Every finding on record at Quarters at Des Peres, The

Based on observation, interview and record review, the facility failed to ensure services were provided to prevent pressure ulcers (skin and tissue damage caused by prolonged, unrelieved pressure on the skin) for one resident (Resident #3). Staff failed to provide ordered treatment to the resident's sacral wound after an incontinent episode, leaving the wound exposed to air and failed to complete ordered daily wound care to the resident's right ankle pressure ulcer for three days while documenting the treatment as completed on the Treatment Administration Record (TAR). The sample size was seven. The census was 122.Review of the facility's Wound Management Policy, revised 11/15/22, showed:Policy: To promote Wound healing of various types of Wounds, the Facility will provide Evidence-Based Treatments in accordance with current Standards of Practice and Physician Orders; Procedure: Wound Management: -Wound Treatment will be provided in accordance with Physician's Order; -Cleansing Method; -Type of Dressing; -Frequency of Dressing Change. Charge Nurse will Notify Physician in the absence of Treatment Orders. Dressing Changes may be provided outside of the frequency parameter in certain situations: -Urine, Feces, or other Bodily Fluids have saturated through the Dressing; -Dressing is Dislodged; -Dressing is Soiled. Wound Dressing's will be Applied in accordance with Manufacturer's Recommendations. Treatment Selection will be based on the Etiology of the Wound. Pressure Injuries will be differentiated from Non-Pressure Wounds. Wound Characteristics/Documentation: -Location of the Wound; -Pressure Injury & Stage; -Non-Pressure-Level of Tissue Destruction; -Size (Shape, Depth, Tunneling and/or Undermining); -Volume & Exudate Characteristics; -Pain Evaluation; -Presence of Infection/Bioburden; -Condition of the Wound Bed & Wound Edges; -Condition of the Peri-Wound;-Resident/Resident Representative Preferences/Goals. Guidelines for Dressing Selection: -Obtain Physician's Order; -Review Wound Care Formulary to assist in Treatment decision process; -Wound Care Formulary may not be appropriate for use in all circumstances; -Treatments will be documented on the Treatment Administration Record. The Effectiveness of Treatments will be Monitored through ongoing Evaluation of the Wound(s). Considerations Modification: -Lack of progression towards healing;-Changes in Wound Characteristics; -Changes in the Resident/Resident Representative's Preferences/Goals (e.g., comfort care associated with end of life in accordance with his/her rights). Review of Resident #3's care plan, revised 1/28/26, showed:-Focus: Resident has a wound to his/her sacrum, stage four (a severe full-thickness wound where skin and underlying tissues are destroyed) that he/she receives treatment to. Resident has a wound to right medial heel and right second toe;-Goal: To remain without complications over through the next review;-Interventions: Low air loss mattress, observe for signs of infection, provide treatment per current order. Refer to physician orders for details. Wound doctor to follow wounds. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/26, showed:-Cognitively intact;-Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device: Yes;-Is this resident at risk of developing pressure ulcers/injuries: Yes;-Current number of unhealed pressure injuries: One;-Number of Stage four pressure ulcers: One;-Other open lesion on the foot: Yes;-Diagnoses included: diabetes, muscle weakness, acquired absence of left leg below knee, acid reflux, neurogenic bladder (the bladder does not empty properly due to a neurological condition), spina bifida occulta (is a mild form of spina bifida caused by a gap forming between the vertebrae in your spinal cord) and pressure ulcer of sacral region stage four. Review of the resident's electronic Physician Order Sheet (ePOS), dated May 2026, showed:-An order, dated 5/6/26, Right Medial Heel: Cleanse with wound cleanser. Apply Santyl (prescription ointment used to help clean wounds and promote healing) with calcium alginate (a gelatinous water-insoluble substance derived from brown seaweed), cover with a 4x4 wrap with kerlix (gauze) and secure with tape. Change daily and as needed if soiled. Every day shift for Wound Care;-An order, dated 5/15/26 to 5/19/26, Sacrum: Cleanse with wound cleanser, pat dry, apply mesalt (sodium chloride-impregnated sterile dressing used to manage heavily draining and infected wounds) cover with Sacral border gauze and change daily and as needed if soiled. Every day shift for Wound care;-An as needed (PRN) order, dated 5/15/26 to 5/19/26, Sacrum: Cleanse with wound cleanser, pat dry, apply mesalt cover with Sacral border gauze and change daily and as needed if soiled every eight hours as needed for wound;-An order, dated 5/19/26, Sacrum: Cleanse with wound cleanser, pat dry, apply mesalt cover with Sacral border gauze and change daily and as needed if soiled. Two times a day (7a-10 am and 4pm -7pm) for Wound care;-A PRN order, dated 5/19/26, Sacrum: Cleanse with wound cleanser, pat dry, apply mesalt cover with Sacral border gauze and change daily and as needed if soiled every eight hours as needed for wound. Review of the resident's TAR, dated May 2026, showed:-An order, dated 5/6/26, Right Medial Heel: Cleanse with wound cleanser. Apply santyl with calcium alginate, cover with 4x4 wrap with kerlix secure with tape. Change daily and as needed if soiled. Every day shift for Wound Care;-Shown as completed on 5/15, 5/16, 5/17, 5/18, and 5/19/26;-An order, dated 5/15/26 to 5/19/26, Sacrum: Cleanse with wound cleanser, pat dry, apply mesalt, cover with Sacral border gauze and change daily and as needed if soiled. Every day shift for Wound care;-Shown as completed on 5/15/, 5/16, 5/17, and 5/18/26;-An as needed (PRN) order, dated 5/14/26 to 5/19/26, Sacrum: Cleanse with wound cleanser, pat dry, apply mesalt cover with Sacral border gauze and change daily and as needed if soiled every eight hours as needed for wound;-TAR was blank on 5/14, 5/15, 5/16, 5/17, 5/18, and 5/19/26;-An order, dated 5/19/26, Sacrum: Cleanse with wound cleanser, pat dry, apply mesalt cover with Sacral border gauze and change daily and as needed if Soiled. Two times a day (7am-10 am and 4pm -7pm) for Wound care. Noted to start at 4pm on 5/19/26;-A PRN order, dated 5/19/26, Sacrum: cleanse with wound cleanser, pat dry, apply mesalt cover with Sacral border gauze and change daily and as needed if soiled every 8 hours as needed for wound-TAR was blank on 5/19/26. Observation and interview on 5/19/26 at 9:40 A.M., showed Resident #3 lay in bed. There was a foul odor in the room noted in the hallway. The resident said he/she did not have much feeling in his/her sacral area and was not always sure when he/she had a bowel movement but did get diarrhea frequently. The resident said he/she had an incontinence episode around 1:30 P.M. yesterday and the dressing to his/her sacrum had to be removed. The dressing to his/her sacrum was not replaced and there was still no dressing on the area. He/She said there was also a wound to his/her right ankle that has not been changed since 5/15/26. The resident said staff had not been in to check his/her brief that morning, only to check his/her blood sugar. Observation and interview on 5/19/26 at 10:22 A.M. showed Assistant Director of Nursing (ADON) A outside the resident's room at the treatment cart. ADON A asks where the odor was coming from and entered the resident's room to talk to the resident and inform he/she was going to complete the resident's wound care. ADON A went back to his/her cart and gathered supplies for the resident's wound care. ADON A said nurses were responsible for completing wound care when he/she was off during the week and on the weekends. He/She was off yesterday. If a resident was soiled and the dressing needed to be removed during incontinence care, the Certified Nursing Assistant (CNA) should have told the nurse so it could be replaced. Observation on 5/19/26 at 10:30 A.M., showed ADON A entered the resident's room. He/She wiped down the bedside table and placed a disposable pad and supplies on the table. ADON A performed hand hygiene and donned a gown and gloves. ADON A removed the resident's brief and had the resident roll to his/her right side. The resident had dried bowel movement covering the sacral area and on the resident's shorts. There was no dressing noted to the resident's sacral area. The resident reported to ADON A the dressing came off yesterday at 1:30 P.M. after an episode of diarrhea. The resident said he/she did not know he/she had another episode of diarrhea since that episode and could not always feel it. Staff had not checked on him/her yet this morning. The ADON started to clean the resident. He/She said he/she needed more wipes, removed the gown and gloves, performed hand hygiene, and left the room. When ADON A returned, CNA E was with the ADON. ADON A washed his/her hands, donned gown and gloves and finished cleaning the resident's bowel movement. CNA E washed his/her hands, donned gown and gloves and then assisted ADON A in placing a new pad under the resident and placed a new brief and shorts on the resident. CNA E also removed the resident's right shoe. He/She then removed the dirty items and placed them in the trash, removed his/her gown and gloves, performed hand hygiene and left the room. ADON A removed gloves, washed hands, and donned new gloves. ADON A completed the wound treatment for the sacral area and noted to the resident that he/she had new areas that he/she