and instructed the facility to send the resident to the hospital for evaluation;-Upon evaluation of the resident's wound at the clinic on 01/13/26, tissue had grown around the sponge and the wound vac sponge was severely adhered to the sternum;-More than one surgeon tried to remove the sponge and was unsuccessful. The resident was in a lot of pain and required morphine (narcotic medication used to treat moderate to severe pain) and oxycodone (narcotic medication used to treat moderate to severe pain). The only option was for the resident to have urgent surgery to remove the sponge;-The resident went too long without a dressing change which resulted in the wound vac sponge adhering to the tissue and sternum requiring surgery to remove the sponge;-The resident required an extended hospital stay and required a behavioral health consult after the resident made statements of wanting to end his/her life due to his/her current situation. During an interview on 02/09/26 at 4:30 P.M., the resident's Cardiothoracic Surgeon said the following:-The resident was alert and oriented and very coherent;-Staff did not change the dressing as ordered and left the wound vac sponge in place for too long which required urgent surgery to remove the sponge;-The resident had ingrowth of tissue into the sponge and the sponge was attached to the sternum;-The resident was in a lot of pain and distress, as a result the only option was urgent surgery to remove the sponge;-The healthy tissue had to be debrided to remove the sponge which resulted in prolonged healing;-Due to the resident's emotional distress over the situation the resident made comments of wanting to end his/her life. The resident required a behavioral health consult and follow-up while in the hospital. MO2717306

Based on interview and record review, the facility failed to act promptly upon the grievances and recommendations of the Resident Council, concerning issues of resident care and quality of life in the facility, and failed to provide the resident council with responses and actions taken regarding their concerns. The facility census was 89.During an interview on 1/12/26 at 10:00 A.M. the administrator said the facility did not have a policy regarding Resident Council meetings and facility response to the meetings, but she would expect for the facility to follow the regulatory requirements. Review of the Resident Council Minutes, dated 11/17/25, showed the following:-Seven residents attended the meeting;-Resident Council President: Resident #10;-The form directed staff to include old business and resolutions and new business and plan of action;-The residents said call light wait times were long;-The residents were waiting lengthy time periods to be changed and long wait times for showers;-The residents complained about the quality of the food and said the chicken was over cooked;-The residents said laundry was being lost and it was taking a long time to be located;-The resident council minutes did not include a response to the residents' concerns. Review of the Resident Council Minutes, dated 12/18/25, showed the following:-Residents in attendance included four residents which included Resident #4;-Old business: listed for follow-up from last month minutes and staff identified as responsible: Call lights (there was no follow-up documented from last month or the staff identified as being responsible);-New business:-Food concerns: Dry chicken and small portions;-Care concerns: Long call light times;-Laundry concerns: Missing laundry;-Housekeeping concerns: Retrain staff on deep cleaning;-Other issues to address: The residents want to see more results from Resident Council;-The resident council minutes did not include a response to the resident concerns. During an interview on 1/7/26 at 3:30 P.M. Resident #4 said the following:-He/She attended the resident council meetings routinely;-There was an ongoing issue with staff not answering call lights in a timely manner and there was never any follow-up from staff to the Resident Council meetings;-He/She had accidents (incontinence) while waiting for staff assistance. That made him/her feel ashamed and like a child. During an interview on 1/14/26 at 11:05 A.M. Resident #10 said the following:-He/She was a retired nurse and the resident council president. He/She attended the monthly Resident Council meetings routinely;-There was never any follow-up from staff on the concerns from the Resident Council meetings;-The issues with staff not answering the call lights were an ongoing problem. He/She waited long periods for staff to answer his/her call light. The facility was short staffed. He/She often had an accident (incontinence) waiting for staff to assist him/her with cares while waiting for staff to answer his/her call light;-The Director of Nursing, Administrator and/or department heads never discussed any of the concerns with him/her or plan of action to correct the issues;-The same concerns were brought up month after month at each meeting and nothing was ever done to address the issues. During an interview on 1/14/26 at 10:45 A.M. the Activity Director said the following:-He/She started as the activity director in October of 2025;-After each council meeting he/she typed up a letter to each department and gave a copy to the Director of Nursing (DON) and the Administrator;-He/She also spoke personally with the DON about care and nursing concerns. He/She wanted to make sure the DON was aware there did not seem to be any improvement from month to month on specific concerns such as call lights;-He/She had been more detailed with the DON so she would have a good understanding what the residents' complaints were;-He/She was not sure what the plan of action was to address the concerns from Resident Council meetings. During an interview on 1/7/26 at 2:00 P.M. and on 1/15/26 at 2:30 P.M. the DON said the following:-She had been the DON since June of 2025;-She was not aware of what her role was involving Resident Council concerns. She had just learned that she was to be receiving monthly copies of the Resident Council minutes and be involved in the follow-up;-She had not received any minutes from the meetings since she became the DON in June;-She was not aware how it worked or who followed up and what was done to address concerns;-She was not aware that Resident Council minutes showed the residents were having issues with call lights not being answered timely;-Staff should answer call lights timely. During an interview on 1/12/26 at 10:00 A.M. the Administrator said the facility had not addressed the issues identified in resident council minutes in November and December.

Based on interview and record review, the facility failed to follow professional standards of practice when staff failed to complete an assessment and documentation or obtain physician orders for treatment related to a fall with injury for one additional sampled resident, (Resident #10) in a review of 11 sampled residents. The facility census was 88. Review of the undated facility policy, Resident Condition Change, showed the following:-Purpose: To observe, record and report any change to the attending physician so that proper treatment can be implemented;-After a resident falls, injuries or changes in physical or mental function, monitor the following: -a. Observe for lacerations. If present, clean and apply dry, sterile dressing or dressing of physician's choice. Note size, depth and amount of bleeding or drainage;-b. Observe for swelling and discoloration, if present, chart size, site, amount and color;-d. Observe and inquire if resident has headache or pain;-k. Observe for gait, posture or balance disorder;-n. Take vital signs and include temperature;-3. Complete an incident, accident or risk management report per facility guidelines;-4. Notify resident's responsible party;-6. Notify physician of condition change, need for treatment orders and/or medication order changes. 1. Review of Resident #10's undated Continuity of Care Document showed the following: -admission on [DATE];-Diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis of one side following a stroke). Review of the resident's baseline care plan, dated 09/17/25, showed the following: -Cognition - confused; -Communication - verbal;-Interventions - monitor condition and report changes to Director of Nursing (DON)/physician as applicable;-Safety concerns - unsteady/unsafe independent transfers;-Bowel and bladder - always incontinent. Review of the resident's electronic health record showed the following:-A neurological assessment flow sheet documented by LPN J on 09/18/25 at 6:15 P.M.;-No documentation of a fall event for 09/18/25;-No documentation in the resident's nursing progress notes of a fall or treatment of any injuries related to a fall on 09/18/25;-No physician orders for treatment of an injury related to a fall on 09/18/25;-No evidence of notification of physician or responsible party related to a fall on 09/18/25. Review of the resident's undated Continuity of Care Document showed the resident discharged from the facility on 09/22/25. During an interview on 09/24/25 at 1:50 P.M., the resident's responsible party said the following: -The resident told him/her and the resident's sibling he/she fell while at the facility when taking himself/herself to the bathroom and had to get himself/herself up off the floor; -When the resident discharged to home, the resident had a bruise on his/her wrist and skin tears on his/her elbows and knee from the fall that had been treated with butterfly (an adhesive bandage to close a wound or flap) bandages; -The facility did not notify him/her of the fall or injuries requiring treatment. Review of the resident's electronic health record, safety event for fall report, dated 10/02/25 (11 days after discharge), documented by the Registered Nurse (RN) Educator, showed the following: -Description: fall in room;-Was fall witnessed? No, must begin 72-hour neurological checks per protocol and document appropriately;-Body observation - location of injury was left blank;-Notifications: attending faxed - no, physician notified - no, resident representative notified - no, care plan reviewed - no. During an interview on 11/18/25, at 1:03 P.M., Licensed Practical Nurse (LPN) D said the following: -He/She was not working when the resident fell but noticed neurological checks were started on the resident and had heard the resident had fallen;-With any resident fall, there should be documentation as well as a progress note, and any orders written if necessary;-With any condition change, the physician and responsible parties should be notified. During an interview on 11/22/25 at 8:31 P.M., LPN J said the following: -He/She was assigned to the resident's unit for a short period of time until another staff member (Registered Nurse F) took over;-He/She did not specifically recall the resident falling;-If he/she started the neurological checks, it would have been for an unwitnessed fall or for a fall with a head injury;-He/She did not specifically recall treating the resident for a skin tear;-If a resident has a fall, the normal procedure was to complete an assessment and nursing note, complete a fall event, notify the physician, notify the responsible party and notify the DON;-He/She only covered the unit for a short period of time and would have passed on to the oncoming nurse the event details; he/she did not complete any of the steps of facility procedure following the resident's fall; -The oncoming nurse should have made a nursing note at the minimum due to completing the neurological checks;-He/She would have passed on in report the need for the neurological checks and would have assumed the nurse taking over would have completed the nursing note, fall event form, notified the physician, notified the responsible party and DON. During an interview on 11/18/25 at 4:30 P.M., RN F said the following: -He/She did not specifically recall taking care of the resident;-He/She was unsure if the resident had a fall while he/she was assigned to care for the resident;-If he/she completed neurological checks on the resident, there must have been a reason to do them, but he/she was unsure of what the reason was;-Neurological checks were usually completed with an unwitnessed fall or a fall with a head injury and should have a nurses note documented when doing neurological checks;-If a resident has a fall, there should be a fall event and nurses notes completed, physician notified if needed and responsible party notified;-If the resident had a fall while he/she was the charge nurse, he/she was unsure why the fall event, nurses note, and notifications were not completed. During an interview on 11/18/25 at 2:22 P.M., the RN Educator said the following:-She was notified the resident had a fall while at the facility after the resident had been discharged home;-A fall event had not been created by the charge nurse LPN J; -She created a fall event for the fall that occurred on 09/18/25 when he/she was made aware of the fall on 10/02/25;-She would expect the charge nurse to make a progress note, notify the responsible party, notify the physician and notify the DON with any fall with injury. During an interview on 11/18/25, at 5:19 P.M., the DON said the following:-She was unaware the resident had a fall at the facility until after the resident was discharged ;-She would expect the charge nurse to complete a fall event for any fall and complete treatment as necessary;-If a resident falls and receives an injury, she would expect to be notified, as well as notifying the physician for orders and notifying the emergency contact. During an interview on 11/18/25 at 5:20 P.M., the administrator said the following:-If a resident falls, or has a condition change, she would expect nursing staff to notify the physician, emergency contact, DON and the Quality Assurance (QA) nurse;-Any resident fall should be documented in the electronic health record. #2626059

Based on observation and interview, the facility failed to routinely post daily staffing sheets and accurately post the number of hours worked by the staff who provided care. The facility census was 89.During an email correspondence dated 1/13/26 12:12 P.M. the administrator said the facility did not have a facility policy specific to posted staffing, but she would expect the facility to follow the regulatory requirements for posted staffing. 1. Observation on 1/7/26 at 3:00 P.M. showed a plastic sleeve attached to a wall at the entrance of the facility. Facility staff verified this was where posted staffing was displayed for the public to view. The plastic sleeve was empty. 2. Review of the posted daily staffing sheet provided by the Director of Nurses (DON), dated 1/1/26, showed the following:-Registered Nurse (RN): 2 worked day shift and hours worked were 24;-RN: 1 worked night shift and hours worked were 12;-Licensed Practical Nurse (LPN): 1 worked day shift and hours worked were 12;-LPN: 1 worked night shift and hours worked were 12;-Certified Medication Technician (CMT): 2 on day shift and hours worked were 24;-CMT: 2 on night shift and hours worked were 24;-Certified Nurse Assistant (CNA): 7 on day shift and hours worked were 80.5.-CNA: 6 on nights and hours worked were 69. Review of the hour details report (employee electronic time sheets), dated 1/1/26, showed the following:-Charge nurse: 3 on day shift and hours worked were 36;-Charge nurse: 2 on night shift and hours worked were 24;-CMT: 1 on day shift and hours worked were 12;-CMT: 2 on night shift and hours worked were 24;-CNA: 9 on day shift and hours worked were 102.5;-CNA: 6 on night shift and hours worked were 66. The posted staffing sheet did not match the actual hours staff worked. On day shift, the posted staffing sheet showed CNA hours worked were 80.5 and actual hours worked were 102.5 (22 hours more then what was posted). On night shift the staffing sheet showed CNA hours worked were 69 when actual hours worked were 66 (3 hours less then what was posted). Review of the posted daily staffing sheet provided by the DON, dated 1/2/26, showed the following:-RN: 1 on day shift and hours worked were 12;-RN: 2 on night shift and hours worked were 20;-LPN: 2 on day shift and hours worked were 24;-LPN: 1 on night shift and hours worked were 4;-CMT: 2 on day shift and hours worked were 24;-CMT: 1 on night shift and hours worked were 12;-CNA: 6 on day shift and hours worked were 69;-CNA: 6 on night shift and hours worked were 69. Review of the hour details report (employee electronic time sheets), dated 1/2/26, showed the following:-Charge nurse: 3 on day shift and hours worked were 36;-Charge nurse: 2 on night shift and hours worked were 24;-CMT: 2 on day shift and hours worked were 24;-CMT: 1 on night shift and hours worked were 12;-CNA: 6 on day shift and hours worked were 67.8;-CNA: 7 on night shift and hours worked were 64.5. The posted staffing sheet did not match the actual hours staff worked. On day shift, the posted staffing showed day shift CNA hours were 69 when actual hours worked were 67.8 (1.2 hours less than what the posted staffing showed) and on night shift, the posted staffing sheets showed 69 hours and actual hours worked were 64.5 (4.5 hours less than what was posted). Review of the posted daily staffing sheet, provided by the DON, dated 1/3/27, showed the following:-RN: None on day shift;-RN 2 on night shift and hours worked were 24;-LPN: 2 on days and hours worked were 24;-LPN: None on night shift;-CMT: 2 on day shift and hours worked were 24;-CMT: 3 on night shift and hours worked were 36;-CNA: 6 on day shift and hours worked were 69;-CNA: 8 on night shift and hours worked were 102.5. Review of the hour details report (employee electronic time sheets), dated 1/3/26, showed the following:-Charge nurse: 3 on day shift and hours worked were 36;-Charge nurse: 2 on night shift and hours worked were 24;-CMT: 2 on day shift and hours worked were 30;-CMT: 3 on night shift and hours worked were 39;-CNA: 6 on day shift and hours worked were 72;-CNA: 7 on night shift and hours worked were 90. The posted staffing sheet did not match the actual hours staff worked. On day shift, the charge nurse hours on the posted staffing sheet showed 24 hours when the actual hours worked were 36 (12 hours more then what was posted on the staffing sheet). On night shift the posted staffing sheet showed CNA hours worked were 102.5 when actual hours worked were 90 (12.5 hours less than the posted staffing sheet). Review of the posted daily staffing sheet, provided by the DON, dated 1/4/26, showed the following:-RN: None on day shift;-RN: 2 on night shift and hours worked were 24;-LPN: on day shift 24 and hours worked were 24;-LPN: None on night shift;-CMT: 2 on day shift and hours worked were 24;-CMT: 3 on night shift and hours worked were 36;-CNA: 6 on day shift and hours worked were 69;-CNA: 8 on night shift and hours worked were 79.5. Review of the hour details report (employee electronic time sheets), dated 1/4/26, showed the following:-Charge nurse: 2 on day shift and hours worked were 24;-Charge nurse: 2 on night shift and hours worked were 24;-CMT: 2 on day shift and hours worked were 30;-CMT: 3 on night shift and hours worked were 39;-CNA: 7 on day shift and hours worked were 67.6;-CNA: 5 on night shift hours worked were 69. The posted staffing sheet did not match the actual hours staff worked. The posted staffing sheet showed on day shift, CNA hours worked were 69 when actual hours worked were 67.6 (1.4 hours less than what was posted) and night shift CNA staff hours worked were 79.5 and actual hours worked were 69 (10.5 hours less than what was posted). Review of the posted daily staffing sheet, provided by the DON, dated 1/5/27, showed the following:-RN: 1 on day shift and hours worked were 12;-RN: 2 on night shift and hours worked were 12;-LPN: 1 on day shift and hours worked were 12;-LPN: 1 on night shift and hours worked were 12;-CMT: 3 on day shift and hours worked were 36;-CMT: 2 on night shift and hours worked were 24;-CNA: 8 on day shift and hours worked were 92;-CNA: 5 on night shift and hours worked were 57.5. Review of the hour details report (employee electronic time sheets), dated 1/5/26, showed the following:-Charge nurse: 3 on day shift and hours worked were 34.5;-Charge nurse: 2 on night shift and hours worked were 24;-CMT: 3 on day shift and hours worked were 32;-CMT: 2 on night shift and hours worked were 24;-CNA: 10 on day shift and hours worked were 82.7-CNA: 4 on night shift and hours worked were 48. The posted staffing sheet did not match the actual hours staff worked. The posted staffing sheet showed on day shift, charge nurse hours were 24 and actual hours worked were 34.5 (10.5 hours more than what was posted), on day shift, CMT posted staffing sheet showed 36 hours when actual hours worked were 32 (4 hours less than what was posted) CNA hours worked were 92 and actual hours worked were 82.7 (9.3 hours less than posted) night shift CNA staff hours worked were 57.5 and actual hours worked were 48 (9.5 hours less than what was posted). Review of the posted daily staffing sheet, provided by the DON, dated 1/6/27, showed the following:-RN: 2 on day shift and hours worked were 24;-RN: 1 on night shift and hours worked were 12;-LPN: 1 on day shift an hours worked were 12;-LPN: night shift an hours worked were 12;-CMT: 3 on day shift and hours worked were 36;-CMT: 2 on night shift and hours worked were 24;-CNA: 7 on day shift and hours worked were 80.5;-CNA: 5 on night shift and hours worked were 57.5. Review of the hour details report (employee electronic time sheets), dated 1/6/26, showed the following:-Charge nurse: 2 on day shift hours worked were 24 (one charge nurse moved to pass medications);-Charge nurse: 2 on night shift hours worked were 24;-CMT: 3 (included a charge nurse) on day shift hours worked were 36;-CMT: 2 on night shift hours worked were 24;-CNA: 7 on day shift hours worked were 59.7 (on day shift one CNA/CMT was moved to pass medications);-CNA: 5 on night shift hours worked were 60. The posted staffing sheet did not match the actual hours staff worked. The posted staffing sheet showed on day shift, the charge nurse hours worked were 36 when actual hours worked were 24 (12 hours less than what was posted) and posted staffing sheet showed day shift CNA hours worked were 80.5 and actual hours worked were 59.7 (20.8 hours less than what was posted). During an interview on 1/7/26 at 2:00 P.M. the DON said she was responsible for posting the staffing sheets and updating them. The posted staffing sheets were not always posted for the public to view and the posted staffing sheets were not always updated to reflect the actual hours worked by nursing staff. During an interview on 1/7/26 at approximately 2:15 P.M. the Administrator said the hours listed as worked by staff on 1/6/26 were incorrect on the daily staff sheet and two additional staff, CMT A and CMT C, were called in to cover the shift. The administrator wrote in CMT A and CMT C on the staffing sheet for 1/6/26 during the interview. During an interview on 1/7/26 at 2:20 P.M. CMT A said he/she did not work at the facility on 1/6/26. During an interview on 1/7/26 at 2:21 P.M. CMT C said he/she did not work at the facility on 1/6/26 Review of the hour details report for the facility, dated 1/6/26, showed CMT A and CMT C did not work on 1/6/26. During an interview at 1/7/26 at 2:30 P.M. the Administrator said she got her days mixed up on who worked what shift. CMT A and CMT C were added to the daily staffing sheet in error.