would report to the physician. ADON A removed the resident's right sock. ADON confirmed the date shown on the dressing was 5/15/26. There was dried brown drainage to the resident's heel. The dressing was stuck to the open area when removed. ADON A cleansed the area with wound cleanser and said the wound care was to be completed daily. The ADON removed his/her gloves, performed hand hygiene, donned new gloves and completed the wound treatment on the resident. ADON A cleaned up the trash, removed his/her gown and gloves, washed hands and left the room with the trash. During an interview on 5/19/26 at 2:40 P.M., Licensed Practical Nurse (LPN) F said nurses were responsible for the wound care and any dressing changes on the weekends and if the wound care nurse was off during the week. The documentation of the wound care should not be marked as completed until after it was done. Something could happen and staff may not have gotten to it. Wounds could deteriorate fast. During an interview on 5/19/26 at 3:05 P.M., the Director of Nursing (DON) said she would expect staff to follow physician orders and to document correctly. They should not have documented something as done if not done. If a resident refused, then she would expect staff to put a note in the medical record. The wound nurse did the majority of the wound care, and the nursing staff was responsible for the more minor care such as skin tears or creams. The nurses were responsible for all the wound care if the wound nurse was not at the facility and on the weekend. She would also expect the CNA to let the nurse know if the dressing came off during care so it could be replaced. During an interview on 5/19/26 at 3:15 P.M., the Administrator said he would expect staff to follow physician orders. Treatments should not be documented as completed if they were not done. Nurses were responsible for wound care if the wound nurse was off. There should have been a note in the medical record if the resident refused treatment. 3013273

Based on interview and record review, the facility failed to provide pharmaceutical services by not providing multiple prescribed blood pressure and diabetic medications to a resident who was newly admitted for 3 days. (Resident #4). The sample was 13. The census was 129. Review of the facility's Physician Order Policy, last reviewed 9/28/22, included:-Policy: To provide guidance and ensure Physician Orders are transcribed and implemented inaccordance with Professional Standards, State and Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, and Director of Nursing (DON).-Procedure: Medications will be ordered from the Pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy, if available. Review of the resident's medical record showed:-admission Friday 5/15/26;-Discharge 5/26/26;-Diagnoses include sacral insufficiency fracture (type of stress fracture that occurs when normal, everyday pressure is applied to a sacrum weakened by underlying conditions like osteoporosis), weakness, anxiety disorder, high blood pressure, and diabetes. Review of the resident's admission progress note, dated 5/15/26 at 6:43 P.M., showed:-Admit to facility from hospital at 4:50 P.M. Admitting diagnosis of Sacral insufficiency fracture. Resident is able to make all needs known. Resident has Left below knee amputation (BKA) with prosthetic leg with his/her in room at bedside. Resident skin is intact. No open areas or areas of concern noted on skin assessment by wound care nurse on admission. Medications verified by physician. Review of the resident's electronic Physician Order Sheet (ePOS) showed:-An order, dated 5/15/26, Amlodipine 10 milligram (mg). Give 1 tablet by mouth every day shift for high blood pressure;-An order, dated 5/15/26, Farxiga Oral Tablet 5 mg. Give 5 mg by mouth every day shift for diabetes;-An order, dated 5/15/26, Fluticasone Propionate Suspension 50 micrograms (mcg)/AC. 2 spray in each nostril every day shift for seasonal allergies;-An order, dated 5/15/26, Glimepiride Tablet 4 mg. Give 4 mg by mouth one time a day for diabetes;-An order, dated 5/15/26, Lisinopril Tablet 40 mg. Give 1 tablet by mouth every day shift for high blood pressure;-An order, dated 5/15/26, Metformin Hcl Tablet 1000 mg. Give 1000 mg by mouth two times a day for diabetes. Review of the resident's, May 2026, Medication Administration Record (MAR) showed:-Amlodipine Tablet 10mg. Give 1 tablet by mouth every day shift for high blood pressure;-Marked NA (Not administered-see notes) 5/16/26, 5/17/26, and 5/18/26;-Farxiga Tablet 5 mg. Give 5 mg by mouth every day shift for diabetes;-Marked NA on 5/16/26, 5/17/26, and 5/18/26;-Fluticasone Suspension 50 mcg-Marked NA on 5/16/26, 5/17/26, 5/18/26, 5/19/26, 5/20/26, and 5/21/26;Glimepiride 4 mg. Give 4 mg by mouth one time a day for diabetes;-Marked NA on 5/16/26, 5/17/26, and 5/18/26;-Lisinopril 40 mg. Give 1 tablet by mouth every day shift for high blood pressure;-Marked NA on 5/16/26, 5/17/26, and 5/18/26;-Metformin 1000 mg twice a day. Give 1000 mg by mouth two times a day for diabetes;-Marked NA 7a-10 dose on 5/16/26, 5/17/26, and 5/18/26;-Marked NA 4p-7p dose on 5/16/26 and 5/17/26. Review of the resident's electronic Medication Administration (eMAR) notes showed:-A progress note, dated 05/16/26 at 5:47 P.M., Metformin Oral Tablet 1000 mg. Med on order;-A progress note, dated 5/17/26 at 8:48 A.M., Glimepiride Oral Tablet 4 mg. On order;-A progress note, dated 5/17/26 at 8:48 A.M., (No medication specified). On order;-A progress note, dated 5/17/26 at 7:38 P.M., Metformin Oral Tablet 1000 mg. Med on order; Review of the resident's progress notes showed:-A progress note, dated 5/18/26 at 1:49 P.M., Call placed to resident's family member. Discussed resident's current diet and medication orders. Also informed family member that resident's medications have been ordered and are scheduled for delivery with this evening's medication delivery. Medication dosages and frequency discussed. During an interview on 6/23/26 at 2:46 P.M., Pharmacist A said the pharmacy is closed on the weekend. There is someone on call but unless they are paged they are not going to know to do anything. The facility has to page us after they leave a voicemail. Pharmacist A said the facility sent the information on 5/17/26 but a page was never sent. The medications were sent on the afternoon of Monday 5/18/26. During an interview on 6/25/26 at 3:10 P.M., Licensed Practical Nurse (LPN) B said he/she has never worked the weekend to have an admission. He/She said if a resident is admitted on the weekend there is pharmacy after hours number. During an interview on 6/25/26 at approximately 3:45 P.M., the corporate representative, corporate DON, and facility DON said the facility recently switched pharmacies and have encountered issues where we have to send things back. The main office is 24 hours. There is an on call service voicemail. They would expect staff to utilize that. We should get medications within the 48 hours of admission. They also have an emergency kit for certain medications. During an interview on 6/25/26 at 4:20 P.M., the Administrator said he would expect the staff to call the on call pharmacy to obtain the medications. The staff should also follow up if they are not received. On 6/25/26 at approximately 5:40 P.M., the Administrator provided a copy of the facility pharmacy records from the emergency kit for Resident #4. It showed Metformin 500 mg, quantity 2, was removed on 5/18/26 at 8:43 P.M. and Ondansetron (nausea medication) 4mg, quantity 1, was removed on 5/20/26 at 3:44 P.M. No other medications were removed for this resident on 5/15/26, 5/16/26 or 5/17/26. 3023735

Based on observation, interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice by failing to document one resident's (Resident #2) insulin administration and blood glucose monitoring on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The sample size was 11. The census was 123.Review of the facility's Notification of a Change in Condition Policy, revised 2/6/25, showed:Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, according to Standards of Practice and Federal and/or State Regulations. Responsibility: All Licensed Nursing Personnel, Nursing Administration, & Director of Nursing. Procedure:-Guideline for Notification of Physician/Resident Representative (not all inclusive): -Significant Change in Medical or Cognitive baseline; -Accident/Incident; -Abnormal Laboratory Results in conjunction with a change in condition; -Significant weight loss/gain as per RAI guidelines or provider specific orders; -Refusal to take Prescribed Medications; -Missing Resident. Document in the Interdisciplinary Team (IDT) Notes:-Resident Change in Condition;-Physician/Physician Extender Notification;-Notification of Resident Representative. 1.Review of Resident #2's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/26, showed:-Cognitively intact;-Diagnoses included diabetes, arthritis, and respiratory failure. Review of the resident's electronic Physician Order Sheet (ePOS), showed:-An order, dated 3/9/26. Notify physician extender if blood sugar less than 70 or greater than 200;-An order, dated 3/13/26. Accuchecks three times a day (TID) with meals and bedtime and as needed (PRN) before snacks;-An order, dated 4/11/26. NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/Milliliter (ML) (Insulin). Inject eight unit subcutaneously (under the skin) before meals and at bedtime for diabetes (DM). Give eight units insulin before meals and at bedtime along with any sliding scale insulin needed;-An order, dated 4/11/26. NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin). Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 -350 = 8 units; 351 - 400 = 10 units. Any accuchecks above 400, give 15 units and recheck in four hours, subcutaneously before meals and at bedtime for DM. Review of the resident's April 2026 MAR/TAR, showed:-Accuchecks TID with meals and bed time and PRN before snacks four times a day for DM at 0800, 1200, 1700, 2100;-NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart)Inject eight unit subcutaneously before meals and at bedtime for DM. Give eight units insulin before meals and at bedtime along with any sliding scale insulin needed at 0600, 1100, 1600, and 2000;-0600 Dose showed blank on 4/12, 4/14, 4/15, 4/16, 4/17, 4/19, 4/20, 4/21, and 4/22/26;-NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart)-Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Any accuchecks above 400, give 15 units and recheck in four hours, subcutaneously before meals and at bedtime for DM;-0600 Dose showed blank on 4/14, 4/15, 4/16, 4/17, 4/19, 4/20, 4/21, 4/22, and 4/23/26;-0600 blood sugar value blank on 4/14, 4/15, 4/16, 4/17, 4/19, 4/20, 4/21, 4/22, and 4/23/26. Review of the resident' s medical record, showed:-A progress note, dated 4/13/26 at 7:26 A.M. Text message sent to physician, regarding the patient's accucheck. At 0315 =15 units Novolog fast acting insulin given sliding scale (SQ). Accu check at 0720 = 598;-A progress note, dated 4/13/26 at 7:52 A.M., Physician texted back. Order for patient to have 20 units of Novolog insulin now instead of sliding scale;-A progress note, dated 4/13/26 at 8:00 A.M., Patient given 20 units Novolog insulin SQ as instructed by physician;-A progress note, dated 4/23/26 at 9:57 A.M., Physician called made aware of BS 538 and covered with scheduled sliding scale, new order received just now to 20 units of Novolog, and will be in to visit this morning in about 15 minutes, noted.-No other progress notes related to physician notification for blood sugar between 4/13/26 and 4/23/26. During an interview on 4/23/26 at 9:30 A.M., Licensed Practical Nurse (LPN) B said there were two nurses to take care of residents on the unit. Registered Nurse (RN) C took Resident #2's blood sugar that morning, 4/23/26. The doctor should be called if the blood sugar was greater than 400. Resident #2's blood sugar typically ran high. RN C documented the insulin. If it was not documented, then it probably was just not documented right then and there. During an interview on 4/23/26 at 9:40 A.M., LPN D said only the nurses checked the resident's blood sugar. The doctor should be notified if the result was less than 60 or greater than 300. The blood sugar reading and insulin given should be documented when it was done. Sometimes they got busy. During an interview on 4/23/26 at 9:52 A.M., RN C confirmed he/she checked Resident #2's blood sugar this morning. The other nurse, LPN B, gave the insulin to the resident. Physician E was notified by text that the resident's blood sugar was high around 8:26 A.M. to 8:45 A.M., but the physician had not gotten back to him/her yet. RN C said he/she asked the resident if the resident had anything to eat. The resident's blood sugar was always high, and he/she always wanted to change his/her sliding scale. RN C said he/she was waiting to see what Physician E wanted to do before administering any additional insulin. RN C said when the blood sugar was this high, you should call the physician instead of waiting. He/She was going to call the physician. During an interview on 4/23/26 at 10:00 A.M., Resident #2 said his/her blood sugar has not been the same since he/she arrived at the facility and they changed all his/her medications. They claim the medications were in the same family and should be the same but they were not for him/her. His/Her blood sugar was constantly up and down. He/She did not feel they were checking it as often as they should or that he/she was getting all of his/her prescribed insulin. Different nurses would administer different things. The physician did not listen, just cuts him/her off. The resident states he/she was Type One Diabetic, and that had to be managed differently than a Type two diabetic. It does not seem like they knew what they were doing. During an observation on 4/23/26 at 10:05 A.M., RN C entered the resident's room and told the resident he/she needed to recheck the resident's blood sugar. RN C said Physician E was on the way to the facility to talk to the resident and said to recheck and give 20 units if the blood sugar was high again. At 10:10 A.M., the blood sugar was 526. The resident was hesitant to take an additional amount of insulin. He/She did allow RN C to administer the 20 units of insulin. RN C said he/she was to recheck the blood sugar in an hour. During an interview on 4/23/26 at 10:20 A.M., Physician E said he/she would expect the staff to follow physician orders. He/She would also expect a phone call if the blood sugar was high and said they did call the physician that morning. Physician E said he/she would talk to the resident again but the last time the resident refused to let the physician increase the insulin dose. Physician E said it can be hard to do something when the resident refused medication changes. Physician E would expect staff to document blood sugar and insulin administered or a note if the resident refused. During an interview on 4/23/26 at 1:22 P.M., RN C said Physician E did change two of the resident's insulin medications per the resident's request. The blood sugar was checked again and was around four something. The resident seemed better, he/she was probably just frustrated. During an interview on 4/23/26 at approximately 1:45 P.M., the resident said the physician talked to him/her and again would not let the resident talk much, but was going to switch the resident back to what he/she was prescribed at the hospital prior to being admitted to the facility. During an interview on 4/23/26 at approximately 3:15 P.M., the Administrator said he would expect staff to follow physician orders and to call the physician as recommended in the order. Blank MAR/TAR could mean resident was not available. There should be a note and should be a note for refusal. For the high blood sugar of 538, the nurse should have called and should have tried again before the hour. The nurse could have also reached out to the onsite Nurse Practitioner. 2978561

Based on interview and record review, the facility failed to notify the responsible party for one resident (Resident #4) following a change in condition, in which the resident fell out of bed, sustained an injury, and was sent to the hospital for an evaluation. The sample size was 11. The census was 123.Review of the facility's Notification of a Change in Condition Policy, revised 2/6/25, showed:Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, according to Standards of Practice and Federal and/or State Regulations. Responsibility: All Licensed Nursing Personnel, Nursing Administration, & Director of Nursing. Procedure:-Guideline for Notification of Physician/Resident Representative (not all inclusive): -Significant Change in Medical or Cognitive baseline; -Accident/Incident; -Abnormal Laboratory Results in conjunction with a change in condition; -Significant weight loss/gain as per RAI guidelines or provider specific orders; -Refusal to take Prescribed Medications; -Missing Resident. Document in the Interdisciplinary Team (IDT) Notes:-Resident Change in Condition;-Physician/Physician Extender Notification;-Notification of Resident Representative. Review of Resident #4's medical record, showed the resident's adult family (Adult Relative #2) member listed as emergency contact #1 on the face sheet. Review of the resident's medical record showed:-admission: [DATE];-Diagnoses include low blood pressure, end stage renal disease (ESRD), and endometrial cancer. Review of the resident's progress notes showed:-A progress note, dated 4/12/26 at 10:38 P.M., Resident fell out of bed and hit his/her head. Upon assessing resident, resident was complaining of left eye pain, right shoulder pain and abdominal discomfort. Blood pressure: 51/31 (Normal 120/80) Pulse :40 (Normal 60-100). Resident sent out to hospital via emergency medical technician (EMT) transport. Assistant Director of Nursing (ADON) made aware and physician.-A progress note, dated 4/13/26 at 3:01 P.M., Resident is admitted to hospital. Review of the resident's care plan, dated 4/14/26, showed:-Focus: Resident is at risk for fall. Gait/balance problems;-Goal: The resident will not sustain serious injury through the review date;-Interventions: Be sure the resident's call light is in reach and encourage the resident to use it, resident needs prompt response to all requests for assistance, follow facility fall protocol, anticipate and meet the resident's needs. During an interview on 4/13/26 at 12:10 P.M., Adult Relative 1 said he/she was not informed of the fall or the transfer to the hospital until the following day when he/she called to talk to the facility social worker. During an interview on 4/28/26 at 2:50 P.M., Adult Relative 2 said he/she was not notified of the fall or that the resident was sent to the hospital until he/she went to the facility the next day to visit the resident. The receptionist informed Adult Relative 2 that the resident was in the hospital and gave the incorrect hospital. The Adult Relative reported he/she then talked to the Administrator, who did not know which hospital. The relative said approximately 2-3 hours later, the Administrator called to report the location of the resident. Adult Resident 2 said he/she would have been expected to be notified at the time of the fall the fall occurred and the location the resident was sent. During an interview on 4/23/26 at approximately 3:15 P.M., the Administrator said he would expect staff to notify the responsible party of any change of condition, if they were sent out and when they returned. He would also expect documentation noted of the attempt or if they left a message. 2980936