Based on observation, interview, and review of the Director of Nursing's (DONs) job description, the facility failed to ensure the DON served full time as DON and did not serve as charge nurse when the facility had an average daily occupancy of over 60 residents. This failure had the potential to affect the completion of nursing administration duties, including (but not limited to) staff training, quality improvement activities, and incident management for all 71 facility residents. The facility census is 71. Findings include: Review of the facility's DON Job description, dated May 2006 provided by the facility, revealed The DON must be in facility, or involved in other work-related activities a minimum of eight hours per day, Monday through Friday. ln addition, routine second shift, third shift, and weekend on-site inspections are to be maintained. During observations during the survey from Monday, 11/11/24 through Thursday 11/14/24, the DON/Infection Preventionist (DON/IP) was observed working on Unit 1 as a floor nurse/charge nurse. During an interview on 11/14/24 at 1:30 PM with the DON/IP, she stated that antibiotics reviews should be done every day, but she was not always able to do this because of having to work as the interim DON/IP and working on the floor. She stated she worked on the floor when needed and typically worked on the floor three days a week as a nurse. The DON/IP commented that she was hired two years ago in another position and was supposed to be the full time IP, but has worked as an interim DON several times over the last year and a half. During an interview on 11/14/24 at approximately 5:20 PM, with the Administrator and DON/IP, the DON/IP said, I work two weeks straight and then off for one day. The Administrator confirmed the DON/IP worked 120 hours every two weeks. The DON/IP stated, When I work on the floor as a nurse, I am the charge nurse. I pass meds [medications], provide wound measurements for the residents. When I'm the nurse in charge I do admissions and discharges. I work two to three days a week as a charge nurse on the unit. The IP/DON said, In between charting, providing treatments for residents, and passing meds, I can make rounds to check on them [the staff] on other units and could delegate nursing responsibilities to other floor nurses when able to focus on DON duties, if possible. The IP/DON stated that she was also the IP. When asked how many hours she serves as the IP, the DON said, 30 hours. The DON stated she had been working dual roles for three and a half months, when two day-shift nurses and two night-shift nurses left. The Administrator stated she worked Monday through Friday and though she could be contacted by staff on the weekend via phone if there was an issue, she typically did not come into the facility on the weekend. The Administrator stated she had contacted the corporate office months ago regarding the use of agency nurses to supplement staff but added, We are still waiting for feedback on agency staffing.

Based on interview, record review, and facility policy review, the facility failed to ensure residents were monitored who were administered psychotropic medications for five of six residents (R23, R48, R49, R56 and R57) reviewed for unnecessary medications out of a total sample of 24 residents. This failure had the potential to lead to unwarranted medication side effects or improperly treated symptoms. The facility census was 71. Findings include: Review of the facility policy (undated) titled; Antipsychotic Medication revealed Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Review of an undated facility policy titled Antipsychotic Medication Use indicated that the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks; the attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; the staff will observe, document, and report to the attending physician regarding the effectiveness of any interventions, including antipsychotic medications; nursing staff shall monitor and report any of the following side effects to the attending physician: sedation, orthostatic hypotension, lightheadedness, dry mouth blurred vision, constipation, urinary retention, increased psychotic symptoms, extrapyramidal effects, akathisia, dystonia, tremor, rigidity and Akinesia or tardive dyskinesia. The facility did not have a policy specific to monitoring for antidepressant agents or psychotropic agents. 1. Review of R23's undated Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE]. R23's diagnosis included depression unspecified. Review of R23's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/24 revealed R23 was assessed by staff to have had memory problems. The MDS indicated R23 had depression and had received antipsychotic medication and antidepressant medication during the seven days prior to the ARD. Review of R23's Orders located in the EMR under the Orders tab revealed an order for Cymbalta (antidepressant) 60 milligrams (mg) twice daily for depressive disorder and quetiapine 25 mg (antipsychotic agent) at bedtime for depressive disorder. The Orders did not include an order for behavior monitoring or side effect monitoring. Review of R23's Care Plan, located in the resident EMR under the Care Plan tab, indicated a focus area for antidepressant medications with interventions which included attempt GDR (gradual dose reduction) per pharmacy recommendations and as needed, assess behavioral symptoms, monitor for adverse reactions to medications. Review of R23's Observations,, Medication Administration Record (MAR), Treatment Administration Record (TAR), Point of Care response, Vitals, and Progress Notes in the EMR revealed no routine documentation related to behavior monitoring or antidepressant/antipsychotic side effect monitoring. During an interview on 11/13/24 at 12:20 PM Licensed Practical Nurse/Unit Manager (LPN/UM) 1 stated if a resident was on a psychotropic medication there should also be an order for behavior and side effect monitoring. Then the monitoring could be viewed on the MAR. She stated the facility used to have behavior and side effect monitoring on everyone but now no one on psychotropic medications had orders for monitoring. LPN1/UM confirmed there were no orders, or documentation, of monitoring for behaviors and side effects for R23. She also confirmed there was no other location in the EMR to routinely document behavior and side effect monitoring. During an interview on 11/13/24 at 5:05 PM the Director of Nursing (DON) stated residents do not have routine behavior and side effect monitoring because the staff document by exception. 18947 2. Review of R49's undated Face Sheet, found in the EMR under the Summary tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included depression, history of hallucinations, and anxiety. Review of R49's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The assessment indicated R49 did not exhibit any behaviors or signs and symptoms of depression during the assessment reference period. Review of R49's physicians Orders dated 11/14/24 and found in the EMR under the Orders tab, revealed an order dated 05/32/22, for Clonazepam (an antianxiety medication) 1 milligrams (mg)by mouth every evening for anxiety and an order dated 06/08/23 for Sertraline (an antidepressant medication) 100 mg by mouth every night for depression. Review of R49's Psychotropic Drug Use Care Plan, dated 06/01/22 and found in the EMR under the Care Plan tab, revealed the resident was receiving psychotropic medications for anxiety and depression. Interventions included please monitor me for an increase in behaviors and adverse reaction/response to my medication and administer my medications as ordered. The plan of care did not indicate any specific behaviors to be monitored related to the administration of R49's psychotropic medication. Review of R49's Medication Administration Recor (MAR) and Treatment Administration Record (TAR), dated 11/01/24 through 11/14/24 and found in the EMR under the Orders tab, revealed nothing to indicate specific behaviors related to the administration of R49's psychotropic medications or side effects of the medication were being monitored. Review of R49's comprehensive EMR revealed nothing to show specific behaviors related to the administration of the resident's psychotropic medications had been identified and were being tracked, side effects of the resident's psychotropic medications were being tracked, or informed consent had been obtained for the administration of R49's psychotropic medications. 3. Review of R56's undated Face Sheet, found in the EMR under the Summary tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included vascular dementia with behaviors, depression, and anxiety. Review of R56's significant change MDS with an ARD of 08/15/24 and found in the EMR under the MDS tab, indicated a BIMS score of 12 out of 15 which indicated the resident was moderately cognitively impaired. The assessment indicated R56 exhibited behaviors (verbal and other behavioral symptoms) on one to three days of the reference period and signs or symptoms of depression on two to six days of the reference period. Review of R56's physicians Orders dated 11/14/24 and found in the EMR under the Orders tab, revealed an order, with an original order date of 06/12/24, for Lexapro (an antidepressant medication) 10 mg by mouth daily for depression, an order, dated 07/24/24, for Lorazepam (an antianxiety medication) 0.5 mg every 8 hours as needed for generalized anxiety disorder, an order dated 98/01/24, for Lorazepam 1.0 mg twice daily routinely for generalized anxiety disorder, an order dated 11/05/24, for Remeron (an antidepressant medication) 30 mg by mouth every morning for depression, and an order dated 11/05/24, for Olanzapine (an antipsychotic medication) 5 mg by mouth twice daily for depression. Review of R56's comprehensive Care Plan dated 11/14/24 and found in the EMR under the Care Plan tab, revealed nothing to indicate a care plan was in place for the resident's behaviors or administration of resident's psychotropic medication. Review of R56's Medication Administration Recor (MAR) and Treatment Administration Record (TAR), dated 11/01/24 through 11/14/24 and found in the EMR under the Orders tab, revealed nothing to indicate specific behaviors related to the administration of R56's psychotropic medications or side effects of the medication were being monitored. Review of R56's comprehensive EMR revealed nothing to show specific behaviors related to the administration of the resident's psychotropic medications had been identified and were being tracked, side effects of the resident's psychotropic medications were being tracked, or informed consent had been obtained for the administration of R56's psychotropic medications. During an interview with the DON on 11/13/24 at 12:14 PM, she confirmed her expectation was a care plan was expected to be in place for resident behaviors and administration of psychotropic medications, side effects of the medications were expected to be tracked. The DON stated she was not aware informed consent should be received for the administration of psychotropic medication or that specific behaviors should be identified and tracked related to the administration of each individual psychotropic medication. 20243 4. Review of R57's undated Admission Record located in the EMR under the Admission tab, indicated the resident was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, major depressive disorder, anxiety disorders, and Alzheimer's disease. Review of R57's Physician Orders dated 10/13/24 - 11/13/24, located in the EMR under the Orders tab, revealed an order for Seroquel (an antipsychotic medication) 25 mg (milligrams) one tablet every day in the morning and Seroquel 100 mg one tablet every day in the evening. Review of R57's November 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no evidence of any monitoring of behaviors, efficacy or side effects related to the antipsychotic medication administered. 51809 5. Review of R48's Face sheet, located under the Resident tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of R48's Quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 09/27/24 revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. Continued review revealed R48 score zero for little interest or pleasure in doing things and feeling down, depressed, or hopeless and did not exhibit behaviors during the seven-day lookback period. Review of R48's comprehensive Care Plan located in the EMR under the Care Plan tab revealed, I have COPD with interventions to include: Administer my medications as ordered . The Care Plan did not address the resident's use of psychotropic medications, symptoms of anxiety, or behavioral interventions. Review of R48's EMR under the Orders tab indicated orders dated 07/24/24 for hydroxyzine (antihistamine) 50 milligrams (mg), one tablet orally three times a day as needed (PRN) for depressive disorder and lorazepam (Antianxiety) 0.5 mg 1 tablet orally three times a day PRN, for COPD. Review of R48's Medication Administration Record (MAR), dated 10/15/24 through 11/13/24 and located in the Reports tab of the EMR, revealed hydroxyzine and lorazepam had been administered concurrently on 10/16/24 at 10:13 PM, 10/18/24 at 10:56 PM, 10/26/24 at 5:22 PM, 10/29/24 at 4:20 PM, 10/30/24 at 5:57 PM, 10/31/24 at 1:39 AM, 11/02/24 at 4:13 PM, 11/03/24 at 4:01 PM, 11/07/24 at 3:53 PM, 11/08/24 at 9:37 PM, and 11/11/24 at 8:42 PM for behaviors/anxiety. Additional review revealed both medications had been effective for treating the behaviors/anxiety. However, the MAR did not indicate the specific behavior treated for each medication. Review R48's Progress Notes tab of the EMR revealed there was no documentation of behaviors expressed by the resident to warrant administration of either PRN medication. During an interview on 11/14/24 at 10:00 AM with Registered Nurse (RN)1, she confirmed R48 did not have monitoring in place related to the psychotropic medications he was being administered. During an interview on 11/14/24 at 1:30 PM with the DON/IP, she stated she expected nursing staff who were administering medications to monitor the effectiveness of the medication as well as the behaviors/symptoms the resident was exhibiting and report unresolved issues to the charge nurse and or the physician as needed to ensure the resident's quality of life and overall wellbeing.

Based on observation, interview, and facility policy review, the facility failed to ensure one medication cart observed out of five medications carts was locked when left unattended. The facility further failed to ensure 18 cards of controlled medications were stored in a double lock manner. Lastly, the facility failed to ensure one medication room observed out of three medications rooms was locked when left unattended. This had the potential for residents, staff, and visitors to access the medications for possible misappropriation. The facility census was 71. Findings include: Review of the undated Medications, Storage of policy indicated that 1. All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medication room, or one or more locked mobile medication carts. 2. All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room or otherwise made immobile, and 15. An unattended medication cart must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it or secured in a locked medication room. 1. During an observation on 11/13/24 at 7:53 AM, the medication cart on Hall 500 on South II Wing was left unlocked and unattended. There were no observed residents in the hallway. Observation further revealed Licensed Practical Nursing (LPN)2 returned to the cart after one minute and noticed that it was unlocked. LPN2 locked the cart and stated she thought she had locked it when she left the cart and had not noticed that it was unlocked. 2. During an observation on 11/14/24 at 3:34 PM, in Hall 100 on North Wing revealed the medication room door was wide open and no staff were in the area or in the medication room to monitor the room. Certified Medication Technician (CMT)3 returned from a room on Hall 100 approximately two to three minutes after the initial observation of the open medication room door and confirmed the door to med room was open. Approximately one minute later LPN1/Unit Manager (UM) came out of the Director of Nursing's (DON) office across the hall from the medication room. LPN1/UM confirmed the door was open and the cabinet with controlled medication in it was also unlocked. Both LPN1/UM and CMT3 confirmed the door to the medication room was to be locked when unattended at all times. LPN1/UM stated the cupboard door containing controlled medications was also to be locked at all times when nursing staff were not accessing the controlled medications. CMT3 was in possession of keys to both the medication room and the cupboard containing cards of overflow-controlled medications. 3. During an observation and interview with LPN1/UM on 11/14/24 at 4:35 PM revealed 18 cards of controlled medications were observed in the medication room on top of the counter, one card each of clonazepam (a medication used to treat seizure disorders and panic disorders 0.5 mg (milligrams), pregabalin (a medication used to treat seizures, fibromyalgia, and nerve pain) 75 mg, lorazepam (a medication used to treat anxiety disorders) 0.5mg and lacosamide (a medication used to treat seizures) 200 mg; two cards each of Oxycodone (a narcotic medication used to treat pain) 5 mg and Hydrocodone (a narcotic medication used to treat pain) 5/325; three cards of Tramadol (a narcotic medication used to treat pain) 50 mg; and seven cards of lorazepam (a medication used to treat anxiety disorders) 1 mg. The LPN1/UM confirmed the 18 cards of narcotic medications were left on the counter and not locked in the cabinet. During an interview on 11/14/24 at 9:41 AM the Administrator confirmed medication carts should be locked at all times. During an interview on 11/14/24 at 4:50 PM the Administrator stated that the expectation going forward is for medication rooms to be locked at all times when unattended and that controlled medications will be maintained in a double lock manner.

Based on observation, interview, record review, and facility policy review, the failed to ensure infection control was maintained during medication administration, failed to ensure oxygen tubing was dated to ensure potential respiratory infection was prevented, and failed to ensure hand hygiene was completed during wound care. This affected four of 24 (Residents (R) 39, R53, R48, and R64) residents. This had the potential for a potential transmission of infection. The facility census was 71. Findings include: 1. During an observation on 11/13/24 at 8:03 AM, Licensed Practical Nurse (LPN)2 poured one ferrous sulfate tablet 324 milligrams (mg) from the pill bottle directly into her bare hand. LPN2 then administered the medication to R39. During an interview on 11/13/24 at 8:23 AM, LPN2 stated that she normally poured a pill directly from the medicine bottle into the medicine cup prior to administration. LPN2 stated that this pill tends to fly away, so she poured it into her hand. LPN2 stated that she did not recall receiving training regarding touching pills with bare hands during medication administration. During an interview on 11/14/24 at 9:41 AM the Administrator stated there was not a specific policy that covered touching pills with bare hands during medication administration. When asked what her expectations were regarding infection control and sanitary practices during medication pass, she stated she expected that medications would be dispensed directly from the pharmacy card or bottle directly into the medicine cup and not touched by hands. 51809 2. Review of R48's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of R48's EMR under the Orders tab indicated orders to administer budesonide (used to treat inflammation in the lungs) suspension for nebulization; 0.5 milligrams (mg)/2 milliliters (mL); 1 ampule (amp); inhalation twice a day and ipratropium-albuterol solution (used to treat COPD) for nebulization; 0.5 mg-3 mg base)/3 mL; 1 ampule; inhalation four times a day. Review of R48's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/27/24 revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating moderate cognitive impairment. During an interview and observation on 11/11/24 at 10:15 AM, R48 stated the nurse hands him the nebulizer and when his treatment is finished, he hangs the mask on the bedrail, and it stays there until his next treatment. R48 continued to state he has never seen the nurse clean the nebulizer cylinder after each use and the mask has never been placed in a bag at the bedside. During observations of R48's room on 11/11/24 at 10:15 AM, on 11/11/24 at 11:43 AM, on 11/12/24 at 10:45 AM, on 11/13/24 at 8:25 AM, and on 11/14/24 at 9:25 AM, a nebulizer mask was hanging on the bedrail next to the window, not bagged or dated. During an interview and observation on 11/14/24 at 9:44 AM with Certified Medication Technician (CMT)1 confirmed R48's nebulizer mask was hanging on the bedrail next to the window, not bagged or dated. She stated the nebulizer mask should be bagged after each use and the medication cylinder should be washed with warm water after each use to prevent mold and the collection of germs. She stated the oxygen tubing and nebulizer equipment are changed weekly on Sundays by the night nurse and placed in a new bag and the bag is dated so staff know it's been changed, and then the person changing the equipment out is to initial it off on the Treatment Administration Record (TAR). During an interview on 11/14/24 at 1:30 PM with the DON/IP stated it was her expectation for all staff to follow the facility's Infection Control Policy and the nurses should be cleaning the nebulizer equipment and bagging it after each use to prevent the residents from getting a potential respiratory infection. 3. Review of the Wound Care and Treatment policy, note dated, revealed hand washing must be done as outlined in the guidelines . 3. Put gloves on. 4. Remove the soiled dressing and place it in the trash bag. Place the soiled scissors on one corner of the setup, not touching any of the other supplies. 5. Remove the gloves and discard them in the bag. 6. Clean scissors with 60 seconds of contact with alcohol and place on a clean [NAME] of setup. 7. Wash your hands and put on clean gloves. Review of R64's Face Sheet, located under the Resident tab of the EMR, revealed he was admitted to the facility on [DATE] with a diagnosis of skin ulcers. Review of R64's EMR under the Orders tab indicated an order dated 10/18/24 to clean left lateral ankle with normal saline (NS), pat dry, apply Xeroform to wound bed. Keep off edges if able, cover with four-by-four and optifoam daily. Review of R64's quarterly MDS with an ARD of 11/01/24 revealed a BIMS of 15 out of 15 indicating the resident was cognitively intact. Continued review revealed R64 had three venous wounds. During observation of R64's wound care on 11/13/24 at 10:45 AM, the Director of Nurses/ Infection Preventionist (DON/IP) applied a gown and gloves outside R64s room prior to entering the room. The DON/IP removed R64's left sock, removed her gloves, applied new gloves without sanitizing her hands first, grabbed a 4x4 gauze in one hand and a bottle of wound cleanser, sprayed the gauze with wound cleanser, and cleaned the left ankle wound. The IP/DON removed her gloves, did not wash, or sanitize her hands, applied new gloves, picked up the xeroform gauze and placed it over the wound, grabbed the optifoam dressing and secured it over the xeroform. The DON/IP then reached in her pocket, removed her ink pen, and dated the new dressing with her gloved hands. Continued observation revealed the DON/IP removed her gloves and without washing or sanitizing her hands she applied new gloves. The DON/IP then picked up a 4x4 gauze in one hand, and a bottle of wound cleanser in the other hand, sprayed the gauze with wound cleanser, cleaned the right-hand skin tear, and applied kerlix and tape with her gloved hands. During an interview on 11/14/24 at 1:30 PM with the DON/IP she stated she was very nervous during the wound care observation and realized after completing R64's treatment she had not washed or sanitized her hands between glove changes during R64's treatments to her wounds and should have. The DON/IP, also stated it was her expectation for all staff to follow the facility's Infection Control Policy. During an interview with the Administrator, she stated for the safety and wellbeing of the residents, she expected all facility staff to follow the facility's Infection Control Policy to prevent the development of diseases and infections. 18947 4. Review of the facility's undated Oxygen Administration Policy read, in pertinent part, Change humidifier and tubing per cleaning guidelines. Review of R53's Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, indicated the resident was admitted to the facility on [DATE]. Diagnosis included chronic COPD. Review of R53's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/25/24 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident was receiving oxygen therapy. Review of R53's physician's Orders found in the EMR under the Orders tab, revealed an order dated 09/05/24, that indicated the resident was to receive oxygen 1 to 2 liters per minute (lpm) via nasal cannula as needed for shortness of breath. Review of R53's comprehensive Care Plan dated 10/25/24 and found in the EMR under the Care Plan tab, revealed no Care Plan for the resident's use of oxygen. During an observation on 11/11/24 at 10:29 AM, on 11/12/24 at 10:22 AM, 3:08 PM, on 11/13/24 at 7:54 AM, and 9:26 AM revealed R53 was observed in her room and the resident's oxygen tubing had a label with a date of 10/21/24 (approximately three to three and one-half weeks prior to the observation dates). During an observation on 11/13/24 with Certified Nursing Assistant (CNA)3 confirmed the resident's oxygen tubing in use was dated 10/21/24 and stated she thought the tubing was supposed to be changed at least once per week. During an observation on 11/13/24 at 10:20 AM along with Licensed Practical Nurse/Unit Manager (LPN1/UM) confirmed the resident's oxygen tubing was dated 10/21/24 and stated the tubing was expected to be changed at least once per week on Sunday nights for prevention of potential infection. She stated the tubing change had been missed. During an interview on 11/13/24 at 12:34 PM with the Director of Nursing (DON) she stated her expectation was oxygen tubing was to be changed at least weekly on Sunday nights for infection prevention.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one resident (Resident (R)375) observed out of a total sample of 24 residents had an assessment and an order for self-administration of medications. These failures placed R375 at risk for medication errors, overdose, or misappropriation of medications. The facility census was 71. Findings include: Review of the facility policy titled, Medication Administration Guidelines, dated 02/07/13 revealed, Remain in the room while the resident takes the medication. Review of the facility policy titled, Medications, Self-Administration, Self-Storage, Leave At Bedside dated 02/07/13 revealed, The resident has a right to self-administer medication unless the interdisciplinary team has determined that this practice is unsafe for an individual resident . Self-administration and self-storage of over-the-counter medications: The resident's ability to self-administer over-the-counter medications and store them at the bedside (including external creams and ointments) shall be determined by the assessment and reassessment. A physician's order for these medications will also include 'may keep at bedside'. Review of R375's Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including insomnia, depression, anxiety, diabetes, low back pain, and constipation. Review of R375's Orders tab of the EMR revealed there was no order or assessment for R375 to have medications at her bedside for self-administration. During an observation on 11/11/24 at 12:34 PM in R375's room, revealed over-the-counter medications bottles on top of R375's dresser and on her bedside table. The room door was open and the resident was not in the room; the medications were visible from the hallway. The medications included, one bottle of melatonin pills (sleep aid), one large bottle of low dose aspirin, one bottle of opened Miralax (polyethylene glycol, a laxative), one bottle of Imodium (anti-diarrheal), one small bottle of lubricant eye drops, and one bottle of Osteo Bi-Flex (arthritis medication) capsules. During an interview on 11/12/24 at 10:26 AM, R375 said, I brought over-the counter medications in from my home. They [staff] know I have it. According to my outside doctor, I'm supposed to take it. During an observation on 11/11/24 at 12:37 PM, Certified Medication Technician (CMT) 1 provided medications in a cup to R375. CMT1 set the cup of medications on the table next to R375's plate. CMT1 walked away without observing R375 take her medications. During an interview on 11/11/24 at 12:38 PM, R375 said, I took the meds. The tech placed them on my table. During an interview on 11/11/24 at 12:40 PM, CMT1 said, Normally I stay with the residents when I pass meds. I trusted that she [R375] would take it. During an observation and interview on 11/12/24 at 10:38 AM with Licensed Practical Nurse (LPN) 2 in R375's room, the LPN confirmed the resident had medications on her dresser and/or bedside table. LPN2 said, These medications should not be in here at her bedside. It's a safety issue. I don't know who allowed her to have these medications, because on admission they are supposed to take things like this away from the residents unless they have been assessed and have a doctor's order but even so, it's still not safe because her husband (R376) has dementia and comes here to visit her. During an interview on 11/13/24 at 11:15 AM, the Director of Nursing/Infection Preventionist (DON/IP) said, Residents may have medications at the bedside if the physician approves; they need an order. Residents require observation and nurses are to complete self-administration of medication observation form [assessment] which should be in residents' chart. If the residents have medications at the bedside, that tells me staff did not go through their belongings at time of admission, that's why they were there (at the bedside). The admitting nurse should have gone through R375's belongings on admission and would have found the medications and stored them. The DON/IP said, I expect nurses to pass medications according to the five rights of medication pass. The nurses/CMTs are to watch residents take the medications, sometimes residents will cheek the medications or just don't take it.