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 53 opportunities observed, 7 errors occurred resulting in a 13.2% error rate (Residents #21 and #22). The census was 124. Review of the facility's Medication Administration - General Guidelines policy, dated 12/2017, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.-Five Rights: Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. -Check #1: Select the medication - label, container and contents are checked for integrity and compared against the Medication Administration Record (MAR) by reviewing the five rights. -Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the five Rights. -Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the five rights.-The MAR is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away, and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions.-If a medication with a current, active order cannot be in the medication cart/drawer, other areas of the medication cart, medication room, and facility (example: other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit (e-kit).-Medications are administered in accordance with written orders of the prescriber.-Refusals of Medication; -Medication refusal must be reported to the prescriber based upon facility guidelines.Documentation (including electronic); -The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. -If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (example: the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is (initialed and circled). An explanatory note is entered on the reverse side of the record. If a vital medication is withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. -If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed and may differ slightly from the procedures for using paper MAR. Electronic systems also describe procedures for secure access, maintaining privacy of resident information, and for and electronic signatures. Maintenance and support procedures for these systems are described in the system user manuals. Procedures will vary between the various electronic systems available. 1. Review of Resident #21's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/25, showed:-Cognitively intact;-Diagnoses included high blood pressure, renal insufficiency (kidneys are not functioning appropriately) and generalized muscle weakness. Review of the resident's Physician's Order Sheet (POS), for October 2025, showed the resident's morning medications included:-Artificial tears eye drops, instill one drop to both eyes three times per day (TID) for eye dryness:-Fluticasone Propionate (Flonase) nasal spray 50 micrograms (mcg), instill one spray to each nostril in the morning, for allergies;-Furosemide 40 (milligrams) mg in the morning for diuretic (water pill, increases urination);-MiraLAX oral packet 17 grams (gm) give 17 gram by mouth in the morning for constipation;-Omeprazole oral delayed release tablet 20 mg, in the morning for gastroesophageal reflux (GERD-chronic digestive disorder where stomach acid repeatedly flows back into the esophagus). Observation on 10/22/25 at 8:05 A.M., showed Certified Medication Technician (CMT) X prepared and administered the resident's morning medications, but did not include Artificial tears, Fluticasone Propionate nasal spray, Furosemide, MiraLAX or Omeprazole. Review of the resident's electronic MAR (eMAR), dated 10/22/25 at A.M. pass, showed the following medications marked as administered by CMT X: Artificial tears, Fluticasone Propionate nasal spray, Furosemide, MiraLAX and Omeprazole. During an interview on 10/23/25 at 11:15 A.M., Resident # 21 said CMT A did not provide his/her morning eye drops during the day on 10/22/25. 2. Review of Resident #22's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included coronary artery disease (CAD-arteries that supply blood to the heart muscle become narrow or blocked), high blood pressure, diabetes (body does not produce insulin to regulate blood sugars) and anxiety. Review of the resident's POS, for October 2025, showed the resident's morning medications included:-Artificial tears eye drops, install two drops to both eyes twice a day (BID) for eye dryness:-MiraLAX oral packet 17 grams, give 17 grams by mouth in the morning for constipation. Observation on 10/22/25 at 8:45 A.M., showed CMT X prepared and administered the resident's morning medications, but did not include Artificial tears, or the resident's MiraLAX. 3. During an interview on 10/23/25 at 11:05 A.M., CMT X said he/she did not administer either resident # 21 or Resident #22 their ordered MiraLAX on 10/22/25. He/She was nervous and forgot to provide the medication. He/She did go back later in the day and administer the residents' eye drops and gave resident #21 his/her Flonase. 4. During an interview on 10/24/25 at 8:50 A.M., the Regional Director of Operations said CMT X had not been honest when he/she reported he/she provided Residents # 21 and Resident #22 with their eye drops and/or Flonase on 10/22/25. CMT X admitted he/she was not honest when approached and questioned by the surveyor. CMT X had been terminated. The Regional Director of Operations expected the MARs to reflect correct omission and administration of medications. It should be documented if a medication is unavailable or if held. There should be appropriate documentation in the resident's progress notes as to why a medication was not administered. All CMTs and nurses should follow the facility policy and procedure on medication administration. 26325492621848

Based on interview and record review, the facility failed to provide acceptable nursing services by failing to report the results of an immediate (STAT) x-ray for one resident (Resident #5) who had complaints of shortness of breath (SOB). Two days after the x-ray, the resident requested to go to the hospital, the hospital found a large pleural effusion (condition where excess fluid accumulates in the pleural space, the thin membrane that separates the lungs from the chest wall) and a chest tube (drains access fluid) had to be placed. Additionally, the facility failed to administer intravenous (IV, method of administering fluids, medications, or nutrients directly into the bloodstream through a needle or catheter inserted into a vein) medications as ordered for two residents (Resident #3 and Resident #12). The census was 127.Review of the facility's Change of Condition policy, last reviewed 2/6/25, showed: -Policy: The attending physician/physician extender (Physicians, Nurse Practitioners, & Physician's Assistants, or Clinical Nurse Specialist) and the Resident Representative (RR) will be notified of a change in a resident's condition, per standards of practice and federal and/or state regulations; -Procedure:-1. Guideline for notification of physician and RR (not all inclusive):-Significant change in medical or cognitive baseline;-Accident or incident;-Abnormal lab results in conjunction with a change in condition;-2. Document in the Interdisciplinary Team (IDT) Notes:-Resident change of condition;-Physician/Physician Extender Notification;-Notification of RR. Review of the facility's Physician Orders policy, last reviewed 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines;-Procedure: -Physician orders shall be provided by licensed practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders;-Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders;-Physician orders must be documented clearly in the medical record. The required components of a complete order: -Date and time of order;-Name of practitioner providing order;-Name and strength of medication or treatment;-Quantity and duration;-Dosage and frequency;-Route of administration;-Indication and diagnosis;-Stop Date, if indicated;-Physician orders that are missing required components, are illegible or unclear must be clarified prior to implementation;-Physician Order Sheet (POS) will be maintained with current physician orders as new orders are received. Discontinued (DC) orders will be marked as discontinued with the date, and all new orders will be written in the appropriate area on the POS with the date the order was received;-Physician orders will be transcribed to the appropriate administration record, Medication Administration Record (MAR) or Treatment Administration Record (TAR);-Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from pharmacy, if available. Review of the facility's Infusion Therapy Medication Administration policy, dated 12/17, showed: -Procedures:-M. Document in Nursing Progress Notes: -1. Date;-2. Time;-3. Flushing agent;-4. Medication, solution;-5. Infusion rate;-6. Site assessment, complications, if any;-7. Patient response to procedure;-8. Type of solution and medication;-9. Duration of medication infusion;-10. Any untoward reactions. 