Based on interview, record review, and facility policy review, the facility failed to ensure code status/advance directives would be honored when the facility failed to obtain a physician's signature or resident/responsible party signature for code status or advance directive paperwork for two residents (R375 and R48) of five residents reviewed for code status out of a total sample of 24 residents. The facility census was 71. Findings include: Review of the facility's undated Cardiopulmonary Resuscitation (CPR) Policy, revealed, Guidelines for CPR: NOTE: Do not initiate CPR if a valid DNR order is in place. Review of the facility's undated Advance Directive policy revealed it did not address code status and provision of or withholding CPR. 1. Review of R375's Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, anxiety disorder, and depression. The Face Sheet documented, Directive Copy on File: Notes-Do Not Resuscitate (DNR). Review of form titled Outside the Hospital Do-Not-Resuscitate (DNR) Order, located in the paper chart at the nurses' station, revealed the form was signed and dated by R375 on [DATE] but there was no physician signature or date on the form. During an interview on [DATE] at 4:38 PM, the Social Services Director (SSD) confirmed R375's DNR form was faxed to the physician, however, the physician had not signed the form because she was on vacation. The SSD stated that typically the nurse would get a verbal DNR order on the same day the form was completed; however, this was not done. The SSD stated there was a covering physician and nurse practitioner on call. The SSD stated in the event there were no orders for DNR, R375 would receive CPR and be considered Full Code status. During an interview on [DATE] at 4:46 PM, Registered Nurse (RN)1 stated she would perform full resuscitation on R375. (RN)1 said, I would normally check the chart to see if the DNR form is signed and if the DNR form is not signed, I would resuscitate. RN1 stated that R375 was fully cognitively intact and made her own decisions. RN1 stated that R375 told her she elected DNR. During an interview on [DATE] at 5:40 PM, R375 said, I do not want resuscitation. It's on my file. I have already signed the DNR form, and the staff are aware of my wishes. During an interview on [DATE] at 11:16 AM, the Director of Nursing/Infection Preventionist (DON/IP) said, in the case a resident should code, a full code means CPR would be started by the nurse. If a resident is a DNR according to the EMR and chart, I would not expect nurses to perform CPR. 51809 2. Review of R48's Face Sheet, located under the Resident tab of the EMR, revealed he was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Continued review revealed a Do Not Resuscitate (DNR) code status. Review of R48's Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] and located in the Resident Assessment Instrument (RAI) tab of the EMR, revealed a Brief Interview for Mental Status score (BIMS) of 13 out of 15 indicating he was cognitively intact. Review of R48's EMR under the Orders tab indicated an order dated [DATE] for Full Code status. Review of R48's Progress Note dated [DATE] revealed the Social Service Director (SSD) spoke with resident today and he has chosen to change code status to Full Code. He did not wish to be put on a vent or anything that breathes for him. Resident code status changed to Full Code. Review of R48's EMR revealed a new code status of DNR dated [DATE]. Review of R48's Care Plan, dated [DATE] and located in the Care Plan tab of the EMR, revealed, I have an Advanced Directive as evidenced by (AEB): Do Not Resuscitate, with interventions to include if observed without pulse and/or respirations, do not start cardiopulmonary resuscitation (CPR), do not call 911; keep my family informed of condition changes and review my code status quarterly and as needed. Review of R48's Hard Chart, located at the nurse's station, revealed a red laminated piece of paper located in the front of the chart that documented, Do Not Resuscitate (DNR). However, there was no documented evidence to support a physician-signed DNR order was placed in the medical record under the Advanced Directive tab or resident-signed code status election. During an interview on [DATE] at 3:30 PM with Registered Nurse (RN)1, she stated a purple signed Out of Hospital DNR form, which would contain the resident/representative signature as well as physician's signature, should be in the hard chart but R48 did not have one. She stated the DNR form should have been completed by the SSD when there was a change in code status and the SSD was responsible for ensuring the code status was updated in the medical record at the time the change was made. During an interview on [DATE] at 3:45 PM with R48, he stated staff had discussed code status with him when he arrived at the facility and he had informed them if his heart stopped beating and he stopped breathing, he did not want anything done to save him. During an interview on [DATE] at 10:20 AM with the SSD, she stated she was responsible for obtaining the code status on admission and making changes as needed. She further stated any nurse can obtain a physician's order and change code status upon the resident's request. The SSD stated changes in code status should be made immediately and a physician's order must be obtained and placed in the resident's chart and updated in the EMR. The SSD stated when a resident was found unresponsive, staff should look at the Hard Chart and the EMR to determine code status. She stated the first line of review would be to look at the Hard Chart to see if the color-coded laminated sheet was in front of the chart. She stated a red laminated sheet located in the front of the chart is for DNR and a purple form is an Out of Hospital DNR form and should be located under the Advanced Directives tab in the hard chart and the form should be signed and dated by the resident or the resident's representative and signed by the physician. She stated a green laminated sheet was located in the front of the chart for Full Code. The SSD stated RN1 brought it to her attention on [DATE] that R48 had conflicting code status orders, and a purple signed Out of Hospital DNR form was missing from R48's Hard Chart. The SSD stated she then went to R48 immediately on [DATE] and asked him what his preference was for code status and the resident told her he wanted to have CPR but if there was no hope, he did not wish to be intubated or be placed on a ventilator. The SSD stated she immediately notified the physician and made the change to the resident's chart. Review of R48's Progress Note dated [DATE] revealed the SSD documented, State surveyor alerted social services that resident had requested DNR status. Provider Partners Health Plan (PPHP), Registered Nurse (RN) and SSD spoke with the resident. It was explained to him what CPR was and what would/could happen. He stated again that he wanted CPR. The resident signed to be a Full Code and the physician signed the order. During an interview on [DATE] at 11:20 AM with the Administrator, she stated it was her expectation for all residents to have the appropriate code status on file and resident code status should be honored. During an interview on [DATE] at 1:30 PM with the Director of Nurses/ Infection Preventionist (DON/IP), she stated she expected nursing staff to obtain a signed resident or resident representative Out of Hospital DNR and signed physicians order and ensure the order was placed under the Advanced Directive tab in the resident's hard chart. She stated she expected the EMR and the Care Plan to reflect the residents' wishes regarding code status. She further stated changes in code status should be updated immediately to ensure the residents' advance directive wishes were honored.

Based on interview and record review, the facility failed to properly notify residents of potential non-coverage and beneficiary financial liability for two of three residents (Resident (R)225 and R227) reviewed for beneficiary notification out of a total sample of 24 residents. This had the potential to place undue financial liability on residents without their knowledge. The facility census was 71. Findings include: The facility did not provide a policy related to Advanced Beneficiary Notice (ABN). 1. Review of R225's undated Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R225 was admitted to the facility on [DATE] and discharged on [DATE]. Review of a document titled Notice of Medicare Non-Coverage (NOMNC) for R225 revealed a NOMNC dated 09/03/24 indicating a coverage end date of 09/14/24. There was no ABN with a benefits end date of 09/14/24 when R225's coverage for skilled nursing was due to end and R225 remained in the facility. Review of R225's Progress Notes revealed R225 remained in the facility and continued to receive skilled nursing care after 09/14/24. 2. Review of R227's undated Face Sheet, located in the Face Sheet tab of the EMR, revealed R227 was admitted to the facility on [DATE] and discharged on [DATE]. Review of a NOMNC dated 08/23/24 for R227 indicated a coverage end dated 08/25/24. There was no ABN with a benefits end date of 08/25/24 when R227's coverage for skilled nursing was due to end and R227 remained in the facility. Review of R227's Progress Notes revealed R227 remained in the facility and continued to receive skill nursing care after 08/25/24. During an interview on 11/14/24 at 6:26 PM the Administrator stated they used the wrong form for beneficiary notices for R225 and R227.

Based on review of facility policy, record review, and interview, the facility failed to ensure one resident (Resident (R) R25) out of three residents reviewed for abuse was free from resident to resident verbal abuse. R25 was verbally abused by R49. This failure created the potential for further resident to resident abuse and for R25 to experience psychosocial harm related to the abuse. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy read, in pertinent part, It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion; and examples include scolding, ignoring, ridiculing, or cursing a resident. 1. Review of R25's undated Face Sheet found in the Electronic Medical Record (EMR) under the Summary tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia without behavioral disturbance and generalized anxiety disorder. Review of R25's annual Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 08/04/24 found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated R25 did not exhibit any behaviors during the assessment reference period. Review of R25's comprehensive Progress Notes, dated 09/01/24 through 11/15/24 found in the EMR under the Notes tab, revealed nothing related to the resident being abused. 2. Review of R49's undated Face Sheet, found in the EMR under the Summary tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease and history of hallucinations. Review of R49's annual MDS with an ARD of 08/03/24 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The assessment indicated R49 did not exhibit any behaviors during the assessment reference period. Review of R49's Progress Note, dated 09/16/24 and found in the EMR under the Notes tab, indicated, Resident (R49) at desk, yelling at another resident (R25) to shut the (expletive) up you stupid (expletive)! Resident began to yell at this writer and CMT (Certified Medication Tech) calling staff stupid (expletive) can't even make her shut up. Resident was asked to return to room. Review of the facility's reportable incident documentation for 09/01/24 through 11/15/24 revealed nothing to indicate the 09/16/24 incident perpetrated by R49 toward R25 was ever investigated. During an interview with LPN1/UM on 11/13/24 at 3:19 PM, she confirmed she wrote the 09/16/24 progress note in R49's record related to the incident of resident-to-resident verbal abuse perpetrated against R25. She stated she witnessed the interaction between R49 and R25 and, although R25 did not recall the incident after it occurred and did not appear to be harmed in any way by the interaction, the incident was potential verbal abuse. During an interview with the Director of Nursing (DON) on 11/13/24 at 3:15 PM, she indicated the Unit Manager (Licensed Practical Nurse1/Unit Manager (LPN1/UM) may have reported the incident to her, but she could not recall for certain. The DON stated all residents were expected to remain free of abuse. During an interview with the Administrator on 11/13/24 at 3:27 PM, she indicated the incident had been discussed in the facility's daily nursing meeting and she was aware of the incident. She stated she was unsure of whether the incident was verbal abuse, but stated her expectation was all residents in the facility were to remain free from abuse of any kind.

Based on review of facility policy, record review and interview, the facility failed to ensure timely reporting of allegations of abuse related to three (Residents (R) R22, R25 and R49) out of a total of three residents reviewed for abuse. R22 reported an allegation of staff to resident abuse and R25 was verbally abused by another resident (R49) and neither incident was timely reported to the State Agency (SA), Ombudsman or local law enforcement. This failure created the potential for these and other residents to experience potential further abuse. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: The facility's undated Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy read, in pertinent part, It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion; and examples include scolding, ignoring, ridiculing, or cursing a resident; and The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. 1. Review of R22's undated Face Sheet found in the Electronic Medical Record (EMR) under the Summary tab, revealed the resident was admitted to the facility on [DATE]. Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference (ARD) of 10/04/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period. During an interview with R22 on 11/12/24 at 9:47 AM, she reported an allegation of potential staff to resident abuse perpetrated against her by a Certified Medication Tech (CMT). The resident did not give the CMT's name. R22 stated whenever she had a bowel movement (BM) in her bed, the staff member would get mean. R22 stated she felt humiliated by the way the staff member spoke to her and stated, She (the staff member) talks to me like I am a piece of (expletive). She is very stern and very nasty. R22 stated when the staff member assisted her with changing her clothing after she had a BM in her bed a couple of days earlier the staff member had grabbed her leg and hurt her and then had yelled at her when she removed the staff member's hand from her leg. R22 stated she had not reported the incident to anyone at the facility. R22's allegation of potential abuse was reported by the surveyor to the Administrator on 11/12/24 at 10:50 AM. The Administrator acknowledged the report and stated she would follow up and initiate an investigation into the allegation. During a follow-up interview with the Administrator on 11/13/24 at 2:32 PM, the survey requested an update on the progress of the investigation. The Administrator stated an investigation into the allegation was ongoing, however no report had been made related to the incident to the SA, the Ombudsman or local law enforcement. She stated she did not know she was required to report to these entities when a recertification survey was being conducted since she thought the surveyors would take care of all of the reporting related to the incident. 2. Review of R25's undated Face Sheet, found in the EMR under the Summary tab, revealed the resident was admitted to the facility on [DATE]. Review of R25's annual MDS with an ARD of 08/04/24 and found in the EMR under the MDS tab, indicated a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated R25 did not exhibit any behaviors during the assessment reference period. 3. Review of R49's undated Face Sheet, found in the EMR under the Summary tab, revealed the resident was admitted to the facility on [DATE]. Review of R49's annual MDS with an ARD of 08/03/24 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The assessment indicated R49 did not exhibit any behaviors during the assessment reference period. Review of R49's Progress Note, dated 09/16/24 and found in the EMR under the Notes tab, indicated, Resident (R49) at desk, yelling at another resident (R25) to shut the (expletive) up you stupid (expletive)! Review of the facility's reportable incident documentation from 09/01/24 through 11/15/24 revealed nothing to indicate the 09/16/24 incident perpetrated by R49 toward R25 was ever reported to the SA, local law enforcement or the local Ombudsman. During an interview with LPN1/UM on 11/13/24 at 3:19 PM, she confirmed she wrote the 09/16/24 progress note in R49's record related to the incident of resident-to-resident verbal abuse perpetrated against R25 and stated the incident had been reported immediately to the DON. During an interview with the Director of Nursing (DON) on 11/13/24 at 3:15 PM, she indicated the Unit Manager (Licensed Practical Nurse1/Unit Manager (LPN1/UM) may have reported the incident to her, but she could not recall for certain. The DON further stated she did not think the incident had ever been reported to any outside agency, including the SA, the local Ombudsman or local law enforcement. The DON stated the reporting should have been done within two hours after the incident occurred. During an interview with the Administrator on 11/13/24 at 3:27 PM, she indicated she was aware of the incident and confirmed the incident had never been reported to the SA, the Ombudsman, or local Law Enforcement. The Administrator stated she was unsure of the reporting requirements related to an incident of Resident-to-Resident abuse.

Based on review of facility policy, record review, and interview, the facility failed to ensure a thorough investigation was completed related to an incident of resident-to-resident verbal abuse involving two (Residents (R )25 and R49) out of a total of three residents reviewed for abuse. This failure created the potential for R25 and other residents to experience further abuse. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy read, in pertinent part, Investigation: It is the policy of his facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. 1. Review of R25's Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia without behavioral disturbance and generalized anxiety disorder. Review of R25's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated the resident was severely cognitively impaired. 2. Review of R49's Face Sheet, found in the EMR under the Summary tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease and history of hallucinations. Review of R49's annual MDS with an ARD of 08/03/24 and found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Review of R49's Progress Note, dated 09/16/24 and found in the EMR under the Notes tab, indicated, Resident (R49) at desk, yelling at another resident (R25) to shut the (expletive) up you stupid (expletive)! resident asked to please return to room and not to speak to other residents that way. Review of the facility's reportable incident documentation from 09/01/24 through 11/15/24 revealed nothing to indicate the 09/16/24 incident perpetrated by R49 toward R25 was ever investigated by the facility. During an interview with Licensed Practical Nurse/Unit Manager (LPN1/UM) on 11/13/24 at 3:19 PM, she confirmed she wrote the 09/16/24 progress note in R49's record related to the incident of resident-to-resident verbal abuse perpetrated against R25 and stated she did not know if the incident had ever been investigated as abuse. During an interview with the Director of Nursing (DON) on 11/13/24 at 3:15 PM, she indicated she thought the incident of abuse might have been reported to her, but she did not know if the incident had ever been investigated by the facility. The DON confirmed it was the responsibility of the Administrator, the DON, and/or the Social Services Director (SSD) to conduct investigations into any allegation of potential abuse or neglect. The DON stated she thought the abuse should probably have been investigated. During an interview with the Administrator on 11/13/24 at 3:27 PM, she indicated she was aware of the incident and confirmed the incident had never been investigated. The Administrator stated the management team had discussed psychiatric services for R49, however the incident had not necessarily been interpreted as abuse. The Administrator stated she was unsure of the investigation procedures related to an incident of Resident-to-Resident abuse.

Based on record review and staff interview, the facility failed to ensure three residents (R9, R48, and R53) of a total of 24 residents reviewed had comprehensive care plans in place to address all of their needs. R9 did not have a care plan with interventions to prevent the resident from experiencing another coffee burn. R48 did not have a care plan in place to address his behaviors or the administration of his psychotropic medications and R53 did not have a care plan in place to address the administration of her oxygen. This failure created the potential for comprehensive care to not be provided for the residents. The facility census was 71. Findings include: 1. Review of R53's Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnosis included chronic obstructive pulmonary disease (COPD). Review of R53's quarterly Minimum Data Set (MDS)with an Assessment Reference Date (ARD) of 10/25/24 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident was receiving oxygen therapy. Review of R53's physician's Orders, found in the EMR under the Orders tab, revealed an order, dated 09/05/24, that indicated the resident was to receive oxygen 1 to 2 liters per minute (lpm) via nasal cannula as needed for shortness of breath. Review of R53's comprehensive Care Plan, most recently dated 10/25/24 and found in the EMR under the Care Plan tab, revealed no care plan for the resident's use of oxygen. During an observation on 11/11/24 at 10:29 AM, R53 was observed in her room receiving oxygen, as well as on 11/12/24 at 10:22 AM, 3:08 AM, on 11/13/24 at 7:54 AM and 9:26 AM. During an interview with Licensed Practical Nurse/Unit Manager (LPN1/UM) on 11/13/24 at 10:46 AM, she confirmed there was no care plan in the resident's record for the use of oxygen and stated there should be a care plan in place. During an interview with the Director of Nursing (DON) on 11/13/24 at 12:14 PM, she confirmed her expectation was care plans should be in place for residents to address all of their needs. During an interview with the MDS Coordinator (MDSC) on 11/14/24 at 11:48 AM, she stated she was behind with care planning for residents and confirmed a care plan should be in place for the administration of R53's oxygen. 51809 2. Review of R48's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed he was initially admitted to the facility on [DATE] with a diagnosis of COPD. Review of R48's EMR under the Orders tab indicated orders dated 07/24/24 for hydroxyzine HCl (antihistamine) 50 milligrams (mg), one tablet orally three times a day as needed for depressive disorder and lorazepam (antianxiety) 0.5 mg 1 tablet orally three times a day as needed for COPD. Review of R48's Comprehensive Care Plan located in the EMR under the RAI tab dated 04/01/24 revealed: I have COPD with interventions to include, administer my medications as ordered . Continued review revealed R48 had not been care planned for Depressive Disorder or Anxiety related to COPD. 3. Review of R9's undated Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnosis included dementia. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/24 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was moderately cognitively impaired. Review of R9's Progress Notes, dated 11/08/24 and found in the EMR under the Notes tab, revealed, R9 returned from dining room by Certified Nursing Assistant (CNA) resident had spilled hot coffee on her left arm and abdomen. Noted resident to have redness with small blisters noted to left wrist and forearm, redness and small blisters also noted to left abdomen. Clothing removed and cool moist compresses held to areas. (Physician) notified of incident and NNO (no new orders) received at this time. (Family Member) notified of incident. Review of R9's comprehensive Care Plan most recently dated 10/21/24 and found in the EMR under the Care Plan tab, revealed nothing to indicate the resident's Care Plan had been updated with interventions to prevent the resident from experiencing another coffee burn. During an interview on 11/14/24 at 10:00 AM with Registered Nurse (RN)1 confirmed R48 was not care planned for his diagnoses of depressive disorder and anxiety so staff would know what to do to treat the resident appropriately. During an interview on 11/14/24 1:30 PM with the Director of Nursing/ Infection Preventionist (DON/IP) she confirmed R48 should have been care planned for his diagnoses of depressive disorder and anxiety to ensure staff provided the care needed to improve R48's overall well-being and quality of life. During an interview with the Administrator and DON together on 11/11/24 at 2:35 PM, the DON stated a lid had been added to R9's coffee cup to prevent further burns, however she was not sure if the intervention had been added to the resident's care plan.

Based on interview, record review, and facility policy review, the facility failed to ensure a final discharge summary was completed upon discharge for one resident (Resident (R) 17) of three residents reviewed for discharge out of a total sample of 24 residents. This deficient practice had the potential to contribute to a lack of continuity of care and lack of necessary treatment and services. The facility census was 71. The findings include: Review of the facility's policy titled, Resident Discharge/Transfer Policy dated March 2015, revealed, Complete discharge summary and post discharge plan of care form. Have resident and/or representative or person responsible for care sign discharge summary and post discharge care form. Place the original form in the record. Review of R17's Face Sheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included: sepsis, palliative care, morbid (severe) obesity, schizophrenia, peripheral vascular disease, pain, diarrhea, constipation, multiple myeloma, type 2 diabetes mellitus. R17 was discharged from the facility on 10/12/24. Review of R17's Recapitulation of Stay and Discharge Summary form, dated 10/12/24 and located in the Observations tab of the EMR, revealed the form was not completed, all questions were left blank. During an interview on 11/14/24 at 1:47 PM, the Social Services Director (SSD) stated R17 was discharged to another facility upon his request on 10/12/24. The SSD stated R17 was admitted from the hospital with a diagnosis of multiple myeloma and was placed on hospice and since R17 had family in another city, he decided to transfer to a facility closer to his family. The SSD verified R17's Recapitulation of Stay and Discharge Summary electronic discharge summary was not completed.

Based on facility policy review, observation, record review, and interviews, the facility failed to implement their scheduled activities programs for residents. The facility also failed to ensure one (Resident (R)9) of two residents reviewed for activities was provided with a consistent activity program to meet their needs. The resident was not offered activities based on assessment of her activity preferences. This failure created the potential for the resident to experience isolation related to lack of participation in facility activities. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's Activity, Volunteer and Recreational Services Policy dated 03/2012 read, in pertinent part, The facility provides for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. 1. Review of the facility's activity calendars for 11/01/24 through 11/30/24 were reviewed and showed activities such as Coffee and Donuts, BINGO, Word Find, Puzzles, Exercise, Whack a Mole, Coloring and Nail Care scheduled at specific times between 10:00 AM and 2:00 PM Monday through Friday. There were religious services offered by the local church on Sundays at 2:00 PM. Scheduled activities during the survey conducted between 11/11/24 and 11/14/24 were as follows: 11/11/24 (Monday): 10:00 AM Veteran's Day Recognition, 12:00 Puzzle, 2:00 Veteran's Day Craft. 11/12/24 (Tuesday): 10:00 AM Whack a Mole, 12:00 Coloring, 2:00 Nail Care. 11/13/24 (Wednesday): 10:00 1:1 Visits, 12:00 Word Find, 2:00 BINGO. 11/14/24 (Thursday) 10:00 Exercise, 12:00 Puzzle, 2:00 Glascow and Friends. Observations of scheduled activities on 11/11/24 through 11/14/24, showed of the 12 activities that were scheduled during that period of time, only the Veteran's Day Recognition (Monday), Whack a Mole (Tuesday), BINGO (Wednesday), and Glascow and Friends (Thursday) occurred. During a phone interview with the Activities Director on 11/14/24 at 1:25 PM, she stated she had been out of the facility for a couple of weeks, and thought other staff members were conducting scheduled activities when she was not in the facility, including evenings and on weekends. The AD stated she had not had time to document activity participation in resident activity logs for the previous few weeks. The AD stated she thought a lot of the residents participated in the church service on Sundays, but did not know if attendance was being documented or not. She stated the facility's Bookkeeper helped with BINGO on BINGO days and she thought Restorative Staff did exercises with residents sometimes. 2. Review of R9's undated Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, indicated the resident was admitted to the facility on [DATE]. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/24 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was moderately cognitively impaired. Review of R9's Activities Care Plan, dated 04/26/22 and found in the EMR under the Care Plan tab, revealed the resident attended activities that she enjoyed with encouragement from staff and that she required staff supervision with activities. The care plan indicated the resident enjoyed going outside and BINGO. Interventions included encourage me to socialize during group activities, give me an activities calendar, and provide one to one visits for sensory stimulation, socialization, and emotional support. Review of R9's Interview for Resident Preferences and Activities Assessment, dated 01/17/24 and found in the EMR under the Observations tab, revealed it was somewhat important or very important for the resident to have books, the newspaper, and/or magazines to read, do things with groups of people, do favorite activities, and participate in religious activities. Review of R9's most recent Activities Assessment, dated 07/29/24 and found in the EMR under the Observations tab, revealed the resident participated in 1:1 activities, group activities, physical activities, projects, and resident council. The assessment indicated the resident enjoyed playing cards, crafts, exercise, music, and watching TV. The assessment indicated the resident's preferred activity participation time was in the afternoon and indicated the resident participated in activities 1/3 to 2/3 of the time. Review of R9's Activities Participation Documentation, dated 09/01/24 through 11/14/24 and provided directly to the surveyor in a binder kept in the Activities Director's Office, revealed no documentation of activity participation between 09/27/24 and 11/14/24. During observations of R9 she was observed either sleeping in her bed or seated in her Broda chair by the nurse's station on 11/12/24 at 9:16 AM, 2:37 PM, 3:05 PM, on 11/13/24 at 9:12 AM, 2:08 PM, on 11/14/24 at 9:35 AM, 1:05 PM and 2:21 PM. The resident was not observed participating in activities during any of the observations. BINGO was offered in the facility's dining room on 11/13/23 from 2:00 PM through 2:45 PM and a music program (Glascow and Friends) was offered on 11/14/24 from 2:00 PM through 3:00 PM, and although the resident was observed to be awake and seated in her Broda chair at the nurse's station at the time of these activities, she was not observed to participate in either of the activities even though the resident's activities assessments indicated interest in these activities. No alternative or 1:1 activities were observed to be offered to R9 during the survey period. During an interview with Licensed Practical Nurse/Unit Manager (LPN1/UM) on 11/12/24 at 2:37 PM, she stated no group activities were being offered on that date because the Activity Director (AD) was out of the building for personal reasons. LPN1/UM confirmed activities were on the activity schedule for 11/12/24, but had not been offered on that day since there was no staff in the building to do them. During an interview conducted by phone with the AD on 11/14/24 at 1:25 PM, she confirmed group activities had not been offered routinely during the most recent two weeks as she had been out of the facility on some days related to personal issues. The AD confirmed R9's activities participation had not been documented on her participation log. During an interview with the Administrator on 11/14/24 at 1:47 PM, she stated activities were expected to be provided to residents based on their individual activities assessment and preferences and participation in activities was expected to be documented.

Based on facility policy review, review of Broda chair instructions, observation, record review, and interview, the facility failed to ensure one resident (R9) of two residents reviewed for pressure sores was provided with adequate care and treatment to prevent skin breakdown. This failure created the potential for the resident to experience further skin breakdown. A total of 24 residents were reviewed in the sample. The facility census was 71. Findings include: Review of the facility's undated Wound Care and Treatment Policy read, in pertinent part, It is the purpose of this facility to prevent and treat all wounds; and There must be a specific order for the treatment; and The care plan should reflect the current status of the wound and appropriate goals and approaches. Review of the facility's undated Instructions for Use When Using a Broda Chair document, provided directly to the survey team, read, Are Additional Cushions Recommended or Required? Not necessarily. Our proprietary Comfort Tension Seating system is typically sufficient for most users when paired with the standard Broda padding that comes with your wheelchair. Whether to use an alternative cushion depends on various factors, including the wheelchair user's skin integrity, wound history, medical conditions, etcetera. Review of R9's undated Face Sheet, found in the Electronic Medical Record (EMR) under the Summary tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included dementia and type 2 diabetes. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/24 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident was at risk for developing pressure ulcers but did not have any current pressure ulcers at the time of the assessment. The assessment indicated a pressure reducing mattress was being used on the resident's bed but indicated a pressure reducing cushion was not in use on the resident's wheelchair. Review of R9's Progress Notes, dated 11/04/24 and found in the EMR under the Notes tab, revealed, Resident has a 2cm (centimeter) slit type open area in coccyx area, order received to start xeroform and cover with mepore (dressing) daily til (sic) healed. Review of R9's pressure ulcer Care Plan, most recently dated 11/13/24 and found in the EMR under the Care Plan tab, revealed the resident had developed a stage 2 pressure ulcer to her coccyx. The care plan indicated the area was to be kept clean and dry, wound treatment was to be done per physician's orders, and a pressure reducing cushion was to be applied to the resident's Broda chair. Review of R9's comprehensive physicians Orders, dated 11/14/24 and found in the EMR under the Orders tab, indicated orders, 11/08/24, that indicated the resident was to receive the following treatment: Xeroform (a wound dressing treatment) once per day (5 (inches) X 9 (inches) topical (to the resident's skin). The order did not include specifics related to what the dressing was being used for, where the dressing was to be applied, or instructions for cleansing and prepping the area of concern when the dressing was applied. Observations of R9 on 11/13/24 at 7:59 AM, 7:59 AM, 9:29 AM, 10:10 AM, 10:56 AM, 12:12 PM and on 11/14/24 at 9:35 AM revealed the resident was sitting in her Broda chair. There was not a pressure relieving cushion on the resident's Broda chair during any of the observations. During an observation of R9 on 11/13/24 at 10:20 AM along with Licensed Practical Nurse/Unit Manager (LPN1/UM) revealed R9 was laying in her bed and her Broda chair was next to the bed. LPN1/UN confirmed there was not a pressure reducing cushion on the resident's Broda chair. LPN1/UM confirmed the resident had developed a stage 2 pressure sore on 11/06/24. She stated administration told her pressure reducing cushions could not be applied to Broda chairs and that was why there wasn't one on R9's chair. LPN1/UM acknowledged there were no specific instructions entered into the wound care orders and stated she would update the orders to indicate the location of the wound and cleansing and dressing instructions related to the wound. During an interview with the Director of Nursing (DON) on 11/13/24 at 12:28 PM, she stated previous administration told her a pressure relieving cushion could not be used in a Broda chair and stated no pressure reducing cushion was being applied since the resident needed a Broda chair. The DON stated she thought the manufacturer's guidelines indicated a pressure reducing cushion could not be used in the Broda chair and stated she would see if she could find the manufacturer's instructions for use for the Broda chair. The DON stated her expectation was orders for wound care were to be complete and specific and the resident's care plan was to be accurate and followed related to the resident's wound care. During a follow-up interview with the DON on 11/13/24 at 3:33 PM, she provided the manufacturer's instructions for use for the Broda chair and confirmed there was nothing on the document to indicate a pressure reducing cushion could not be used in the chair. She stated, a cushion can be used and should have been applied (to the resident's Broda chair).

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse when nurse aide (NA) A yelled and cursed at the resident. The facility census was 62. Review of the facility Abuse Prevention Policy and Procedure Checklist, undated, showed the following: -The resident has the right to be free from abuse by anyone; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 4/6/23, showed the following: -Adequate hearing; -Makes self-understood and understands others; -Severe cognitive impairment; -Required limited assistance of one staff member with toilet use and personal hygiene; -Required extensive assistance of one staff member with dressing; -Frequently incontinent of bowel and bladder; -Diagnoses included unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems). Review of the resident's care plan last revised, 4/17/23, showed the following: -The resident will be allowed to make decisions regarding his/her daily care; -The resident had incontinence of bowel and bladder and needed assistance with toileting and hygiene; -The resident needed cueing and assistance with personal hygiene. Review of the facility's Initial Reporting form, dated 7/4/23, at 3:00 P.M. showed the following: -Allegation of verbal/mental abuse, alleged perpetrator was NA A; -Date and time of incident, 7/3/23 at 8:30 P.M. to 10:00 P.M.; -Witnesses, NA B and NA C; -Reported by certified nurse aide (CNA) D on 7/4/23 at 2:00 P.M. During an interview on 7/18/23 at 2:15 P.M. NA B said the following: -He/She worked 2:00 P.M. to 10:00 P.M. on 7/3/23. NA A came in early, around 6:00 P.M. to help out; -NA B heard NA A yelling at the resident and NA B looked down the hall, the resident was in the hallway, outside of his/her room; -NA A was up in Resident #1's face and the resident was crying. The resident asked NA A what did he/she do wrong. NA A told the resident to shut up and go back into his/her room; -The resident walked backwards into his/her room and looked like he/she was afraid. NA A walked away and said in a loud tone, I wish someone would give his/her ass an Ativan ( medication used for anxiety) and drug him/her up, because he/she (Resident #1) was getting on his/her nerves. During an interview on 7/18/23 at 2:45 P.M. NA C said the following: On 7/3/23 at around 8:30 P.M. to 9:00 P.M., he/she was assisting residents to bed for the night when he/she and NA B were at the nurse's station and heard Resident #1 crying and asked will you help me, I'm wet. The resident was standing in the doorway of his/her room; -NA A was up in the resident's face waving his/her hands and started yelling, You are fine, shut the hell up and go back in your room. The resident asked what he/she did wrong. The resident became more upset with actual tears running down his/her face. The resident often cried out for help and would repeat help me, help me, but the resident never had tears. The resident scooted backwards and appeared afraid; -NA A started to walk away and yelled out, Will someone give this resident an Ativan!. During an interview on 7/18/23 at 1:30 P.M., CNA D said he/she worked 6:00 A.M. to 2:00 P.M. shift on 7/4/23. NA A was hateful and yelled at the resident. During an interview on 7/18/23 at 12:40 P.M. the Director of Nursing (DON) said the following: -She interviewed both NA B and NA C separately and both reported that NA A yelled at Resident #1 and told the resident to shut up, and that NA A was waving his/her hands in the resident's face and said someone give the resident a sleeping pill; -She questioned the resident about the incident and at first the resident didn't want to say anything, then the resident said he/she and the aide were yelling at each other, and it was over, the resident said he/she did not know why the staff member thought he/she could bully him/her, and said he/she was not having it; -After the investigation was completed NA A was terminated for verbal abuse. During an interview on 7/18/23 at 1:00 P.M. the administrator said the following: -On 7/4/23 the DON called her and said that staff had reported that NA A told the resident to shut up and go back to his/her room; -She told the DON to suspend NA A and to start an investigation; -At first she thought only NA C witnessed the incident, then they interviewed NA B separately and he/she also witnessed the incident, and their version of events were similar; -The resident was interviewed and was able to recall the incident the following day and said the staff member had tried to bully him/her; -After completing the investigation NA A was terminated for verbal abuse. MO00220964

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse when nurse aide (NA) A yelled and cursed at the resident. The facility census was 62. Review of the facility Abuse Prevention Policy and Procedure Checklist, undated, showed the following: -The resident has the right to be free from abuse by anyone; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 4/6/23, showed the following: -Adequate hearing; -Makes self-understood and understands others; -Severe cognitive impairment; -Required limited assistance of one staff member with toilet use and personal hygiene; -Required extensive assistance of one staff member with dressing; -Frequently incontinent of bowel and bladder; -Diagnoses included unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems). Review of the resident's care plan last revised, 4/17/23, showed the following: -The resident will be allowed to make decisions regarding his/her daily care; -The resident had incontinence of bowel and bladder and needed assistance with toileting and hygiene; -The resident needed cueing and assistance with personal hygiene. Review of the facility's Initial Reporting form, dated 7/4/23, at 3:00 P.M. showed the following: -Allegation of verbal/mental abuse, alleged perpetrator was NA A; -Date and time of incident, 7/3/23 at 8:30 P.M. to 10:00 P.M.; -Witnesses, NA B and NA C; -Reported by certified nurse aide (CNA) D on 7/4/23 at 2:00 P.M. During an interview on 7/18/23 at 2:15 P.M. NA B said the following: -He/She worked 2:00 P.M. to 10:00 P.M. on 7/3/23. NA A came in early, around 6:00 P.M. to help out; -NA B heard NA A yelling at the resident and NA B looked down the hall, the resident was in the hallway, outside of his/her room; -NA A was up in Resident #1's face and the resident was crying. The resident asked NA A what did he/she do wrong. NA A told the resident to shut up and go back into his/her room; -The resident walked backwards into his/her room and looked like he/she was afraid. NA A walked away and said in a loud tone, I wish someone would give his/her ass an Ativan ( medication used for anxiety) and drug him/her up, because he/she (Resident #1) was getting on his/her nerves. During an interview on 7/18/23 at 2:45 P.M. NA C said the following: On 7/3/23 at around 8:30 P.M. to 9:00 P.M., he/she was assisting residents to bed for the night when he/she and NA B were at the nurse's station and heard Resident #1 crying and asked will you help me, I'm wet. The resident was standing in the doorway of his/her room; -NA A was up in the resident's face waving his/her hands and started yelling, You are fine, shut the hell up and go back in your room. The resident asked what he/she did wrong. The resident became more upset with actual tears running down his/her face. The resident often cried out for help and would repeat help me, help me, but the resident never had tears. The resident scooted backwards and appeared afraid; -NA A started to walk away and yelled out, Will someone give this resident an Ativan!. During an interview on 7/18/23 at 1:30 P.M., CNA D said he/she worked 6:00 A.M. to 2:00 P.M. shift on 7/4/23. NA A was hateful and yelled at the resident. During an interview on 7/18/23 at 12:40 P.M. the Director of Nursing (DON) said the following: -She interviewed both NA B and NA C separately and both reported that NA A yelled at Resident #1 and told the resident to shut up, and that NA A was waving his/her hands in the resident's face and said someone give the resident a sleeping pill; -She questioned the resident about the incident and at first the resident didn't want to say anything, then the resident said he/she and the aide were yelling at each other, and it was over, the resident said he/she did not know why the staff member thought he/she could bully him/her, and said he/she was not having it; -After the investigation was completed NA A was terminated for verbal abuse. During an interview on 7/18/23 at 1:00 P.M. the administrator said the following: -On 7/4/23 the DON called her and said that staff had reported that NA A told the resident to shut up and go back to his/her room; -She told the DON to suspend NA A and to start an investigation; -At first she thought only NA C witnessed the incident, then they interviewed NA B separately and he/she also witnessed the incident, and their version of events were similar; -The resident was interviewed and was able to recall the incident the following day and said the staff member had tried to bully him/her; -After completing the investigation NA A was terminated for verbal abuse. MO00220964