1. Review of Resident #5's face sheet, showed diagnoses included hypertensive heart failure, congestive heart failure, peripheral vascular disease and weakness. Review of the resident's care plan, in use during survey, showed:-Focus: Resident prefers independent leisure; -History/potential for behavior problem: Alcohol consumption to excess; -The resident is at risk for falls, deconditioning, gait/balance problems and episodes of incontinence; -Resident has the potential for impaired skin integrity related to a history of wounds. Review of the resident's progress notes, showed:-On 8/2/25 at 1:53 P.M., Nurse was called to patient (pt) room related to fall, nurse observed pt walker facing the door and pt on the floor behind the walker. Nurse observed wet pull up. Shoes noted on pt. When asked what happened, pt replied I was headed to the bathroom when I lost my balance. Range of motion completed, aides and nurse used the Hoyer (mechanical lift) to lift pt up to wheelchair. Physician and resident representative aware;-On 8/3/25 at 11:06 A.M., Complaints of pain noted, as needed (PRN) oxy (pain medication) given as ordered hour later, effective. Patient on incident follow up for fall. Patient alert x 4 (to person, place, time and situation), walks with walker;-On 8/4/25 at 12:20 P.M., late entry: Resident was discussed during the Interdisciplinary Team (IDT) meeting in relation to a recent fall while self-transferring to the bathroom. Fall occurred without apparent injury; however, risk for future falls remains a concern. Current interventions in place to reduce fallrisk include PT/OT, reeducation on using the call light to ask for assistance, and proper footwear. Staff re-educated resident on safety precautions with follow up fall protocol in place. Resident's care plan updated accordingly;-On 8/4/25 at 2:32 P.M., Late Entry: Resident on incident follow up (IFU) precautions. No complaints of pain or discomfort at this time. Resident is currently resting in recliner in room with call light in reach;-On 8/6/25 at 11:30 A.M., Late Entry: Upon assessment resident complaint of shortness of breath. Oxygen saturation (sats) read 85% (normal range, 95-100%). Resident denies any complaints of pain or chest pains, 2 liters (L) of oxygen was applied to resident and oxygen sats increased to 94%. Resident continues to complain of shortness of breath. Physician notified and STAT chest x-ray was ordered;-On 8/6/25 at 12:57 P.M., Late Entry: The change in condition reported on this CIC Evaluation are/were: Shortness of breath; At the time of evaluation resident/patient vital signs, weight and blood sugar were:-Blood Pressure: 129/65 (normal 120/80) on 8/6/2025 at 11:19 A.M. Position: Sitting right arm;-Pulse: 69 (normal range, 60-100) on 8/6/2025 at 12:33 P.M.;-Respirations: 16 (normal 12-20) on 8/6/2025 at 12:33 P.M.;-Pulse Oximetry: O2 97% on 8/6/2025 at 12:32 P.M. Method: Room Air;-Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Respiratory Status Evaluation: Shortness of breath;-Pain Status Evaluation: Does the resident/patient have pain? No-Nursing observations, evaluation, and recommendations are: Resident complaints of shortness of breath, physician notified. New order received and implemented. STAT chest x-ray;-Primary care provider feedback: X-ray;-New intervention Orders: Oxygen (if available);-On 8/6/25 at 5:30 P.M., Late Entry: The change in condition on this CIC evaluation are/were: shortness of breath. At the time of evaluation resident/patient vital signs, weight and blood sugar were: -Blood Pressure: BP 155/91 - 8/7/2025 10:18 A.M. Position: Lying right arm;-Pulse: 69 on 8/6/2025 at 12:33 P.M. Pulse Type: Regular-Respirations: 16.0 on 8/6/2025 at 12:33 P.M.-Weight: 290.0 pounds (lb) on 8/6/2025 5:05 P.M. Scale: Standing-Pulse Oximetry: Oxygen 97.0% on 8/8/2025 at 10:00 A.M. Method: Oxygen via Nasal Cannula;-Outcomes of physical assessment: respiratory status elevation: shortness of breath;-Primary care provider feedback: X-ray;-New intervention Orders: Oxygen (if available);-On 8/6/25 at 7:50 P.M., x-ray received, no fractures noted. Physician notified. Power of Attorney (POA) notified, no new orders received at this time. Review of the resident's x-ray results, dated 8/6/25, showed:-Procedure: Chest;-Clinical information: Shortness of breath;-Findings: AP (Anterior-Posterior) view of the chest submitted. No prior studies. Asymmetric density right base (abnormal finding) and possible effusion (abnormal collection of fluid in a body cavity) presented view. Left lung without focal opacity by one view (normal finding). No pneumothorax (air accumulates in the space between the lining and chest wall). The cardiac silhouette is enlarged by AP technique. Left chest pacer;-Impressions: Right basilar opacity (shadow or darkening seen on a chest x-ray) one view. Correlate clinically for atelectasis (collapse of whole lung or area of the lung), chronic scarring, and/or pneumonia. Review of the resident's progress notes, showed:-On 8/7/25 at 8:48 P.M., during rounds, resident did not report any pain or voice any concerns to this nurse. Resident was provided with ice water and his/her call light place within reach;-On 8/8/25 at 10:25 A.M., resident complaint of shortness of breath this morning. Vital signs taken within normal limits. Resident and family member requested transfer to the emergency room for further evaluation. Physician notified. During an interview on 8/12/25 at 12:10 P.M., the hospital employee reported the nurse at the facility told the son the chest x-ray was clear. When the hospital scanned the patient, they noted a large right pleural effusion, and a chest tube was placed. The family told the facility nurse the resident needed to go to the hospital due to new use of oxygen and sounding gurgly (making a low, bubbling sound). During an interview on 8/28/25 at 1:55 P.M., the Assistant Director of Nursing (ADON) said the resident was transported out in the evening. The nurse assigned to the resident no longer works at the facility. It was not reported to the ADON the resident had shortness of breath. The ADON was aware of the x-ray but believed it due to the fall the resident had. The ADON expected staff to notify the physician if the resident continued to have shortness of breath and had a continued need for oxygen. During an interview on 8/28/25 at 1:18 P.M., the Director of Nursing (DON) said the x-ray results are received by the charge nurse, and they are reported to the physician. She expected staff to notify the physician of reports based on what was reported. The results are expected to be reported within that shift and attempts to contact the physician are documented. Nursing staff are expected to document in real time. The DON reviewed the resident's x-ray results and said the resident might have some pneumonia based on what it said. She expected nursing to contact the physician if the resident continued to have shortness of breath, requiring the use of oxygen. She expected physician's orders to be followed and for staff to be knowledgeable of and follow facilities policies. 2. Review of Resident #3's face sheet, showed his/her diagnoses included severe sepsis (systemic (conditions that affect the entire body or multiple organ systems) infection) with septic shock (life-threatening condition that occurs when an infection triggers a widespread inflammatory response that leads to dangerously low blood pressure and organ failure), diabetes, acute (a sudden onset and has a short duration) kidney failure, weakness and cognitive communication deficit. Review of the resident's care plan, dated 8/15/25, showed:-Focus: Activities of daily living (ADL, daily self-care activities) deficit related to quadriplegia (complete or partial paralysis (partial or complete loss of muscle function and movement) of both arms and both legs);-Goal: Resident requires assistance with ADL care and mobility. Here on a skilled rehab stay to increase in strength, mobility, endurance and independence;-Interventions: -Bed mobility: Totally dependent on staff for repositioning and turning; -Dressing: Dependent on staff; -Eating: Dependent one assist; -Personal hygiene and oral care: Dependent on staff; -Transfer: Two assist with Hoyer; -Discuss any concerns related to loss of independence, decline in function; -Encourage discussion of feelings about self-care deficit as indicated. Review of the resident's MAR, dated 8/14/25 through 8/16/25, showed:-Ertapenem Sodium (antibiotic) Solution Reconstituted (the process of adding a liquid diluent to a dry ingredient to make a specific concentration of liquid) one gram (gm). Use one gm intravenously (IV) every 24 hours for infection for five days, order date 8/14/25 at 8:00 P.M.; -On 8/14/25 at 11:22 P.M., Not Administered See Nurses Note (NA); -On 8/15/25 at 7:44 P.M., NA. Review of the resident's progress notes, dated 8/14/25 through 8/16/25, showed no progress notes regarding the ertapenem not being administered. No notifications to the physician or RR the ertapenem was not administered as ordered. During an interview on 8/29/25 at 9:55 A.M., Pharmacy Representative (PR) said a one-day supply of ertapenem was sent to the facility on 8/14/25. The remaining four-day supply was sent on 8/15/25. Review of the resident's hospital Emergency Department (ED) record, dated 8/16/25, showed: -Resident presents to ED via Emergency Medical Services (EMS) from the facility with hypotension (low blood pressure) and dizziness on 8/16/25;-Resident was admitted on [DATE] with hypotension and unresponsive. Resident was transferred to the intensive care unit (ICU) for septic shock for urinary tract infection (UTI). Resident was treated with meropenem (antiobotic) for seven days for gram neagitive sepsis. A Peripherally Inserted Central Catheter (PICC, a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart) was placed in left upper extremity (UE) prior to discharge to facility on 8/14/25 so the resident could continue the antibiotic for three days. Resident reported he/she did not receive any infusions through his/her PICC line since his/her discharge from the hospital. Attempts were made to obtain medical records from the facility ended in the facility staff hanging up on the hospital;-Resident was started on vancomycin (antiobotic) and cefepime (antiobotic) in ED. Will continue overnight pending infectious disease (ID) consult. 