Based on interview and record review, the facility failed to ensure two residents (Resident #1 and #2) of seven sampled residents, received medications as ordered by their physicians. The facility failed to administer three doses of an anti-seizure medication to Resident #1. The resident experienced seizures following the missed doses of medication and required hospitalization . The facility also failed to follow physician medication orders including daily administration of an antibiotic following surgery for Resident #2. The resident's surgical incision deteriorated with increased drainage and odor and required hospitalization for wound care and intravenous antibiotics. The facility census was 65. The administrator was notified on 7/1/22 at 10:30 A.M. of the Immediate Jeopardy (IJ) which began on 4/29/22. The IJ was removed on 7/1/22, as confirmed by surveyor onsite verification. Review of the facility's policy on Physician's Orders, undated, showed the following: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Physician orders must be reviewed and renewed; -Medication orders must specify the type, route, dosage, frequency, and strength of the medication ordered; -Only a licensed nurse or therapist may accept telephone/verbal orders from a licensed physician. Review of the facility's policy, titled Physician Services, undated, showed physician orders and progress notes shall be maintained in accordance with current Omnibus Budget Reconciliation Act (OBRA) regulations and facility policy. Review of the facility's policy Medication Ordering and Receiving from Pharmacy, dated July 2021, showed the following: -Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt; -New medication orders are written on a medication order form provided by the pharmacy, written in the chart by the physician, electronic order, or written on a transfer order form and transmitted to the pharmacy; -Refills are ordered via the pharmacy link or through any available refill option in the electronic medical record system. Alternatively, the re-order label may be peeled and faxed to the pharmacy. If the re-order label is not available, the prescription number, resident name, and medication name, will be written on the re-order form and ordered as follows: -Reorder medication three days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand; -Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy provider; -During regular pharmacy hours, the pharmacy is notified of the emergency or stat order, the order is then phoned, sent electronically, or faxed to the pharmacy; -Controlled substances are reordered when a three day supply remains to allow for transmittal of the required written prescription to the pharmacist; -The dispensing pharmacy is called if an emergency arises requiring immediate pharmacist consultation concerning appropriateness of therapy, drug information, etc.; -Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. The facility must make every effort to ensure that medications are available to meet the needs of each resident; -The nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability, and optional therapies that are available, obtain a new order and cancel/discontinue the order for the non-available medication, and notify the pharmacy of the replacement order. 1. Review of Resident #1's care plan, dated 5/3/21, showed the following: -The resident was at risk for injury related to a seizure disorder. The resident wears a helmet for safety related to seizure history when out of bed; -Administer anti-seizure medications as ordered; -Monitor and report signs of seizure; -Nursing staff and physician to monitor lab work and make adjustments as necessary. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/21/22, showed the following: -The resident's cognition was moderately impaired; -Diagnoses included seizure disorder/epilepsy. Review of the resident's physician orders for April 2022 showed the following: -Oxcarbazepine (anticonvulsant medication) 300 milligrams (mg) by mouth twice a day; -Vimpat (anticonvulsant medication that is a controlled substance) 100 mg by mouth twice a day. Review of the resident's Medication Administration Record (MAR) for April 2022 showed the following: -On 4/29/22 at 8:03 P.M. Licensed Practical Nurse (LPN) A documented the evening dose (8:00 P.M. to 10:00 P.M.) of Vimpat 100 mg was not administered because the drug/item was unavailable; -On 4/30/22 at 7:52 A.M. LPN B documented the morning dose (7:00 A.M. to 10:00 A.M.) of Vimpat was not administered because the drug/item was unavailable; -On 4/30/22 at 9:01 P.M. LPN A documented the evening dose (8:00 P.M. to 10:00 P.M.) of Vimpat 100 mg was not administered because the drug/item was unavailable. Review showed no documentation staff contacted the resident's physician or the pharmacy about the missed doses of Vimpat. Review of the resident's nurse's note, dated 4/30/22 at 11:55 P.M., showed the following: -The resident's roommate pushed the call light. The resident was found in their room face down on the floor beside his/her bed seizing (having a seizure); -The resident had three to four witnessed concurrent seizing episodes lasting about one to two minutes with only about 30 seconds in between; -The resident was turned on his/her side and then lifted back into bed once seizure activity ceased; -The resident had a small, red abrasion to the left side of the face, also a nickel size area of bruising starting near the left eye; -The resident had redness and abrasions to both knees and his/her right arm; -Staff received a verbal order from the physician to send the resident to the emergency room for evaluation due to seizures and being on a blood thinner; -Staff called 911 and the resident was taken to the hospital by emergency medical services (EMS). Review of the resident's hospital note, dated 5/1/22, showed the following: -Chief Complaint: Per EMS the resident had a cluster of three to four seizures under five minutes; -Impression: Long standing epilepsy; -The resident was epileptic and the nursing home ran out of Vimpat; -Appears the resident missed doses of Vimpat due to a pharmacy issue at the facility; -The resident's seizures had been well controlled on Vimpat 100 mg twice a day and oxcarbazepine 300 mg twice a day with the last seizure in 2019; -Plan: Continue Vimpat 100 mg twice a day and oxcarbazepine 300 mg twice a day. During an interview on 6/13/22 at 2:05 P.M., LPN A said he/she waited to see if the pharmacy delivered the resident's Vimpat on 4/29/22 as there was none of the medication available to administer for the evening dose. The medication did not arrive with the pharmacy delivery that night. LPN A was not sure if the medication had been reordered or not. LPN A left a note for the day shift nurse to call and check on the medication. LPN A was not sure what happened regarding the medication after that. LPN A said at that time he/she did not yet have access to the online pharmacy portal to check the status of the medication or to reorder the medication. LPN A did not recall if he/she contacted the physician about the missed medication or not. During an interview on 6/13/22 at 2:25 P.M., LPN B said on 4/30/22 the resident's Vimpat was not available for administration. LPN B said usually before a controlled substance medication ran out, staff send an order to the pharmacy, the pharmacy sends a fax request to the physician to get it completed so the medication can be dispensed. LPN B did not recall contacting the pharmacy or the physician about the missing medication. Usually LPN B contacted the physician after the first dose of a medication was missed and he/she should have done so. During an interview on 6/13/22 at 2:12 P.M. and 4:12 P.M., the administrator said she expected staff to notify the physician after the first dose of a medication was missed. Staff should contact the pharmacy and order the medication be sent stat (immediately) to the facility. The administrator was not aware that Resident #1 went without his/her seizure medication on 4/29/22 and 4/30/22 until today. During an interview on 6/24/22 at 9:19 A.M., the resident's physician's nurse said the physician would expect facility staff to notify him/her after the first missed dose of a medication. 2. Review of Resident #2's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of two staff members with transfers, toileting, and walking in room; -Required extensive assistance of one staff member with personal hygiene; -Required limited assistance of one staff member with dressing; -Not steady, only able to stabilize with staff assistance while moving from seated to standing position, walking, moving on and off the toilet and during surface-to-surface transfers; -Required a walker or a wheelchair for mobility. Review of the resident's hospital discharge instructions and physician orders, dated 5/9/22, showed the following: -Reason for hospitalization was lumbar stenosis (a narrowing of the open spaces in the lower (lumbar) spine that puts pressure on the spinal cord and nerves traveling through the spine) with laminectomy (surgical procedure removing a portion of the vertebra to reduce pressure on the spinal cord and nerves) and cyst (abnormal fluid filled sacs in the joints of the spine) removal from lumbar spine; -Activity as tolerated; -Acetaminophen (Tylenol) 325 milligrams (mg) three times daily, next dose due 5/9/22 at 6:00 P.M.; -Azithromycin (Zithromax, antibiotic medication) 500 mg daily, next dose due 5/10/22; -Cyclobenzaprine (muscle relaxant medication) 10 mg three times daily; -Stop taking meloxicam (arthritis medication) 15 mg; -If you notice any swelling, redness, drainage or heat around the incision, notify the neurosurgeon's office immediately; -Signed and dated 5/9/22 at 12:10 P.M. at the time of hospital discharge. Review of the resident's POS, dated 5/9/22, showed the following: -Diagnosis of encounter for surgical aftercare following surgery on the nervous system, repeated falls, radiculopathy (nerve disease such as pinched nerve) of lumbar region, need for assistance with personal care, abnormal gait and mobility, edema (swelling), sciatica (nerve pain caused by pinching of the lumbar spine resulting in pain that radiates down the leg), muscle weakness; -Acetaminophen 325 mg two tablets every 6 hours as needed for pain (hospital discharge orders directed the medication be given three times daily); -Cyclobenzaprine 10 mg every 8 hours as needed for muscle spasm (hospital discharge orders directed the medication be given three times daily); -Meloxicam 15 mg daily (hospital discharge orders directed the medication be stopped); -Zithromax 500 mg daily was not included on the POS. Review of the resident's nurses' note, dated 5/9/22 at 5:45 P.M., showed staff documented the resident returned from the hospital. Incision on back assessed with 34 staples, clean, dry, and without areas of concern. Review of the resident's skin assessment, dated 5/9/22, showed the resident had a 19.5 centimeter (cm) by 0.25 cm incision to the mid-lower back with 34 staples in place. The incision was clean and dry without areas of concern. Review of the resident's MAR, dated 5/9/22 (date of readmission) through 5/24/22 (date of facility discharge), showed the following: -Acetaminophen 325 mg, two tablets every 6 hours as needed. Staff documented administration of one dose on 5/12/22 at 9:51 P.M. No documentation staff administered acetaminophen 325 mg was administered three times daily as instructed on the hospital discharge physician's orders; -Cyclobenzaprine 10 mg every 8 hours as needed for muscle spasms. Staff documented no administration from 5/9/22 through 5/24/22. No documentation Cyclobenzaprine 10 mg was administered three times daily as instructed on the hospital discharge physician's orders; -Meloxicam 15 mg daily, staff documented from 5/9/22 through 5/24/22 administered daily in the morning. (hospital discharge physician's orders included discontinue Meloxicam 15 mg daily); -No staff documentation Zithromax 500 mg daily was administered as instructed on the hospital discharge physician's orders. Review of the resident's nurses' note showed on 5/11/22 at 10:12 A.M., staff documented the resident had increased back pain since readmission. Review of the Primary Care Physician's progress note, dated 5/12/22, showed the following: -On rounds today the resident had been readmitted to the facility after having back surgery. The resident did not have the operation he/she was scheduled to have and had some type of cystic structure removed from the spinal column and the incision was a little larger than what was anticipated. The resident required more pain medication; -The resident was well developed and in distress from sciatica (pain caused by compression of a spinal nerve root in the lower back) down the right leg; -The Physician's Order Sheet was reviewed and medications reconciled; -The progress note did not include the resident's current list of medication. Review of the resident's nurses' note, dated 5/14/22 at 10:04 P.M., showed staff documented the resident's surgical incision dressing was changed with moderate amount of serosanguineous (thin watery, red or pink tinged wound drainage) drainage noted (no order for a dressing change). Review showed no documentation the resident's care plan, dated 5/15/22, included staff direction regarding care of the resident's surgical wound, pain management, mobility status or ability to complete activities of daily living. Review of the resident's nurses' notes showed the following: -On 5/17/22 at 11:12 P.M., staff documented the resident's lower back incision was red, but with no infection. Staples in lower back incision; -On 5/24/22 at 11:38 A.M., staff documented light green drainage was noted from the resident's incision. Surgeon's office was notified. Educated family member to monitor incision and if fever or warmth developed to notify the surgeon. Resident was discharged home. During interview on 6/13/22 at 12:30 P.M., LPN D said the following: -The resident's lumbar spine incision looked good on admission with 34 staples in place. The incision started draining serosanguineous drainage within a few days and continued to have drainage with no odor. On 5/24/22, he/she noted the incisional drainage was green in color and had a slight odor. He/She called the surgeon's office on 5/24/22, after the resident's discharge from the facility and reported the green drainage and wound odor. The facility had not notified the surgeon previously the incision was draining serosanguineous drainage and required frequent dressing changes. During interview on 6/13/22 at 12:40 P.M., LPN C said the resident perspired a lot and required frequent incisional dressing changes, usually more than once per day. The serosanguineous drainage from the incision started shortly after admission. During interview on 6/13/22 at 3:30 P.M., LPN D said the following: - LPN D reviewed the resident's hospital discharge instructions and physician's orders. LPN D said staff did not follow the surgeon's discharge orders dated 5/9/22 and did not administer the resident's medications as ordered. Staff did not administer the resident any doses of Zithromax 500 mg daily, did not administer cyclobenzaprine 10 mg three times daily or acetaminophen 325 mg three times daily as ordered. Staff administered the resident meloxicam 15 mg daily although the hospital discharge orders included instruction to discontinue meloxicam 15 mg daily. Staff should enter the hospital discharge orders into the resident's medical record and follow the medication orders as written. Staff should review the orders with the resident's primary care physician on admission. She was unaware the resident was supposed to be on antibiotics daily since 5/9/22. Staff had not transcribed the surgeon's discharge orders as written into the resident's facility medical record. Staff had called the primary care physician and notified him the resident had returned and of the change in the resident's condition following surgery including the new medication orders. During interview on 6/14/22 at 9:50 A.M., the resident's family member and responsible party said while in the facility the resident's incision was oozing and the bandage frequently rolled up. He/She requested staff to change the dressing almost every day. The wound drainage got on the washable pad the resident sat on and had an odor that started the first four or five days after admission to the facility. On 5/24/22 he/she took the resident home and within three hours found the incision was gaping open with the staples pulling apart and oozing a lot of green drainage with very foul odor. The wound looked and smelled infected. He/She took the resident to the surgeon the following day and the resident was admitted to the hospital for intravenous antibiotics and another surgical procedure to wash out and clean up the wound. During interview on 6/14/22 at 9:40 A.M. the surgeon's nurse said on 5/25/22 the resident was seen in the surgeon's office for follow up and removal of the staples. The odor from the resident's surgical incision was strong and was noted while the resident sat in the waiting room. He/She removed the dressing covering the surgical incision and found a gaping incision with staples no longer intact. The wound had a strong odor with green drainage. The resident was admitted to the hospital for a wound wash and intravenous antibiotics. The resident continued currently on oral antibiotics and wound care daily. The facility should have provided the resident medications as ordered on the hospital discharge orders including Zithromax 500 mg daily to prevent infection. The resident should have had acetaminophen three times daily and cyclobenzaprine three times daily for pain control and comfort while healing. The facility did not notify the surgeon of any change in the resident's incision, the drainage or need for frequent wound dressing changes. After assessing the incision the surgeon was concerned the facility had not notified him/her of the wound condition. During an interview on 6/29/22 at 10:07 A.M., the resident's primary care physician (PCP) said he would expect facility staff to notify him of the resident's hospital discharge orders on 5/9/22 so he could approve them or make changes. The PCP said he agreed with the hospital discharge orders and would have expected staff to follow them as written. During interview on 6/13/22 at 4:15 P.M., the administrator said staff should follow the physician's orders as provided to the facility from the hospital discharge instructions. Staff should administer the resident's medications as the surgeon ordered on discharge from the hospital. If the resident had a change in wound status or change in condition, staff should notify the physician. Staff should have notified the resident's surgeon with any change in the resident's wound, increased drainage or change in appearance. Staff should document any change in a resident's wound status in the resident's record. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO200661 MO201970

Based on interview and record review, the facility failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR; an emergency procedure that is performed when a person's heartbeat or breathing has stopped) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to perform CPR and upon police arrival, they were the ones to initiate CPR on the full code resident. The facility census was 61. The administrator was notified on [DATE] at 2:20 P.M. of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by the surveyor onsite verification. Review of the American Heart Association, Emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Signs of [CONDITION(S)]: -Sudden loss of responsiveness. The person doesn't respond, even if you tap him/her hard on the shoulders, or ask loudly if he/she is okay. The person doesn't move, speak, blink or otherwise react. -No normal breathing. The person isn't breathing or is only gasping for air. -If you have tried and failed to get the person to respond, and you think the person may be suffering [CONDITION(S)], here's what to do: -Yell for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an automated external defibrillator (AED), if there's one on hand. Tell them to hurry - time is of the essence. If you're alone with an adult who has these signs of [CONDITION(S)], call 911 and get an AED (if one is available). -Check breathing. If the person isn't breathing or is only gasping, administer CPR. -Give CPR: Push hard and fast. Push down at least two inches at a rate of 100 to 120 pushes a minute in the center of the chest, allowing the chest to come back up to its normal position after each push. -Use the AED as soon as it arrives. Turn it on and follow the prompts. -Continue administering CPR until the person starts to breathe or move, or until someone with more advanced training takes over, such as an emergency medical services (EMS) team member. Review of the facility's, undated, CPR policy showed the following: -Purpose: to ventilate and establish circulation on a resident with absence or respiration and pulse; -Equipment: [CONDITION(S)] board or hard surface, sphygmomanometer and stethoscope, airbag, oxygen, suction machine, disposable CPR mask; -Guidelines: The following guidelines are for a one-adult rescuer CPR: 1) Determine unresponsiveness by tapping or gently shaking the resident and shouting, Are you okay?; 2) Call out for help; 3) Delegate a specific individual to check resident clinical record for CPR or no CPR orders; have individual call paramedics, attending physician and administrative personnel per facility guidelines and report back to you as soon as possible; 4) Do not start CPR if resident is breathing and has a pulse. Start emergency oxygen and delegate a specific individual to stay with the resident and monitor vital signs. Notify the attending physician of the resident's condition and request further orders for care; 5) Position the resident by turning on back as a unit, supporting head and neck; -Circulation: 6) Determine pulselessness. Palpate the carotid pulse gently to avoid compressing the artery on side of victim; 7) Maintain head tilt with other hand; -Note: Delegate a specific individual to check on status of paramedics and instructions from attending physician and report back to you as soon as possible; 8) If resident is pulseless: a) Make sure resident is on a hard surface; i.e.: backboard or floor; b) Perform external chest compressions by locating correct hand position on lower half of sternum; c) Find the xiphoid process by palpation; place two fingers over the distal end of this process and heel of hand above this point (never place hands over the xiphoid process); d) With arms straight, elbows locked and shoulders over your hands (over the resident's sternum), perform 30 compressions at a rate of 80 to 100 per minute. Note: Compress in a straight downward motion (do not rock or roll) 1.5 to 2 inches for an adult resident. Maintain contact between resident's chest and your hands at times to assure correct position. Use equal compression and relaxation; keep hands on sternum during upstroke. Count compressions; 9) Open the airway and deliver two rescue breaths; 10) Repeat cycle of 30 compressions to two breaths. Performing four cycles before you evaluate the resident; -Airway: 11) Position yourself close to the resident, comfortably, at the resident's shoulder level; 12) Open airway with head tilt/chin lift maneuver; maintain open airway; -Breathing: 13) Determine breathlessness. Maintain the open airway, place your ear over the resident's mouth and nose; a) Look for chest rise and fall; b) Listen for exhalation; c) Feel for exhaled air; 14) If resident is breathless: a) Perform rescue breathing by gently pinching resident's nose shut with your thumb and index finger; b) Take a deep breath; put your lips around the resident's mouth to create an airtight seal or use CPR mask. If using disposable two-way valve CPR mask and facemask, place firmly over the resident's nose and mouth to create an airtight seal; c) Deliver two full breaths, each [MEDICATION(S)] one to one and one-half seconds; d) Pause to inhale between breaths; 15) Observe the chest rise (adequate ventilation volume); 16) Allow deflation between breaths; -Reassessment: 17) Evaluate resident by checking carotid pulse; a) If a pulse is present, but resident has no respirations, continue rescue breathing at approximately 12 ventilations per minute; b) If pulse and respirations are absent, continue CPR and evaluate resident periodically; -Continue CPR: 18) Ventilate twice, observe chest rise; 19) Resume compression/ventilation cycles; 20) Feel for carotid pulse every few minutes; 21) Once CPR is started, do not discontinue until: a) Qualified help arrives (paramedics); b) A physician pronounces the resident dead and gives orders to discontinue CPR; 22) When arrangements are made for transportation, notify the ambulance company that CPR will be or may necessary during transfer; -CPR Certification: 23) Facility must maintain and document a minimum of one CPR certified staff member per shift on duty, not including any staff members needed to provide transport services; 24) Staff members who are CPR certified will provide documentation to facility's Director of Nursing and/or designee, and annually thereafter; a) Records of CPR certification will be maintained and available for surveyor review; b) Administrator will monitor for compliance; 25) CPR certification must be designated for healthcare providers to be acceptable (i.e.:, must include mouth breathing); a) On-line only First Aid and CPR is not acceptable; b) The course should be face-to-face or a hybrid course that includes hands-on skills practice and assessment from a certified instructor prior to certification. Review of the facility's, undated, Emergency Cart supply list and policy, showed the following: -Purpose: To ensure the facility was prepared for emergency care; -Guidelines: 1) The emergency cart will be located at the South 1 Nurse's Station; 2) Items that may be stocked and maintained on the emergency cart as follows: -Oxygen Supplies: oxygen tank (E tank); oxygen regulator; oxygen tubing; green connector (Christmas tree connector); oxygen wrench for E tank; oxygen mask x 2; oxygen cannula x 2; ambu bag; and air ways; -Suction Supplies: suction machine; suction tubing; suction catheter x 2; and yanquer suction tip x 2; -Equipment: stethoscope; blood pressure cuff; goggles; back board; blood spill kit; flashlight; scissors; box of medium gloves; box of large gloves; sharps container; alcohol gel; -Nursing Supplies: alcohol pads; band-aids; [MEDICATION(S)] pads; eye pads; tongue bladed; 4 x 4's; wound cleanser; ABD pads x 4; sterile cotton applicators; tape; steri-strips; trash bags; and kling x 1 bag; 3) Emergency cart should be restocked after each use and covered; 4) Emergency cart should be cleaned and restocked weekly through the facility cleaning schedule. 1. Observation on [DATE] at 10:00 A.M. of the wall behind the North nurses station, showed a wall mounted AED device. Observation on [DATE] at 11:00 A.M. of the South 1 nurses station area, showed the following: -A wall mounted AED device on the wall behind the nurses station; -A covered, emergency crash cart contained the items listed on the Emergency Cart supply list and policy. Review of Registered Nurse (RN) A's employee file showed the following: -He/She had an active RN license that expired on [DATE]; -His/Her RN job description included he/she was to perform selected acts for the promotion of health and in the care of persons who were ill, injured or experiencing altercations in the normal health process; implement or delegate aspects of care in a timely manner, including the execution of physician orders; chart nurses' notes in an informative and descriptive manner that reflect the care provided to the resident, as well as the resident's response to the care; knowledge and skills abilities were to include knowledge of professional nursing practices, basic human physical needs, ability to apply nursing techniques to specific patient situations, ability not to pose a direct threat to the health or safety of other individuals in the work place, ability to meet the general health requirements set forth by the guidelines of the facility, which include medical and physical examination. RN A signed the job description on [DATE], acknowledging he/she fully understood the requirements of the job and agreed to perform the identified essential functions in a safe manner and in accordance with the facility's established procedures; -He/She was issued a Basic Life Support (BLS; BLS course trains participants to promptly recognize several life-threatening emergencies, give high-quality chest compressions, deliver appropriate ventilations and provide early use of an AED) certification from the American Heart Association on [DATE] with recommended renewal date of ,d+[DATE]; -The certification documented he/she completed cognitive and skills evaluations in accordance with the curriculum of the American Heart Association BLS (CPR and AED) program; -He/She was CPR certified. Review of Certified Medication Technician (CMT) C's employee file showed the following: -His/Her CMT job description included he/she had the knowledge skills and abilities of basic aid practices and guidelines; the ability to provide personal care for the frail elderly and for acute, chronic and terminally ill patients; the ability to relate information concerning a resident's condition; the ability not to pose a direct threat to the health or safety of other individuals in the work place; the ability to meet the general health requirements set forth by the guidelines of the facility, which include medical and physical examination. CMT C signed the job description on [DATE], acknowledging he/she fully understood the requirements of the job and agreed to perform the identified essential functions in a safe manner and in accordance with the facility's established procedures; -He/She was issued a BLS certification from the American Heart Association on [DATE] with recommended renewal date of ,d+[DATE]; -The certification documented he/she had completed cognitive and skills evaluations in accordance with the curriculum of the American Heart Association BLS (CPR and AED) program; -He/She was CPR certified. Review of Certified Nurse Assistant (CNA) D's employee file showed no documentation he/she was CPR certified. Review of the facility staffing schedules for [DATE] showed the following: -RN A was scheduled to work night shift, 6:00 P.M. to 6:00 A.M.; -CMT C was scheduled to work evening shift, 2:00 P.M. to 10:00 P.M.; -CNA D was scheduled to work evening shift, 2:00 P.M. to 10:00 P.M. 2. Review of Resident #1's face sheet showed the following: -Date of admission [DATE]; -Directive was a full code; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital referral paperwork, dated [DATE], showed the resident weighed 108 pounds. Review of the resident's baseline care plan, dated [DATE], showed the following: -The resident arrived to facility on [DATE] at 3:00 P.M. via facility van. The resident was transferred from the hospital post hospitalization for [CONDITION(S)], [CONDITION(S)] (broad term for brain disease that alters brain function or structure caused by infection, tumor and stroke) due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Full code status; -Cognition: alert/cognitively intact; -Disease Management Concerns/Goals/Interventions: diabetes, [CONDITION(S)], respiratory, and weakness. Review of the resident's medical chart showed no page in the front of the chart or within the chart that was green or red in color (to indicate code status). Review of the resident's [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Code Status: full code (listed in two places on the orders); -Admit to facility for skilled aspiration pneumonia; -Speech therapy was discontinued due to the resident being within functional limitation for communication and swallowing as of [DATE]; -Regular diet with double portions each meal. Review of a 911 Event Report, dated [DATE], showed at 7:56 P.M., a call was received from the facility with a request for resident assist. The resident was non-responsive and not breathing. The resident was not awake, not breathing and CPR was in progress. Review of a voice recording between a 911 Operator and the caller, undated, showed the following: -911 Operator: Tell me exactly what happened; -Caller: Well, we got a resident, they went in and he/she was non responsive, hanging over the bed, he/she's not breathing. Haven't had time to try to get vitals, but he/she's definitely not breathing. He/She is a full code; -911 Operator: Do you guys have CPR in progress?; -Caller: Yeah, yeah. I'm not in the room, but there's two people there; -911 Operator: And I'm just verifying that there is a nurse on scene with him/her; -Caller: Yes. Review of the resident's facility nursing notes showed RN A documented on [DATE] at 7:57 P.M., a staff found the resident unresponsive and leaning on the end of the bed. The resident was moved to the floor. Staff was unable to palpate a pulse, and did not observe the resident breathing. Staff started CPR while RN A called 911. Review of the resident's facility nursing notes showed RN A documented on [DATE] at 8:26 P.M., correction to previous note (dated [DATE] at 7:57 P.M.). Staff were attempting to obtain vital signs and CPR did not start until police arrived at 8:02 P.M. Emergency Medical Services (EMS) here at 8:05 P.M. EMS crew stated after awhile, they had a pulse. The resident was placed on stretcher and taken out of facility at 8:25 P.M. Review of RN A's undated written statement, provided by the facility, showed on [DATE] he/she was informed the resident had fallen at approximately 6:30 P.M. Staff assisted the resident to bed and took vital signs. The resident's blood pressure was a bit low and the resident was advised to ask for help if he/she needed to get up. Later, the RN heard the intercom buzzing while he/she administered medications on the North unit. When he/she answered the intercom, the caller had hung up. CMT C came running from the South unit and said he/she needed RN A in a hurry. CMT C reported Resident #1 was unresponsive. The RN ran to the resident's room and found the resident standing at the foot of the bed, leaning over the footboard with his/her head on the bed. The resident was not responding. Staff lowered the resident to the floor where he/she was observed for breathing and attempted to palpate a pulse. CMT C brought vital sign equipment to the resident's room. He/She did not see any breathing or feel a pulse. He/She said he/she would go call 911 and asked staff to start CPR. He/She called 911, and started documentation and paperwork, then went to the front door to let responders in. Two local police officers arrived at approximately 8:03 P.M. He/She directed them to Resident #1's room from the South nurses' station and returned to the front door for emergency medical services (EMS) to arrive. EMS arrived at approximately 8:05 P.M. He/She directed them to the resident's room, then continued documentation at the nurses' desk. He/She then brought the documentation to the resident's room. When he/she arrived to the resident's room, the police were doing CPR. EMS took over care, intubating the resident and obtaining vascular access. A few minutes later, another EMS crew (paramedics) arrived and assisted with giving medications to the resident. One of the paramedics said the resident had a strong pulse. The resident was readied for transport and transferred to a stretcher. EMS left the facility with the resident at approximately 8:25 P.M. During an interview on [DATE] at 01:37 P.M., RN A said the following: -He/She was the night shift charge nurse responsible for the resident on [DATE]. His/Her shift started at 6:00 P.M. and ended on [DATE] at 6:00 A.M.; -CMT C and CNA D alerted him/her that Resident #1 had fallen near the South nurses station while walking from the dining room to his/her room; -He/She assessed the resident at that time; -He/She left the resident's room between 6:30 P.M. and 7:00 P.M. The resident sat on the side of his/her bed at that time; -He/She was on the North unit when he/she heard the intercom around 7:30 P.M. and then saw CMT C running to him/her from the South unit; -CMT C told him/her Resident #1 was unresponsive; -He/She and CMT C went to the resident's room where he/she saw the resident standing at the foot of the bed, bent over at the waist over the foot of the bed, his/her head was on the mattress, his/her feet were on the floor and his/her hands were on the bed; -Only he/she and CMT C were in the resident's room at this time; -Resident #1 did not respond to his/her verbal calling or physical touch; -He/She said CMT C and CNA D moved the resident to the floor. He/She may have helped, but he/she could not remember; -He/She watched for breathing from the resident's chest and felt for a radial pulse for 15 to 20 seconds; -He/She was not sure if he/she detected a pulse; -He/She saw CMT C with a blood pressure cuff, but did not see him/her place it on the resident; -CMT C said, Why don't you go call 911. He/She agreed with the suggestion and went to the South nurses station and called 911; -He/She instructed CMT C and CNA D to start CPR and he/she left the room; -He/She did not see either staff start CPR. He/She did not know if either staff was CPR certified, but they should have been. He/She assumed CMT C and CNA D were CPR certified because they had worked at the facility longer than he/she had; -After the call, he/she began completing documentation, like the transfer sheet, he/she knew he/she would need; -He/She went to the front door and waited maybe three minutes before the local police arrived and he/she let them in; -He/She knew they arrived at 8:03 P.M. because he/she could recall the time on the clock; -The resident had been unresponsive for probably 30 minutes at that time; -He/She took the police to the South nurses station and pointed them in the direction of the resident's room and then returned to the front door to await EMS arrival; -Two to three minutes later, EMS arrived. He/She let EMS in the building, took them to the South nurses station, and pointed them in the direction of the resident's room; -He/She could recall seeing CMT C standing in the doorway/hallway at that time; -He/She gathered the documentation he/she prepared and went to the resident's room; -When he/she got to the room, he/she saw the two police officers performing CPR on the resident, EMS was gathering their stuff to take over and they intubated the resident; -He/She was CPR certified and had learned through his/her CPR training to start CPR as soon as possible. That would be when one discovered a lack of pulse and/or breathing; -He/She knew the resident was a full code status; -He/She had not listened for breath sounds with a stethoscope; -He/She did not perform CPR on the resident; -It might have been more appropriate to send CNA D or CMT C to call 911 and he/she begin CPR; -He/She had not been given any facility education regarding specific roles during CPR like who was to do the CPR and who was to make the call to 911. Review of CNA D's written statement, dated and signed on [DATE], provided by the facility, showed on [DATE], he/she came to work at 2:00 P.M. He/She and CMT C worked the North unit. Around 7:15 P.M. to 7:30 P.M., he/she asked Resident #1 if he/she was finished with his/her dinner tray. Resident #1 said he/she was going to finish it, so CNA D left the resident's room. Around 7:50 P.M. to 8:00 P.M., CNA D was assisting another resident behind a closed door when he/she heard two loud knocks on the door. He/She walked out into the hallway and went to Resident #1's room. He/She saw Resident #1 hunched over his/her bed. CMT C was running to get RN A. He/She gently nudged the resident's back and asked him/her if he/she was okay. There was no response. He/She saw vomit on the bedspread. About five minutes later, CMT C and RN A came in the resident's room. Staff laid the resident on the floor. He/She was not breathing. Staff tried to get a pulse and there was none. He/She covered the resident with a sheet. Paramedics arrived about 15 minutes later and they revived the resident and took him/her out. During an interview on [DATE] at 12:24 P.M., CNA D said the following: -He/She worked the evening shift, 2:00 P.M. to 10:00 P.M., on [DATE]; -He/She went into Resident #1's room around 7:30 P.M. to pick up the resident's supper tray. He/She observed the resident lying in bed with the head of the bed up, and the resident's feet were in the bed. The resident was still eating his/her supper, so the resident asked CNA D not to take his/her tray away; -He/She was assisting another resident when he/she heard a knock on the door around 7:55 P.M. to 8:00 P.M.; -When he/she opened the door, he/she saw Certified Medication Technician (CMT) C running down the hallway; he/she saw CMT C's medication cart outside of Resident #1's room and thought something must be going on in the resident's room, so he/she went to Resident #1's room; -When he/she got to the resident's room, he/she saw Resident #1 hunched over his/her bed; his/her feet were on the floor; his/her waist was over the foot board, his/her head was on the mattress, and his/her hands were on the bed; -He/She touched and shook the resident; he/she thought the resident had fallen; -He/She called the resident's name four times with no response from the resident; -He/She noticed vomit on the resident's bed; the vomit looked yellow or orange in color and like phlegm; -He/She noticed Resident #1 was not breathing; -CMT C and Registered Nurse (RN) A entered the resident's room; -CMT C and RN A assisted the resident to the floor; -RN A placed a pulse oximeter (device that measures the oxygen level in the blood) on the resident's finger and a wrist blood pressure cuff on the resident's wrist; -RN A instructed him/her to get a stethoscope; -He/She ran to the South nurses station and got a stethoscope, and as he/she was running back down the hall, RN A stepped out into the hallway and told him/her to never mind. RN A said they did not need the stethoscope. RN A said the resident was not living anymore and had passed away; -He/She went into the resident's room, and RN A went to the South nurses station; he/she saw RN A on the phone; -When he/she entered the room, the blanket and fitted sheet had been stripped from the resident's bed; the resident was still on the floor at the foot of the bed where he/she was when CNA D left the room to get the stethoscope; -He/She could not recall what CMT C was doing, maybe washing the resident's face; -He/She and CMT C lifted the resident's head and placed a pillow from the resident's bed under his/her head, and then laid a bed sheet over the resident; -CMT C told CNA D he/she had it from there and CNA D could go back to assisting the resident he/she had been assisting when all of this started; -He/She left Resident #1's room; -He/She saw EMS and RN A in the resident's room around 8:15 P.M. to 8:20 P.M.; -He/She saw the police in the resident's room and in the hallway, but he/she did not know when they arrived or what they had done; -RN A had not instructed him/her to begin CPR at any time; -He/She was not CPR certified; -He/She did not see any facility staff perform CPR on the resident; -He/She did not know the resident's code status, but knew the code status could be found on the computer or in the resident's chart. Review of CNA D's written statement, written and provided by CNA D during the on-site visit on [DATE], showed around 6:30 P.M. (on [DATE]), staff assisted Resident #1 to his/her room and into bed. Around 7:30 P.M., CNA D asked Resident #1 if he/she was finished with his/her tray from dinner. Resident #1 said he/she wanted to finish it, so CNA D left the resident's room. Between 7:55 P.M. and 8:00 P.M., he/she was assisting another resident when he/she heard two loud knocks and stepped out into the hall. He/She had a feeling something was wrong with Resident #1. He/She saw CMT C running to the North nurses station. He/She saw Resident #1 hunched over the foot of his/her bed. He/She lightly shook the resident and said the resident's name. He/She noticed vomit on the resident's bed and by his/her mouth. The resident was unresponsive. CMT C and RN A came in the resident's room five minutes later. RN A started getting a pulse and blood pressure and asked him/her to get a stethoscope. He/She grabbed one at which point RN A came out of the resident's room and said the resident had passed and did not need it. CMT C and he/she laid the resident down on the floor with a pillow under his/her head and a sheet from his/her shoulders down. CMT C said he/she could finish cares from there and sent CNA D to return to the resident he/she had been caring for prior to this incident. Five to ten minutes later, the EMTs arrived and he/she noticed police with them. He/She was informed they revived the resident and took him/her out. During an interview on [DATE] at 10:33 A.M., CMT C said the following: -He/She was CPR certified; -He/She was not sure of the resident's code status, but knew that information was located on the computer or in the resident's chart; -On the evening of [DATE] around 7:30 P.M., he/she found the resident standing at the foot of his/her bed, leaning or kneeling over the foot board with his/her chest against the footboard, his/her face was straight down on the mattress, and his/her arms were to his/her side; -He/She entered the resident's room, called the resident's name, trying to get him/her to respond. The resident did not respond; -He/She felt for a pulse at the resident's carotid artery, and did not detect a pulse; -He/She did not think he/she could move the resident to the floor by himself/herself so he/she yelled for help, but no one came; -He/She left the unresponsive resident in the position he/she found him/her and went to the South nurses station; -While on his/her way to the nurses station, he/she knocked on a closed resident room door where he/she thought CNA D was; -As he/she continued to the nursing station, CNA D opened the closed resident room door and CMT C instructed CNA D to go to Resident #1's room; -When he/she reached the nursing station, he/she used the intercom to call for RN A who was on the North hall, but there was no answer; RN A was the only licensed staff in the building; -He/She then ran to the North hall, found RN A and told him/her he/she was needed in the resident's room because the resident was unresponsive; -Upon their entry to the resident's room, the resident was in the same position he/she last saw him/her and CNA D stood in the room; -RN A checked the resident for a carotid pulse and a radial pulse; -RN A did not detect a radial pulse, and the resident was cool to touch; -He/She told RN A, We need to call 911, and RN A left the room; -He/She did not see RN A watch for breaths or listen for breath sounds before leaving the room; -RN A did not give him/her or CNA D any instruction when he/she left the resident's room; -He/She and CNA D lowered the resident to the floor at the end of the bed and noticed the resident had vomited; -The vomitus on his/her face appeared to be undigested, unidentifiable food; -He/She got a cloth to clean the resident's face, because he/she wanted to get his/her face clean before EMS arrived; -When he/she looked up, the police were there. They entered the room and immediately used their AED and initiated the defibrillator and began CPR; -He/She stepped to the resident's doorway or out of the room at that time; -Police asked him/her what the resident's code status was. He/She hollered up the hallway to RN A who was at the South nurses station to ask. RN A yelled back that the resident was a full code; -Police were still doing CPR when EMS entered the room and then the paramedics took over the CPR; -RN A did not return to the resident's room until after EMS arrived; -In his/her CPR training, he/she was taught to start CPR once it was determined the resident was without a pulse and not breathing and on a flat surface; -He/She had not thought to have RN A help him/her get the resident to the floor and begin CPR when they first entered the room; -He/She should have started CPR once he/she and CNA D got the resident to the floor, but he/she was concerned about the vomit on the resident's face; -He/She could not recall anything about a sheet being taken off the bed or placed over the resident. Review of CMT C's written statement, written and provided by CMT C during the on-site visit on [DATE], showed between 7:30 P.M. and 8:00 P.M. while doing the medication on South 1 300 hall, he/she observed Resident #1 kneeling at the end of his/her bed with his/her face down in the bed. He/She tried to get the resident to respond by calling the resident's name name and touching him/her. He/She checked for a carotid pulse. He/She received no response from the resident, felt no pulse, and the resident was cold to touch. He/She yelled for help and no one responded. He/She left the resident's room because he/she was unable to reposition the reside