3. Review of Resident #12's face sheet, showed his/her diagnoses included human herpes virus 6 encephalitis (HHV-6, brain inflammation caused by the human herpes virus), epilepsy (seizures), diabetic, heart failure, weakness and need for assistance with personal care. Review of the resident's care plan, dated 8/8/25, showed:-Focus: Resident requires IV therapy acyclovir (antiviral medication used to treat infections) three times a day through 8/13/25;-Goal: Will not have complications or adverse reactions when receiving IV therapy for 30 days;-Interventions: -Administer IV therapy as ordered, explain procedure to the resident; -Change dressing to insertion site as ordered/ indicated; -Observe for possible side effects- report abnormal symptoms to physician; -Observe the IV site for edema (swelling), redness, drainage, etc. Report abnormal findings to physician. Review of the resident's MAR and progress notes, dated 8/7/25 through 8/26/25, showed:-Acyclovir powder, use 730 milligrams (mg) IV three times a day for viral infection until 08/13/25, order date 8/7/25 at 5:37 P.M., DC 8/10/25 at 12:39 A.M.; -On 8/7/25 at 10:00 P.M., blank (no documentation); -On 8/8/25 at 6:00 A.M., blank; -On 8/8/25 at 2:00 P.M., blank; -On 8/8/25 at 10:00 P.M., blank; -On 8/9/25 at 6:00 A.M., blank; -On 8/9/25 at 2:00 P.M., blank; -On 8/9/25 at 10:00 P.M., blank;-Progress note dated 8/11/25 at 10:03 A.M., Pharmacy called and relayed problem with acyclovir IV medication. Due to dosage, storage and reconstitution needed, pharmacy would like the physician to be called and possibly change the dosage to ensure integrity of medication. Please follow up with pharmacy about new order;-Progress note dated 8/11/25 at 10:56 A.M., Nurse verified Acyclovir dose with physician per pharmacy inquiry, give 1000 mg IV three times a day. Call placed to pharmacy to provide updated order;-Acyclovir powder, use 1000 mg IV three times a day for viral infection, order date 8/11/25 at 10:48 A.M., DC on 8/12/25 at 1:59 P.M.: -On 8/12/25 at 6:00 A.M., NA;-Progress note, dated 8/13/25 at 3:03 P.M., IDT Risk Meeting held today regarding the resident is currently receiving Acyclovir prophylaxis (action taken to prevent disease) without a designated stop date related to a viral infection/outbreak. Resident is compliant with the medication regimen and tolerating it well with no reported side effects at this time;-Progress note, dated 8/13/25 at 10:43 P.M., Resident still remains on ABT for viral outbreak. No adverse reactions noted at this time;-Acyclovir powder, use 750 mg IV every eight hours for viral infection until 08/18/25, order date 8/14/25 at 10:53 A.M.; -On 8/15/25 at 6:00 A.M., NA; -On 8/15/25 at 2:00 P.M., NA; -On 8/15/25 at 10:00 P.M., NA; -On 8/16/25 at 6:00 A.M., NA;-Progress note, dated 8/16/25 at 10:32 P.M., Resident remains on ABT Acyclovir 750mg intravenously. No adverse reaction noted;-No progress notes regarding missed doses of IV ABT;-No progress notes with notification to physician and RR regarding missed doses of IV ABT. During an interview on 8/29/25 at 9:55 A.M., PR said the acyclovir was first sent out on 8/11/25 and the last time it was sent to the facility was on 8/15/25. The pharmacy sent out a seven-day supply total to the facility. 4. During an interview on 8/28/25 at 1:18 P.M., the DON and Administrator said they expected staff to follow physician orders. They expected staff to be knowledgeable of and to follow the facility policies. They expected if staff documented NA in the resident's MAR for a progress note to be entered on why the medication was not administered. On 8/29/25 at 1:23 P.M., the DON and Administrator said if an IV ABT was not administered as ordered, they expected notifications to the physician and RR to be documented in the resident's progress notes. 2593947

Based on interview and record review, the facility failed to ensure nursing staff documented the reason for residents' transfer or discharge in the medical record. The facility failed to record the medically justified reason for 3 residents who were transported to the hospital after a change in condition (Residents #4, #1, and #10). The sample was 20. The census was 127. Review of the facility's Discharge and Transfer-Involuntary policy, last reviewed 10/7/21, showed:-Policy: Transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria, as outlined below, are met;-Procedure: -1. The facility reserves the right to transfer a resident deemed acutely ill by the physician to a hospital or other facility better equipped to meet the resident's health care needs;-2. A written or telephone order is required from the attending physician for the discharge of a resident, except in emergency situations;-3. The Interdisciplinary team (IDT) and the resident's physician must document in the resident record when a resident is transferred or discharged ;-4. The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility including an opportunity to participate in the decision of where to transfer;-6. See Discharge Plan/Summary policy for information on the Discharge Summary and discharge documents;-7. Before a facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and the resident representative or legal representative that specifies the duration of the bed-hold policy and the facility's policies regarding bed-hold;-9. The resident's clinical record shall be completed and forwarded to the medical records department following the discharge, transfer, or death of the resident. 1. Review of Resident #4's face sheet, showed: -admission: [DATE];-Diagnoses included dependence on renal dialysis (the process of filtering the blood for individuals with kidney failure), high blood pressure, diabetes, cognitive communication deficit, weakness and need for assistance with personal care. Review of the resident's care plan, dated 8/20/25, showed: -Focus: The resident needs dialysis three times a week related to renal failure, created 8/20/25;-Goal: -The resident will have immediate intervention should and sign or symptoms of complications from dialysis occur through the review date, created 8/20/25; -The resident will have no signs or symptoms of complications from dialysis through the review date, created 8/20/25;-Interventions: -Check and change dressing daily at access site. Document, created 8/20/25; -Encourage resident to go for the scheduled dialysis appointments. Resident receives hemodialysis in facility Tuesday, Thursday and Saturday, created 8/20/25; -Monitor and document report to physician signs and symptoms of depression. Obtain order for mental health consult if needed, created 8/20/25; -Monitor, document and report as needed (PRN) any signs and symptoms of infection to access site: Redness, swelling, warmth or drainage, created 8/20/25; -Monitor, document and report PRN for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa (moist, inner lining of mouth), changes in heart and lung sounds, created 8/20/25. Review of the resident's progress notes, showed: -On 8/28/25 at 12:53 P.M., IDT: Resident receives skilled services physical therapy (PT) occupational therapy (OT). Resident was sent to hospital this A.M. and remains there at this time;-On 8/27/25 at 11:36 A.M., skin wound note;-No progress note documenting the medical reason resident went to the hospital. Review of the medical record, showed:-No situation, background, appearance, review and notify (SBAR) assessment completed;-No transfer form completed; -No documentation of the reason why the resident was transported to the hospital. Review of the census, dated 8/28/25 at 1:03 P.M., showed resident still active and not discharged . Review of the resident's order summary, showed no order on 8/27/25 or 8/28/25 to send resident to the hospital for evaluation and treatment. During an interview on 8/29/25 at 9:05 A.M., Certified Medication Technician (CMT) A said he/she did not work the previous day so if the resident went to the hospital, he/she did not know why the resident was sent to the hospital. CMT A said he/she was not aware the resident went to the hospital the previous day. CMT A did not get anything in report about the resident being in the hospital. During an interview on 8/29/25 at 9:09 A.M., Licensed Practical Nurse (LPN) B said he/she did not get information about the resident in report about the resident going to the hospital or why. LPN B said if a resident is sent to the hospital, the nurse calls the physician, the family and Director of Nursing (DON) LPN B said the reason and condition of the resident when they are sent out would be documented in the resident's progress notes and the notifications would also be documented in the progress notes. LPN B said an SBAR and transfer assessment would also be completed on why and when the resident was sent to the hospital. During an interview on 8/29/25 at 1:23 P.M., the Director of Nursing (DON) said the resident was sent out on night shift due to shortness of breath (SOB). 