Based on interview and record review, the facility failed to have a system in place to ensure certified in cardio-pulmonary resuscitation (CPR) staff was available on all shifts 24 hours a day/seven days a week. The facility identified 32 residents as full code status (CPR required in the event of cardiac or respiratory arrest). Further review showed the facility staff performed CPR on one resident (Resident #6) whose wishes were to be a Do Not Resuscitate (DNR), in a review of nine sampled residents. The facility census was 78. The administrator was notified on [DATE] at 5:16 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Record review of the facility's policy for CPR, dated (MONTH) (YEAR), showed the following: -Purpose: To ventilate and establish circulation on a resident with absence of respirations and pulse; -Do not initiate CPR if a valid DNR order is in place; -Facility must maintain and document a minimum of one CPR certified staff member per each shift on duty, not including any staff members needed to provide transport services; -Staff members who are CPR certified will provide documentation to the facility's Director of Nursing (DON) and/or designee, and annually thereafter; -Records of CPR certification will be maintained and available for surveyor review; -Administrator will monitor for compliance. Review of Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Survey & Certification Group memorandum revised [DATE] showed the following: -Subject: CPR in Nursing Homes; -CPR Certification: Staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment. 1. Record review of the facility's nursing schedule dated [DATE] through [DATE] showed no certified CPR staff member was on duty on the 10:00 P.M. to 6:00 [NAME]M. shift on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. During an interview on [DATE] at 4:55 P.M., Human Resources said the following: -He/she gets copies of licensed nurse's accreditations, including CPR cards if they have them; -He/she did not alert the DON if a licensed staff member did not have a CPR card; -He/she was not monitoring which staff was currently CPR certified and which staff had expired CPR certifications. 2. Record review of Resident #6's face sheet, undated, showed the following: -The resident was admitted to the facility on [DATE]; -DNR (if a person's heart stopped beating and/or they stopped breathing, no resuscitation procedures would be performed to keep them alive). Record review of the resident's electronic medical record showed the resident was a DNR. Record review showed the resident had signed a DNR on [DATE] and the physician signed on [DATE]. Record review of the resident's nurse's notes, dated [DATE] at 1:40 P.M., showed the following: -Registered Nurse (RN) J went into the resident's room and found the resident seated in his/her recliner. The resident had no pulse and no respirations. Staff placed the resident on the floor and started CPR with chest compressions and artificial breathing. The DNR paperwork that was not in the chart was not signed by the physician. The social service designee found the signed paperwork after the ambulance arrived. Per Emergency Management System (EMS) stop CPR. CPR stopped and the charge nurse came to the room and stated that the facility had received a physician order [REDACTED]. During an interview on [DATE] at 10:20 [NAME]M., RN J said the following: -He/she performed CPR on the resident because the DNR in the resident's chart was not signed by the physician; -The sheet requesting to be DNR had been signed by the resident. During an interview on [DATE] at 11:10 [NAME]M., the Director of Nursing said the following: -She did the staffing for the licensed nurses and Certified Medication Technicians; -She thought Human Resources obtained the licensed nurse's CPR certification card and if someone was not current with their CPR, that Human Resources would let her know; -She thought she had staffed at least one CPR certified staff on each shift; -She expected staff to honor resident's wishes regarding code status; -She expected staff to not perform CPR on a DNR resident. During an interview on [DATE] at 5:39 P.M., the Administrator said the following: -She expected one CPR certified staff member on each shift; -She expected staff to honor resident's wishes regarding code status; -She had recently noted that the facility did not have a CPR certified staff member for each shift and that the facility had scheduled a CPR class for all licensed staff on [DATE]. NOTE: NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level [NAME] Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Base on interview and record review the facility failed to notify one resident's (Resident #1) of five sampled residents' family and physician when the resident's Tresiba (an insulin used to treat high blood sugar) was not available. On the evening of 1/18/18 the physician ordered NPH (an insulin used to treat high blood sugar) twice daily. Staff did not notify the resident's family of the change in the resident's insulin on 1/18/18. On 1/19/18 the resident's blood sugar was 505 (Lipincott Manual of Nursing Practice 7th Edition, copyright 2001 shows normal blood sugar range of 60-100) milligrams per deciliter (mg/dl). Staff did not notify the resident's physician of the elevated blood sugar at the time. An hour later, the resident developed difficulty swallowing and had slurred speech. Staff did not notify the resident's physician at that time. When the facility did notify the physician (1 hour and 45 minutes after the resident's elevated blood sugar reading and 45 minutes after the resident's swallowing and speech problems), the resident was transferred to an regional hospital with a with a critical blood sugar and diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids. The more [MEDICATION NAME] in the blood the more ill the person will become). The facility census was 77. 1. Review of the facility's Resident Change of Condition Policy dated (MONTH) (YEAR) showed the following: - Observe, record and report any condition change to the attending physician; - Notify the resident's responsible party. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/18, showed the resident's [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. -Tresiba Flex Touch Pen (insulin) 100 units per milliliter (ml) give 10-20 units subcutaneous (SQ) at bedtime; -[MEDICATION NAME] (fast acting insulin) 100 units per ml per sliding scale before meals at 6:30 A.M., 11:30 A.M., and 4:30 P.M. -If blood sugar is 70 to 140, give 0 units; -If blood sugar is 141 to 180, give 2 units; -If blood sugar is 181 to 220, give 4 units; -If blood sugar is 221 to 260, give 6 units; -If blood sugar is 261 to 300, give 8 units; -If blood sugar is 301 to 350, give 10 unit; -If blood sugar is greater than 350, give 12 units; -If blood sugar is greater than 350, call the physician. Review of the resident's Medication Administration Record [REDACTED].M. dose of Tresiba because the medication was not available. Review showed no documentation the resident's physician or family was notified the Tresiba was not available. During an interview on 8/20/18 at 3:17 P.M. LPN (Licensed Practical Nurse) B said the following: -She cared for the resident on 1/17/18; -The resident had an order for [REDACTED].>-She did not give the medication because the facility did not have it; -He/she did not call the physician; -He/she did not notify the resident's family the Tresiba was not available. Review of the resident's POS dated, 1/18/18 at 8:19 P.M. showed the following: -Discontinue Tresiba; -Administer NPH (an insulin to treat [MEDICAL CONDITION], trade name [MEDICATION NAME] N) 50 units twice daily; -[MEDICATION NAME] 100 units per ml per sliding scale before meals at 6:30 A.M., 11:30 A.M., 4:30 P.M. and at 8:00 P.M. -If blood sugar is 70 to 150, give 0 units; -If blood sugar is 151 to 250, give 3 units; -If blood sugar is 251 to 300, give 5 units; -If blood sugar is 301 to 400, give 8 units; -If blood sugar is 401 to 450, give 10 units; -If blood sugar is greater than 450 call the physician. Review showed no documentation the resident's family was notified of the new order for [MEDICATION NAME] N insulin. Review of the resident's MAR indicated [REDACTED].M., the resident's blood sugar was 505. There was no documentation showing staff contacted the resident's physician regarding the resident's elevated blood sugar. Review of the resident's nurse's notes dated 1/19/18 documented at 9:45 A.M. showed the following: -At 7:30 A.M. the resident had blowing respirations (slow labored breathing); -His/her speech was slurred; -The resident was agitated at times, kicked at the staff and had removed his/her clothes twice; -The resident was unable to suck through a straw; -He/she had difficulty swallowing. There was no documentation showing staff notified the resident's physician of the change in condition at that time. Review of the resident's nurse's notes dated 1/19/18 documented at 9:45 A.M. showed the following: -Staff notified the resident's physician at 8:15 A.M. and updated him/her on the resident's condition (1 hour and 45 minutes after the resident's blood sugar was found to be 505 and 45 minutes after the resident had difficulty swallowing, blowing respirations and slurred speech); -Staff received an order to send the resident to the emergency room (ER). Review of the resident's ER report dated 1/19/18 showed the following: -The history and physical information showed the resident presented to the ER with generalized weakness and difficulty breathing; -The ER received report approximately one hour ago that the resident's bilateral arms would not work and he/she could not hold them against gravity. Later this improved but his/her mentation (mental status) had decreased and she became poorly responsive and with tachypnea (fast breathing); -The resident's blood glucose was more than 500 mg/dl (reference range 70 to 105 mg/dl); -He/she had focal (neurological) weakness; -His/her pupils were fixed (indicates an emergency situation), with an upward left gaze; -Agonal respirations (gasping, labored breathing, strange vocalizations and sudden involuntary jerk or spasm; -He/she was intubated (insertion of a tube into the trachea for ventilation); -The physicians question if the resident had a stroke or [MEDICAL CONDITION]; -The resident had profound diabetic ketoacidosis; -The resident transferred to a different hospital due to the need of a higher level of care. During an interview on 8/31/18 at 11:00 A.M., the director of nursing said the she considered a medication change a change in condition. During an interview on 8/31/18 A.M. at 10:56 A.M., the administrator said if a resident has a change in condition or medication, he expected staff to notify the resident's family or emergency contact. During an interview on 8/23/18 at 11:26 A.M., and 9/7/18 at 11:33 A.M., the resident's physician said the following: -He /she expected staff to call when the facility did not have the Tresiba; -Staff should have called him immediately when the resident's blood sugar was 505, he would have had staff call for an ambulance and the resident sent to the ER; -Staff should have called him and and ambulance when the resident had slurred speech, was agitated and unable to suck through a straw; -Waiting to report the resident's condition from 6:30 A.M. to 8:15 A.M. was unacceptable; -He/she said the outcome of diabetic ketoacidosis was avoidable. MO 9

Based on interview and record review the facility failed to follow physician orders [REDACTED].#1) of five sampled residents. On 1/17/18, staff did not administer the resident's Tresiba (an insulin used to treat high blood sugar) because the medication was not available. Staff did not notify the physician the medication was not available until the next night. On the evening of 1/18/18 the facility received an order for [REDACTED].M. and did not administer insulin at 8:00 P.M. On 1/19/18 when the resident's blood sugar was 505 (Lipincott Manual of Nursing Practice 7th Edition, copyright 2001 shows normal blood sugar range of 60-100) milligrams per deciliter (mg/dl), staff did not administer the resident's NPH insulin or the resident's [MEDICATION NAME] sliding scale (a specific amount of insulin to be administered according to blood sugar readings) insulin. The resident was transferred to the local emergency room , then transferred to a regional hospital with a critical blood sugar and diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids. The more [MEDICATION NAME] in the blood the more ill the person will become). The facility census was 77. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/18, showed the resident's [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. -Tresiba Flex Touch Pen (insulin) 100 units per milliliter (ml) give 10-20 units subcutaneous (SQ) at bedtime; -[MEDICATION NAME] (fast acting insulin) 100 units per ml per sliding scale before meals at 6:30 A.M., 11:30 A.M., and 4:30 P.M. -If blood sugar is 70 to 140, give 0 units; -If blood sugar is 141 to 180, give 2 units; -If blood sugar is 181 to 220, give 4 units; -If blood sugar is 221 to 260, give 6 units; -If blood sugar is 261 to 300, give 8 units; -If blood sugar is 301 to 350, give 10 unit; -If blood sugar is greater than 350, give 12 units; -If blood sugar is greater than 350, call the physician. Review of the resident's Medication Administration Record [REDACTED].M. dose of Tresiba because the medication was not available. During an interview on 8/20/18 at 3:17 P.M. LPN (Licensed Practical Nurse) B said the following: -He/she cared for the resident on 1/17/18; -The resident had an order for [REDACTED].>-She did not give the medication because the facility did not have it; -He/she did not call the physician. Review of the resident's POS dated 1/18/18 at 8:19 P.M. showed the following: -Discontinue Tresiba; -Administer NPH (an insulin to treat [MEDICAL CONDITION], trade name [MEDICATION NAME] N) 50 units twice daily; -[MEDICATION NAME] 100 units per ml per sliding scale before meals at 6:30 A.M., 11:30 A.M., 4:30 P.M. and at 8:00 P.M. -If blood sugar is 70 to 150, give 0 units; -If blood sugar is 151 to 250, give 3 units; -If blood sugar is 251 to 300, give 5 units; -If blood sugar is 301 to 400, give 8 units; -If blood sugar is 401 to 450, give 10 units; -If blood sugar is greater than 450 call the physician. Review of the resident's MAR indicated [REDACTED] -Staff did not check the resident's blood sugar at 4:30 P.M.; -Staff did not check the resident's blood sugar at 8:00 P.M.; -Staff did not administer the resident's [MEDICATION NAME] N insulin at 8:00 P.M.; -There was no documentation showing why staff did not administer the medication. Review of the resident's MAR indicated [REDACTED].M., the resident's blood sugar was 505. There was no documentation showing staff contacted the resident's physician regarding the resident's elevated blood sugar. Review of the resident's nurse's notes dated 1/19/18 documented at 9:45 A.M. showed the following: -At 7:30 A.M. the resident had blowing respirations (labored); -His/her speech was slurred; -The resident was agitated at times, kicked at the staff and had removed his/her clothes twice; -The resident was unable to suck through a straw; -He/she had difficulty swallowing. There was no documentation showing staff notified the resident's physician of the change in condition at that time. Review of the resident's MAR indicated [REDACTED] -At 8:00 A.M., staff did not administer [MEDICATION NAME] N 50 units at scheduled 8:00 A.M. dose due to the resident was unresponsive and did not swallow, (medication was not oral, but to be injected subcutaneously); -At 8:49 A.M. the resident's [MEDICATION NAME] sliding scale was not administered due to the resident was not responsive and did not swallow (medication was not oral, but to be injected subcutaneously). During an interview on 8/10/18 at 11:45 A.M. LPN A said the following: -He/she did not give the resident the ordered [MEDICATION NAME] or [MEDICATION NAME] because the resident did not have a gag reflex; -When the resident left the facility he/she had blowing respirations and his/her speech was slurred. Review of the resident's nurse's notes dated 1/19/18 documented at 9:45 A.M. showed the following: -Staff notified the resident's physician at 8:15 A.M. and updated him/her on the resident's condition (1 hour and 45 minutes after the resident's blood sugar was found to be 505 and 45 minutes after the resident had difficulty swallowing, blowing respirations and slurred speech); -Staff received an order to send the resident to the emergency room (ER). Review of the resident's ER report dated 1/19/18 showed the following: -The history and physical information showed the resident presented to the ER with generalized weakness and difficulty breathing; -The ER received report approximately one hour ago that the resident's bilateral arms would not work and he/she could not hold them against gravity. Later this improved but his/her mentation (mental status) had decreased and she became poorly responsive and with tachypnea (fast breathing); -The resident's blood glucose was more than 500 mg/dl (reference range 70 to 105 mg/dl); -He/she had focal (neurological) weakness; -His/her pupils were fixed (indicates an emergency situation) with an upward left gaze; -Agonal respirations (gasping, labored breathing, strange vocalizations and sudden involuntary jerk or spasm; -He/she was intubated (insertion of a tube into the trachea for ventilation); -The physicians question if the resident had a stroke or [MEDICAL CONDITION]; -The resident had profound diabetic ketoacidosis; -The resident transferred to a different hospital due to the need of a higher level of care. During an interview on 8/31/18 at 11:00 A.M., the DON said she expected staff to implement physician orders. During an interview on 8/31/18 at 10:56 A.M. P.M., the administrator said the following: -The DON is responsible to ensure physician orders [REDACTED].>-He would have expected staff to follow physician orders; -He expected staff to implement the orders when received; -He expected staff to notify the physician if medications are not available. During an interview on 8/23/18 at 11:26 A.M., and 9/7/18 at 11:33 A.M., the resident's physician said the following: -He /she expected staff to call when the facility did not have the Tresiba; -He/she expected staff to check the resident's blood sugar before meals and at bedtime as ordered; -He/she expected staff to administer the resident's [MEDICATION NAME] and [MEDICATION NAME] as ordered; -Staff should have called him immediately when the resident's blood sugar was 505, he would have had staff call for an ambulance and the resident sent to the ER; -Staff should have called him and and ambulance when the resident had slurred speech, was agitated and unable to suck through a straw; -Waiting to report the resident's condition from 6:30 A.M. to 8:15 A.M. was unacceptable; -He/she said the outcome of diabetic ketoacidosis was avoidable. MO 9

Based on interview and record review the facility failed to provide appropriate care and services for two of six sampled residents (Residents # 2 & #4). The facility failed to ensure anti [MEDICAL CONDITION] medications were available and administered as ordered by the physician for one resident (Resident #4) with a [DIAGNOSES REDACTED]. The facility failed to transcribe discharge hospital orders, follow physician's orders [REDACTED].#2). The facility's census was 76. 1. Review of the facility's physician's orders [REDACTED]. -Each resident must be under the care of a licensed physician; -physician's orders [REDACTED]. -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Only a licensed nurse or therapist may accept telephone/verbal orders from a licensed physician; -Such orders must be countersigned by the issuing physician. 2. Review of the facility's Emergency Drug Supply Policy, dated March 2015, showed the following: -Purpose: To obtain drugs on a prompt and timely basis; -Licensed nurses have access to the emergency drug supply; -Emergency drug supply is available for immediate administration of a medication not otherwise obtainable in the time required. The emergency drug supply will be available and stored in such a manner so as to make it inaccessible to residents, bur readily accessible to licensed personnel; -A physician's orders [REDACTED]. -When necessary, the nurse will break the seal and remove the prescribed medication. 3. Review of Resident #4's hospital discharge orders, dated 1/25/17, showed the following: -admitted : 1/14/17; -Discharge Diagnosis: [REDACTED]. -Discharge to the facility; -If have questions or concerns after discharge to call the Neurologist. Review of the resident's Post Acute Care Transfer Report Medication Reconciliation, dated 1/25/17, showed the following: -Continue [MEDICATION NAME] (diuretic and antihypertensive) 25 mg once daily; -Continue [MEDICATION NAME] (anticonvulsant) 200 mg every 12 hours; -Continue [MEDICATION NAME] (antibiotic) 100 mg every 12 hours to complete on evening of 1/25/17; -Continue [MEDICATION NAME] 30 mg times one day, then 20 mg times one day, then 10 mg times one day, then 5 mg times one day, then stop; -Discontinue [MEDICATION NAME] (anticonvulsant) 500 mg every 12 hours; -Continue [MEDICATION NAME] 1500 mg every 12 hours; -Hand written on the report dated 1/25/17 (untimed), Clarified [MEDICATION NAME] order with the resident's primary care physician continue [MEDICATION NAME] 500 mg every 12 hours signed by Licensed Practical Nurse (LPN) A (no physician co-signature). Review of the resident's physician's orders [REDACTED]. -admitted : 1/25/17; -[DIAGNOSES REDACTED]. -[MEDICATION NAME] 25 mg once daily; -[MEDICATION NAME] 500 mg every 12 hours, start 1/25/17 and end date 1/25/17 (discontinue date); -[MEDICATION NAME] 100 mg every 12 hours, start 1/25/17; -[MEDICATION NAME] 200 mg every 12 hours, start 1/25/17. Review of the resident's Medication Administration History, showed the following: -On 1/26/17 at 7:00 A.M., [MEDICATION NAME] 25 mg not administered: Drug unavailable; -On 1/25/17 at 6:00 P.M., [MEDICATION NAME] 100 mg not administered: Drug unavailable. Comment: Waiting on pharmacy delivery; -On 1/26/17 at 7:00 A.M., [MEDICATION NAME] 30 mg not administered: Drug unavailable; -On 1/25/17 at 6:00 P.M., [MEDICATION NAME] 200 mg not administered: Drug unavailable. Comment: Waiting on pharmacy delivery; -On 1/26/17 at 6:00 A.M., [MEDICATION NAME] 200 mg not administered: Drug unavailable. Comment: Pharmacy has not delivered yet; -On 1/26/17 at 6:00 P.M., [MEDICATION NAME] 200 mg space was blank; -On 1/27/17 at 6:00 A.M., [MEDICATION NAME] 200 mg not administered: Drug unavailable. -No documentation staff administered [MEDICATION NAME]. Staff failed to administer [MEDICATION NAME] for one day, [MEDICATION NAME] times one dose, [MEDICATION NAME] for one day, [MEDICATION NAME] and [MEDICATION NAME] were never administered. Review of the resident's progress note, dated 1/27/17 at 1:32 P.M., showed the nurse was called to the resident's room by a family member. The resident had food in his/her mouth and would not swallow, the nurse attempted several times to get the resident to swallow the food or spit the food out, the resident finally swallowed part of the food and spit some out. The resident was sitting on the bed and stiffened then slumped to the right side and was unresponsive. After approximately one minute the resident started having a [MEDICAL CONDITION] for approximately one minute, he/she stopped then started seizing again for approximately one minute, after he/she stopped seizing he/she slumped forward, the nurse called to the therapist that was passing in the hall to get help. The resident was placed on his/her side with head elevated. The ambulance was called. Noted the resident had blood coming from his/her mouth, but was unable to determine where the bleeding came from. The resident's family member was at bedside for the duration and accompanied the resident to the local hospital. Review of the outlying hospital history and physical, dated 1/27/17, showed the following: -Reason for admission: [DIAGNOSES REDACTED]; -History of present illness: The resident has a left hemispheric grade 3 [DIAGNOSES REDACTED] (cancer of the brain) with two recent admissions for [MEDICAL CONDITION]. Most recently, he/she was discharged on [DATE]th. At the time of discharge two days ago he/she was on 1500 mg twice daily of [MEDICATION NAME] and 200 mg of [MEDICATION NAME] twice daily. The resident's family member reports that the resident was doing well and even walking with therapy yesterday. He/she had a [MEDICAL CONDITION] at the nursing home today and was taken to the local hospital. The physician at the local hospital evaluated the resident and conversed with this hospital. On conversation it was noted that his/her [MEDICATION NAME] dose was not where it was supposed to be, he/she was only on 500 mg twice daily despite the fact that he/she was discharged on 1500 mg twice daily from this hospital. On arrival to the neurology floor he/she was noted to have persistent left facial twitching that did not respond to intravenous [MEDICATION NAME] (controlled substance sedative) , therefore he/she is being transferred to the Intensive Care Unit (ICU) for closer monitoring; -Physical Examination: He/she had persistent right facial twitching when first examined. He/she had forced right gaze preference. He/she would not respond or follow commands to verbal command. When pinched on his/her extremity he/she did grimace and then made unintelligible audible noises. After administration of 2 mg of [MEDICATION NAME] the twitching persisted, but did slow down in frequency. His/her gaze preference resolved and his/her eyes deviated to midline, although he/she was still noncommunicative and not able to follow commands. -Plan: Admit to ICU. Give her intravenous [MEDICATION NAME] (anticonvulsant). Give him/her an additional intravenous load of [MEDICATION NAME] and [MEDICATION NAME]. Resume his/her previous doses of [MEDICATION NAME] 1500 mg twice daily and [MEDICATION NAME] 200 mg twice daily. Will administer benzodiazepines (tranquilizer) judiciously. He/she will have nothing by mouth for the meantime, so will hold his/her oral medications, but if fortunate enough to get the [DIAGNOSES REDACTED] to resolve, can resume oral meds when appropriate. He/she will have frequent neuro checks. He/she will have [MEDICAL CONDITION] precautions. Will start intravenous hydration with vitamin supplementation. Will order rehab and therapy evaluation. Prognosis is guarded at this point in time. During an interview on 1/31/17 at 9:13 A.M., the resident's family member said the following: -The resident was still in ICU; -The resident had failed his/her swallow test; -The resident's speech is extremely impaired and he/she was able to speak clearly before the [MEDICAL CONDITION] and it is unknown if that will improve. During an interview on 1/31/17 at 2:25 P.M., LPN A, said the following: -He/she clarified with Primary Care Physician B the [MEDICATION NAME] order because 1500 mg twice a day was a high dose and that he/she wanted to continue at 500 mg twice a day. During an interview on 2/14/17 at 10:04 A.M. and 12:58 P.M., LPN A said the following: -He/she must have discontinued the [MEDICATION NAME] order on the 25th when he/she clarified the order; -The [MEDICATION NAME] should have been on the Physician order [REDACTED]. -[MEDICATION NAME] was available in the Emergency kit, but [MEDICATION NAME] was not; -[MEDICATION NAME] could have been obtained from the back up pharmacy. -When residents are admitted from hospital, the orders are reviewed, clarified with primary physician, then transcribed; -The orders are then put into the computer and linked with the pharmacy. During an interview on 2/1/17 at 9:58 A.M., the resident's Neurologist, said the following: -The resident was discharged on [MEDICATION NAME] 1500 mg twice a day and would have expected the facility to continue at that dose or call and clarify with him/her since he/she was the specialist that had treated the resident; -1500 mg was a normal dose for someone with the resident's history of [MEDICAL CONDITION]; -The resident's Neurologist denied receiving any call from the facility or primary care physician in regards to the resident's medications or dosage; -The resident not receiving his/her anti [MEDICAL CONDITION] medications could have contributed to the resident having a [MEDICAL CONDITION]. During an interview on 2/9/17 at 9:02 A.M., Primary Care Physician B said the following: -The resident was a new patient to him; he had not ever seen the resident; -He denied LPN A clarified the [MEDICATION NAME] order with him or one of his associates; -He would have expected all medications to be available and given as ordered; -He did not know that the resident did not receive any of his/her anti [MEDICAL CONDITION] medications while at the facility; -He would have expected if a nurse was questioning a dose of anti [MEDICAL CONDITION] medications on a new resident that he/she would call the discharging physician for clarification. 4. Review of Resident #2's local hospital Transfer Orders for Receiving Facility, dated 1/27/17, showed the following: -admitted : 1/23/17; -Discharge Diagnosis: [REDACTED].>-Current Discharge Medication List: [MEDICATION NAME] (antibiotic) 875/125 milligram (mg) every 12 hours for 7 days. [MEDICATION NAME] (statin, used to treat high cholesterol and triglyceride levels) 10 mg daily at bedtime. [MEDICATION NAME] (inhaled steroid and decongestant) 50 microgram (mcg) one spray in each nostril twice daily. [MEDICATION NAME] ([MEDICAL CONDITION] medication) solution one drop in both eyes at bedtime. Review of the resident's physician's orders [REDACTED]. -admitted : 1/27/17 1:15 P.M.; -[DIAGNOSES REDACTED]. -[MEDICATION NAME] 10 mg daily at bedtime; -[MEDICATION NAME] 50 mcg one spray each nostril twice a day; -[MEDICATION NAME] solution one drop in both eyes at bedtime. -No order for [MEDICATION NAME] 875/125 mg every 12 hours for seven days. Review of the resident's Electronic Administration Count, showed on 1/27/17 at 8:00 P.M., no [MEDICATION NAME], and [MEDICATION NAME] was administered as ordered. During an interview on 2/3/17 at 3:09 P.M., the Director of Nursing (DON) said the following: -The [MEDICATION NAME] should have been ordered and was missed during transcribing of hospital discharge orders; -She would expect staff to pull medications from the Emergency kit to give the first dose if medications were not available at the facility. 5. During an interview on 2/9/17 at 9:10 A.M., the administrator said the following: -He would expect staff to clarify orders as needed; -He would expect staff to transcribe orders accurately from hospital discharge orders; -He would expect staff to administer medications as ordered; -He would expect staff to utilize the Emergency kit as needed for medications not yet at the facility from the pharmacy. MO 5

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one resident (Resident #1) of six sampled residents who was assessed with [REDACTED]. Staff failed to document offering pain medication when necessary and failed to notify the physician when the resident wasn't taking scheduled [MEDICATION NAME] (Tylenol) and [MEDICATION NAME] (relieves pain for certain conditions in the nervous system). Staff failed to notify a physician when the resident's as needed pain medication was ineffective or to ensure the resident's pain was addressed when the resident's hospice provider had not obtained requested medications for pain. The facility census was 85. 1. Review of the facility's Pain Management Guideline, dated 2/10/15, showed: -Guideline Statement: To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life, in concert with the resident's plan of care and goals for pain management; -Guideline: Functions of appropriate pain management include, but not limited to; -Ensuring involvement of resident in pain management; -Recognizing and reporting pain as a 5th vital sign; -Assessing pain and evaluating response to pain management interventions using a pain management scale based on resident self-report or objective assessment for the cognitively impaired; -Intervening to treat pain before the pain becomes severe; -Documenting pain assessment and interventions prior to giving medication, evaluation activities should be recorded in a concise manner per the plan of care; -Recognize that residents who have chronic pain will benefit most from an effective, scheduled pain medication regimen; -Resident/Family and Staff Education: Understating the importance of effective pain management for quality of life; -Assessment: Pain assessment tools: Numeric Rating Scale, Verbal Descriptor Scale and *PAINAD (Pain in Advanced Dementia) are utilized to screen and assess pain level for cognitively intact and cognitively impaired residents; -For residents who are experiencing behaviors affecting themselves or others, consider pain as a possible trigger for behaviors and evaluate accordingly; -The comprehensive assessment includes the frequency, intensity, location, description, current treatment, effectiveness of treatment, and what makes pain worse or what makes pain better; -Reassessments are conducted quarterly via MDS (Minimum Data Set), a federally mandated assessment instrument required to be completed by facility staff, following changes in condition when pain is suspected, after a fall, or with worsening of pain that the resident feels is beyond acceptable level; -Documentation: -Disciplines will strive to use consistent methods of evaluation methods of evaluation and descriptors/ratings in documentation; -Upon admission, the licensed nurse screens each resident for pain and documents finding on the Clinical Health Status/Pain Evaluation tool; -The physician is notified of pain assessment findings and order(s) obtained for pharmacological and/or non-pharmacologic interventions, if indicated; -Appropriate required prescriptions for narcotic pain medications are obtained and transmitted to the pharmacy; -The nurse develops a plan of care for pain management, if indicated, including the use of non-pharmacological interventions; -Based on initial screening/assessment results, the licensed nurse and available interdisciplinary team (IDT) members establish a frequency of ongoing pain monitoring based on resident need, findings are documented on the electronic medication administration record (eMAR) and/or progress note; -The licensed nurse/IDT periodically evaluates frequency of as needed (PRN) medication usage and consults physician regarding routine pain medication, if indicated; -The licensed nurse updated the plan of care to reflect changes to interventions for ongoing pain management; -Following an acute change in condition when pain is suspected, and after any fall, the licensed nurse assesses the resident for pain, using the appropriate pain scale and documents assessment findings; The licensed nurse discusses the findings with the resident's physician and receives any new orders for evaluation and treatment of [REDACTED].>-A plan of care is developed/updated and the resident is monitored for pain with findings documented in the progress note and/or eMAR until stable; -The IDT and resident evaluate the effectiveness of each resident's pain management plan at the time of the initial comprehensive assessment, quarterly, following a significant change, after a fall, and annually; -Findings and/or recommendations are documented in the medical record, as indicated, and the plan of care is updated as needed; -Resident's Rights Residents have the right to choose their level of sedation and pain management as long as they receive education and can make informed choices; -Monitoring/Compliance: -Residents are evaluated for pain upon admission, change as condition and as indicated using standardized pain scales; -Care plan is in place and reflects current pain management interventions; -Documentation and observation of care and treatment reflects ongoing monitoring of pain levels and interventions, the documentation will be reflected on the eMAR and progress notes; -Residents receiving PRN pain medication are evaluated for routine pain management schedules. 2. Review of Resident #1's admission MDS, dated [DATE], showed the following:: -Long and short term memory problems; -Trouble concentrating, short tempered; -Easily annoyed per staff; -Physical behaviors; -No pain and no PRN pain medication use; -Two stage II pressure ulcers (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) and [MEDICAL CONDITION]. Review of the resident's physician orders, dated 7/1/15 through 8/31/15, showed: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (relieves pain for certain conditions in the nervous system) 10 mg two capsules two times a day for pain; -[MEDICATION NAME] (Tylenol) 500 mg, one tablet by mouth three times a day for pain; -[MEDICATION NAME]-[MEDICATION NAME] (narcotic combination drug used to treat moderate to moderately severe pain) tablet 5-325 mg one tablets every four hours as needed for pain related to other chronic pain; -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg two tablets by mouth every four hours as needed for pain related to other chronic pain; -[MEDICATION NAME] 500 mg one tablet as needed for pain; -[MEDICATION NAME] HCL (medication used to treat moderate-to-severe pain) tablet 50 mg, give 1/2 tablet by mouth every four as needed for pain; -Hospice consult. Review of the resident's care plan, dated 7/7/15, showed: -Hospice services at the resident and family's choice for end of life care; -The resident will have comfort care and pain at acceptable level; -Evaluate effectiveness of medications/interventions to address comfort; -Notify hospice of any change in condition or medication changes. Review of the resident's nurse's progress note, dated 7/16/15, showed: -At 11:17 A.M., the resident sat in the hallway by the nurse's station in his/her wheelchair and continued to yell out loudly almost continuously and staff nor his/her spouse were able to verbally comfort him/her; -He/she refused to take any medications and pushed the nurse and his/her spouse's hands away; -A call was placed to hospice for consideration of alternate medications for pain and anxiety as the resident was grimacing and was restless in his/her chair; -It was requested the physician be asked about a [MEDICATION NAME] (treats moderate to severe chronic pain), [MEDICATION NAME] gel (used for nausea in hospice residents) and possible [MEDICATION NAME] (opioid pain medication); -The hospice nurse said he/she would contact the physician and relay the request; - There was no further documentation regarding the resident's pain or contact with the physician. Review of the resident's eMAR, dated 7/16/15, showed the following: -Assess pain level every shift; medicate if necessary every shift; -Pain level during the day shift was 0 (on a scale of 0-10 with 0 being no pain and ten the worst pain). (Nurses progress note for the same day at 11:17 A.M. showed the resident yelled out continuously, could not be comforted, hospice was contacted for alternative pain medications for pain and anxiety); -Pain level during the evening shift was 6 and the resident had nausea and vomiting; -Pain level during the night shift was 6. -There was no as needed pain medication documented as given for the resident's pain, (nurses notes showed the resident had pain, yelled out, was grimacing and restless). Review of the resident's hospice progress note, dated 7/16/15 untimed, showed the resident was hollering out and had been yelling all night. Review of the resident's hospice progress note, dated 7/17/15 untimed, showed the resident's spouse and son/daughter were asking about medications that were requested yesterday ([MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] gel). Telephone call to the physician's office regarding medications, the nurse called the physician around 12:00 P.M. yesterday requesting medications. Awaiting return phone call. The staff said the resident was awake hollering until 5:00 A.M. Review of the resident's nurse's progress notes, dated 7/17/15, showed the following: -At 7:49 A.M., hospice called the facility questioning if they had received an order from the resident's physician yesterday regarding increase in pain and anxiety medication. No orders were seen on the physician order [REDACTED]. hospice know and hospice said, I'm going to call this again right now; -At 9:30 A.M., hospice nurse at the facility, it was reported the resident was up until after 5:00 A.M., the hospice nurse said she had spoken with the physician's office this A.M. regarding requested orders yesterday. The office said the physician was out of town but they would take care of getting the orders. If the hospice nurse hadn't heard from the physician's office by the time she left she would call again, if she had no results from the physician's office by noon she would call the medical director for orders; -At 11:12 A.M., staff gave the resident two [MEDICATION NAME]-[MEDICATION NAME] tablets the resident's spouse had requested for the resident's pain; -At 11:29 A.M., the resident was loud and disruptive, agitated and squirming in the chair; -At 1:16 P.M., the PRN medication was ineffective, the resident was still squirming in his/her chair; -At 1:42 P.M., hospice said he/she had not heard from the physician's office yet, the facility staff asked her to contact their medical director and he/she said the medical director's office closed at noon. Stressed the facility needed something for the resident today and that the resident had been awake for two hours yelling out. As needed oral medication was ineffective at this time, the hospice nurse said he/she would contact his/her supervisor and try to get something expedited; -At 3:30 P.M., the hospice supervisor said they had called the physician's office three times today but he/she would call them again. If he/se did not get a response from them he/she was going to insist the hospice medical director give the orders. He/She said hospice would get the scripts, it was explained that if pharmacy had the scripts by 6:00 P.M. they would deliver them tonight; -At 3:46 P.M., increased agitation; -At 6:14 P.M., a physician came to see the resident and ordered [MEDICATION NAME] 2.5 mg intramuscularly (IM), may repeat if necessary if no results in two hours one time; -At 9:16 P.M., [MEDICATION NAME] IM was slightly effective; -At 10:17 P.M., the resident was alert and oriented to self only, usually does not verbally communicate if you can get him/her to calm down enough to talk to him/her he/she will usually answer yes and no questions. He/She will yell out over and over. There had been times where he/she had been awake yelling over and over for several hours at a time despite different attempts and methods to relieve pain or agitation. He/She can become combative with care, yelling at present time; -At 11:54 P.M., continued to yell, he/she had been repositioned, offered fluids and snack and he/she refused. - There was no documentation staff offered pain medication. Review of the resident's eMAR, dated 7/17/15, showed the following: -Assess pain level every shift; medicate if necessary every shift; -Pain level during the day shift was not evaluated; -At 11:12 A.M., staff gave the resident [MEDICATION NAME]-[MEDICATION NAME] two tablets for pain, the resident's pain level was a 7 (on a scale of 0-10) and the medication was ineffective; -Pain level during the evening shift was 6 and the resident had nausea and vomiting; -Pain level during the night shift was 5. Review of the resident's nurse's progress notes dated 7/18/15, showed the following: -At 5:37 A.M., staff notified the physician resident's [MEDICATION NAME] that was given on 7/17/15 was not effective and that the [MEDICATION NAME] and [MEDICATION NAME] given at 12:45 A.M. (not documented on the eMAR) was not effective either, awaiting call back; -At 10:44 A.M., staff gave [MEDICATION NAME] HCL 50 mg,as needed for pain, the resident was yelling and having anxiety; -At 10:45 A.M., staff gave [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg as needed for pain, the resident was up all night; -At 10:46 A.M., nurse came on at 6:00 A.M., the resident screamed until breakfast at 7:30 A.M., rested for one hour and began screaming again, repositioned two times before 9:30 A.M. in chair. -At 1:55 P.M., [MEDICATION NAME] 100 mg prescribed for pain wasn't given; -At 1:58 P.M., the PRN was ineffective and [MEDICATION NAME] prescribed for pain was not given. There was no documentation why the resident's [MEDICATION NAME] or [MEDICATION NAME] was not given. Review of the resident's eMAR, dated 7/18/15, showed the following: -Pain level during the day shift was 0 (on a scale of 0-10); -At 8:00 A.M., [MEDICATION NAME] 100 mg, two capsules, twice a day was not given, the reason the medication was not given was hold/see nurse's notes; -At 8:00 A.M., [MEDICATION NAME] 500 mg, one tablet three times a day for pain was not given, the reason the medication was not given was resident refused; -At 10:44 A.M., [MEDICATION NAME] HCL 50 mg, 1/2 tablet given, ineffective; -At 10:45 A.M., [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg two tablets given, ineffective; --At 12:00 P.M., [MEDICATION NAME] 500 mg, one tablet three times a day for pain was not given, the reason the medication was not given was hold/see nurse notes. Review of the resident's nurse's progress notes, dated 7/19/15, showed the following: -At 11:39 A.M., [MEDICATION NAME] HCL 50 mg as 1/2 tablet as needed given for verbal outbursts and pain; -At 11:40 A.M., [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg one tablet as needed given for verbal outburst and pain; -At 12:44 P.M., [MEDICATION NAME] 500 mg prescribed for pain was not given; -At 12:45 P.M., the resident was in his/her room with verbal outbursts and refused medication, given three times before swallowing; -At 1:30 P.M., [MEDICATION NAME] 100 mg prescribed for pain wasn't given; -At 1:31 P.M., [MEDICATION NAME] 500 mg prescribed for pain was not given; -At 1:35 P.M., PRN administration was ineffective. -There was documentation why the resident's [MEDICATION NAME] or [MEDICATION NAME] was not given. Review of the resident's eMAR, dated 7/19/15, showed the following: -At 8:00 A.M., [MEDICATION NAME] 100 mg, two capsules, twice a day was not given, the reason the medication was not given was other/see nurse's notes; -At 8:00 A.M., [MEDICATION NAME] 500 mg, one tablet three times a day for pain, the reason the medication was not given was other/see nurse's note; -At 10:45 A.M., [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg one tablet given as needed, ineffective; -At 11:39 A.M., [MEDICATION NAME] HCL 50 mg as needed given, pain level 5, ineffective; -At 12:00 P.M., [MEDICATION NAME] 500 mg, one tablet three times a day for pain, the reason the medication was other/see nurse's note. Review of the resident's progress notes dated 7/20/15, showed orders and prescription faxed to the pharmacy for [MEDICATION NAME]. During interview, on 8/6/15 at 2:27 P.M., LPN E said on 7/16/15 the resident was yelling the whole shift. He/she tried calling the resident's physician and tried to get a prescription written for [MEDICATION NAME] and a [MEDICATION NAME] because the resident was spitting out his/her medications. He/she thought the staff had received an order for [REDACTED]. He/she didn't know the facility didn't receive an order. The resident was in pain and sometimes he/she could tell you and sometimes he/she couldn't. The pain assessment was on the eMAR and should be done every shift. On 7/16/15, the resident rated his/her pain a 5 (on a scale of 0-10) and he/she thought he/she had given the resident something for the pain. He/she attempted to give the resident medication but he/she would not take his/her medication and he/she forgot to document this. He/she wasn't sure what the policy was if Hospice did not respond with resident's medication changes. During interview, on 8/17/15 at 2:15 P.M., Registered Nurse C said on 7/16/15 the hospice nurse came in and the resident was yelling. Another nurse did give the resident some [MEDICATION NAME]-[MEDICATION NAME] at 2:00 P.M. The medication should of been documented in the eMAR and show if it was effective or not and he/she did not know if the resident's [MEDICATION NAME] was effective or not. There was no documentation. If the resident was in pain the staff would document the pain in the progress note and the eMAR. The effectiveness was not documented because there was no place to write it. If the resident had Hospice the staff go through them for the resident's medications and they usually act quickly after notifying them a few times. During interview on 8/6/15 at 5:50 P.M., Licensed Practical Nurse (LPN) A said the resident yelled a lot especially when he/she touched his/her stump and he/she could tell he/she was in pain. The resident would just yell and if the resident was in pain staff was to call the physician and if there was no response contact the medical director. When the resident finally received his/her [MEDICATION NAME] it kept him/her asleep and comfortable. During interview on 8/6/15 at 3:40 P.M., the Interim Director of Nursing Services (DNS) said if a resident required pain medication and the physician did not call the staff back within two hours he/she would expect the staff to call the physician back by the end of their shift. The staff requested narcotics for Resident #1 which required a prescription and the physician and medical director were on vacation. The staff should of called the medical director and asked if the resident should be sent to the emergency room for a pain evaluation. He/she would expect staff to evaluate the resident's pain level prior and after giving pain medication. He/she would expect staff to notify the physician if the resident wasn't taking his/her routine ordered medication. During interview on 9/1/15 at 11:30 P.M., the resident's physician's nurse said the following: -On 7/16/15, a nurse from the facility called and requested [MEDICATION NAME], and [MEDICATION NAME] gel for the resident; -The nurse at the facility said the resident had been hollering and had an order for [REDACTED]. -He/she told the nurse to give the [MEDICATION NAME] to the resident every four hours as prescribed until the physician was back in the office on 7/17/15; -The nurse from the facility never said the resident wasn't taking his/her prescribed routine medications for pain; -On 7/17/15, the physician's nurse attempted to contact the facility from 1:44 P.M. through 4:15 P.M., he/she called the facility five times and was unable to speak to a nurse; -He/she let hospice know he/she was unable to get a hold of a nurse and a physician would be out that evening to see the resident; -If the facility was unable to control the resident's pain with PRN pain medications they should of called the physician on call through the hospital exchange. MO # 3