2. Review of Resident #1's face sheet, showed: -admitted on [DATE];-discharged on 6/30/25;-readmitted on [DATE];-discharged on 8/15/25;-Diagnoses included dependence on renal dialysis, cognitive communication deficit, weakness and need for assistance with personal care. Review of the resident's care plan, dated 6/27/25, showed:-Focus: The resident receives hemodialysis (HD, medical treatment for kidney failure that uses a machine to filter waste products and excess fluid from the blood) three times a week related to renal (kidney) failure, created 6/27/25;-Goal: The resident will have immediate intervention should and sign or symptoms of complications from dialysis occur through the review date, created 6/27/25; -The resident will have no signs or symptoms of complications from dialysis through the review date, created 6/27/25;-Interventions: -Check and change dressing daily at access site. Document, created 6/27/25; -Do not draw blood or take blood pressure in arm with graft, left arteriovenous (AV) fistula (a connection that's made between an artery and a vein for dialysis access), created 6/27/25; -Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis in facility three times a week, created 6/27/25; -Monitor and document report to physician signs and symptoms of depression. Obtain order for mental health consult if needed, created 6/27/25; -Monitor, document and report PRN any signs and symptoms of infection to access site: Redness, swelling, warmth or drainage, created 6/27/25; -Monitor, document and report PRN for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa (moist, inner lining of mouth), changes in heart and lung sounds, created 6/27/25. Review of the resident's progress notes, showed no progress notes on 6/30/25 when the resident was sent to the hospital. Review of the medical record, showed on 6/30/25 an SBAR with unable to determine marked under situation, no vital signs documented from 6/30/25, appearance left blank. No medical reason documented on the form on why the resident was sent to the hospital. Review of the HD treatment flowsheet completed by dialysis clinic, dated 6/30/25, showed the resident complained of SOB labored breathing noted, resident lethargic. Resident hypoxic (deficiency in the amount of oxygen reaching the tissues) with oxygen saturations (Sp02, measures amount of oxygen in the blood, normal SpO2 is between 90 and 100 percent (%)) in the 80's. Treatment discontinued at 68 minutes. Resident referred to facility for further evaluation. Review of the resident's order summary showed no order on 6/30/25 to send resident to the hospital for evaluation and treatment. 3. Review of Resident #10's face sheet, showed:-admitted on [DATE];-discharged on 8/25/25;-Diagnoses included cerebral infarction (stroke), posterior reversible encephalopathy syndrome (PRES, rare neurological disorder characterized by reversible brain swelling in the back part of the brain), hemiplegia (weakness on one side of the body) and hemiparesis following cerebral infarction, anemia (iron deficiency), and muscle weakness. Review of the resident's care plan, dated 8/25/25, showed:-Focus: The resident is at risk for falls, confusion, and deconditioning;-Goal: The resident will be free of minor injury;-Interventions: Anticipate and meet the resident's needs; -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; -Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; -Family request bed to be placed up against wall; -Low bed with fall mat; -Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident, family, caregiver, Interdisciplinary team (IDT) as to causes; -The resident needs activities that minimize the potential for falls while providing diversion and distraction. Review of the resident's progress notes, showed:-On 8/22/25 at 6:50 A.M., resident noted to have slid out of bed and on to the floor trying to ambulate without assistance. This nurse assessed resident for injury, bruising and redness, none noted at this time. Per resident he/she is having pain to left arm and right shoulder. New order for x-ray to both extremities. Given Tylenol 325 milligrams (mg) for pain. Resident placed back into bed by Certified Nurse Aide (CNA) x 2. Bed locked and lowered for safety. Call light in reach;-On 8/22/25 at 6:30 P.M., resident's female family advocate at bedside request information regarding resident medication orders. Resident in bed aware/talkative with visitor and stated ok to speak with her/him. Resident son also present on the phone to verify information. Request resident to have x-ray left arm s/p fall related to complaints of pain. Resident in bed with discomfort noted with care/repositioning. Physician made aware. Given new order x-ray lower upper extremities (LUE). X-ray company made aware;-On 8/22/25 at 8:01 P.M., X-ray tech here at this time to perform exam. Resident resting in bed. Cooperative with care. No acute distress noted;-On 8/23/25 at 7:12 A.M., rested safely/comfy in low bed. Aroused easily to stimuli. Voices needs. Continued left side weakness. Positioned comfortably with no acute distress noted. G-tube p/i flushed without difficulty. Peri care provided with incontinence. No acute distress noted. Head of bed (HOB) elevated. Bed low. Call light in reach. Review of the medical record, showed no documentation of the resident transported to the hospital. 4. During an interview on 8/29/25 at 1:33 P.M., the Director of Nursing (DON) said staff completes a change in condition form and transfer form when a resident is transported to the hospital. They receive orders from the physician and notify the resident representative if it is not the resident. If the resident is unresponsive, they will notify the family. She expected there to be a progress note. The progress note should include the vital signs and who was notified. If it is not documented in real time, they will document what time the resident was transported by Emergency Medical Technician (EMT). Most of the time, they do not know where they are transporting the resident. If staff are aware, it should be included in the progress note. She expected nursing staff to report if a resident was sent to the hospital. 2571345

Based on interview and record review, the facility failed to follow their policy for four sampled residents who received dialysis (the process of filtering the blood for individuals with kidney failure). Resident #18 had an inconsistent order for dialysis days, with the order showing Monday, Wednesday and Friday and the resident received dialysis on Tuesday, Thursday and Saturday, and the care plan did not list the scheduled chair time and location for dialysis treatment. Additionally, the facility failed to contact and document the notification to the physician and resident representative (RR) when his/her dialysis treatment ended early. Resident #2 did not have physician orders that included the location for the dialysis services and the scheduled dialysis chair time and failed to ensure the dialysis services had been addressed on the resident's individual care plan. The facility failed to complete the dialysis communication forms (vital signs taken prior to dialysis treatment and vital signs taken after treatment with communications from the dialysis clinic) for each treatment for Resident #19 and failed to document the scheduled chair time on his/her care plan. The facility failed to document Resident #4's scheduled chair time on his/her care plan. The census was 127.Review of the facility's Hemodialysis (HD, the process of filtering the blood for individuals with kidney failure) Protocol policy, not dated, showed: -This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis;-Protocol:-The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include:-1. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility;-2. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices, and;-3. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services;-Compliance Guidelines:-1. The facility will inform each resident before or at the time of admission, and periodically thereafter during the resident's stay, of dialysis services available;-2. The facility will coordinate and collaborate with the dialysis facility to assure that:-a. The resident's needs related to dialysis treatments are met;-b. The provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments;-c. Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist (kidney doctor), attending practitioner and dialysis team, and;-d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff;-3. The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes;-4. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to:-a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; -b. Physician/treatment orders, laboratory values, and vital signs; -c. Advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners; -d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; -e. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; -f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; -g. Changes and/or declines in condition unrelated to dialysis; -h. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility;-5. The facility will immediately contact and communicate with the attending physician, resident/representative, and designated dialysis staff (i.e. nephrologist, registered nurse) any significant changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan;-6. The facility will assure that arrangements are made for safe transportation to and from the dialysis facility;-7. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications;-8. The facility will communicate with the dialysis facility, attending physician and/or nephrologist any significant weight changes, nutritional concerns, medication administration or withholding of certain medications prior to the dialysis treatment and document such orders;-9. The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record. The facility will coordinate with the dialysis facility for rescheduling of the resident's dialysis treatment if canceled;-10. The facility will ensure that the physician's orders for dialysis include: -a. The type of access for dialysis (e.g. graft, arteriovenous shunt, external dialysis catheter) and location; -b. The dialysis schedule; -c. The nephrologist name and phone number; -d. The dialysis facility name and phone number; -e. Transportation arrangements to and from the dialysis facility; -f. Any medication administration or withholding of specific medications prior to dialysis treatments; -g. Any fluid restriction if ordered by the physician. Review of the facility's Change of Condition policy, last reviewed 2/6/25, showed:-Policy: The attending physician/physician extender (Physicians, Nurse Practitioners, & Physician's Assistants, or Clinical Nurse Specialist) and the Resident Representative (RR) will be notified of a change in a resident's condition, per standards of practice and federal and/or state regulations;-Procedure:-1. Guideline for notification of physician and RR (not all inclusive):-Significant change in medical or cognitive baseline;-Refusal to take prescribed medications;-2. Document in the Interdisciplinary Team (IDT) Notes:-Resident change of condition;-Physician/Physician Extender Notification;-Notification of RR. 1. Review of Resident #18's face sheet, showed his/her diagnoses included dependence on renal dialysis, weakness, abnormalities of gait and mobility, need for assistance with personal care, cognitive communication deficit and high blood pressure. Review of the resident's care plan, dated 8/10/25, showed:-Focus: The resident receives hemodialysis three times a week in facility related to renal failure;-Goal: -The resident will have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date; -The resident will have no signs or symptoms of complications from dialysis through the review date;-Interventions: -Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (specify frequency); -Monitor and document report to physician signs and symptoms of depression. Obtain order for mental health consult if needed;. -Monitor, document and report PRN any signs and symptoms of infection to access site: Redness, swelling, warmth or drainage; -Monitor, document and report PRN for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa (moist, inner lining of mouth), changes in heart and lung sounds;-The care plan did not list the scheduled chair time or the days of the week the resident received dialysis. Review of the resident's order summary, showed receives dialysis at the facility, dialysis days: Monday, Wednesday and Friday, chair time 6:00 A.M., order date 8/14/25. Review of the resident's dialysis communication forms, dated 8/12/25 through 8/30/25, showed:-The resident receiving dialysis on Tuesday, Thursday and Saturday;-On 8/16/25, Patient's condition or events during/post (after) dialysis: Resident cut treatment time by 40 minutes. Complaints of pain in buttocks;-On 8/26/25, Patient's condition or events during/post dialysis: Resident cut treatment time by 70 minutes due to blood pressure never below 100 systolic (SBP, top number in blood pressure reading, normal is below 140). Review of the resident's progress notes, dated 8/9/25 through 8/29/25, showed no notifications to the physician or RR when the resident's treatment ended early on 8/16/25 and 8/26/25. 2. Review of Resident #2's face sheet, showed his/her diagnoses included dependence on renal dialysis, respiratory failure with hypoxia (insufficient oxygen), heart failure and high blood pressure. Review of the resident's care plan, dated 8/8/25, showed no identification of the resident's dialysis. Review of the resident's order summary, showed dialysis days Monday, Wednesday and Friday, order date 8/8/25. The order did not show the location the resident would receive dialysis or the scheduled chair time. 3. Review of Resident #19's face sheet, showed his/her diagnoses included dependence on renal dialysis, kidney failure, weakness, abnormalities of gait and mobility, heart failure and high blood pressure. Review of the resident's care plan, dated 7/9/25, showed:-Focus: The resident receives hemodialysis three times a week in facility Monday, Wednesday and Friday related to renal failure;-Goal: The resident will have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date;-Interventions: -Check and change dressing daily at access site. Document; -Monitor and document report to physician signs and symptoms of depression. Obtain order for mental health consult if needed; -Monitor, document and report PRN any signs and symptoms of infection to access site: Redness, swelling, warmth or drainage;-Monitor/document/report PRN for signs and symptoms of the following: Bleeding, hemorrhage (bleeding from a broken blood vessel, either inside or outside the body), bacteremia (presence of bacteria in bloodstream), septic shock (life-threatening condition that occurs when an infection triggers a widespread inflammatory response that leads to dangerously low blood pressure and organ failure);-The care plan did not list the scheduled chair time. Review of the resident's dialysis communication forms, showed the facility was missing sheets for the following dates, 7/18/25, 7/23/25, 7/25/25, 7/30/25, 8/4/25, 8/11/25, 8/15/25, 8/18/25, 8/22/25, 8/25/25, 8/27/25 and 8/29/25. 4. Review of Resident #4's face sheet, showed his/her diagnoses included dependence on renal dialysis, high blood pressure, diabetes, cognitive communication deficit, weakness and need for assistance with personal care. Review of the resident's care plan, dated 8/20/25, showed: -Focus: The resident needs dialysis three times a week related to renal failure;-Goal: -The resident will have immediate intervention should any sign or symptoms of complications from dialysis occur through the review date; -The resident will have no signs or symptoms of complications from dialysis through the review date;-Interventions: -Check and change dressing daily at access site. Document; -Encourage resident to go for the scheduled dialysis appointments. Resident receives hemodialysis in facility Tuesday, Thursday and Saturday; -Monitor and document report to physician signs and symptoms of depression. Obtain order for mental health consult if needed; -Monitor, document and report as needed (PRN) any signs and symptoms of infection to access site: Redness, swelling, warmth or drainage; -Monitor, document and report PRN for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa (moist, inner lining of mouth), changes in heart and lung sounds;-The care plan did not list the scheduled chair time. 5. During an interview on 8/28/25 at 1:18 P.M., the Administrator and Director of Nursing (DON) said they expected staff to be knowledgeable of and to follow the facility policies. They expected physician orders to be followed. They expected the dialysis communication forms to be completed each day a resident went to dialysis. They expected the completed dialysis communication forms to be scanned into the resident's medical record. They expected residents who receive dialysis to have orders and a care plan that lists the location the resident attends dialysis, the chair time the resident would attend dialysis and the days of the week the resident would attend dialysis. 2571345

Based on interview and record review, the facility failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when the facility failed to accurately complete a post (after) fall 72 hour monitoring report (neurological (neuro) evaluation - pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; and equality of hand grip strength) if the fall was unwitnessed or if the resident had an incident hitting their head for one resident (Resident #10). The facility failed to complete incident follow up documentation (IFU) for 72-hours. The facility also failed to update the resident's care plan timely. The facility failed to offer as needed (PRN) pain medications post fall. The facility also failed to ensure x-rays were completed for the resident's right extremities in accordance with physician's orders. The facility failed to document the resident's transfer to the hospital for further assessment following the fall. The sample was 20. The census was 127.Review of the facility's Accident and Incident Documentation and Investigation, dated 8/30/18, showed:-Policy: Accidents and/or Incidents involving Residents will be investigated and documented on an Incident Report entry in the EHR. An Incident is defined as an occurrence which is not consistent with the routine operation of the Facility or the routine care of a particular Resident. Accidents and Incidents will be analyzed for trends or patterns to enable the Facility to enhance preventive measures to reduce the occurrence of Incidents;-Procedure: The Licensed Nurse assigned at the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the Accident/Incident, and for notifying the Supervisor, Director of Nursing, and/or the Administrator as appropriate;-The Licensed Nurse at the time of the Incident is responsible for initiating/completing the Incident Report, ensuring that all items have been completed as applicable to the Accident/Incident;-The Licensed Nurse at the time of the Incident is responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth in the incident report;-If the incident/accident is related to a visitor; documentation in the medical record will not be applicable;-Notification and documentation: The Licensed Nurse shall document the incident and notify the supervisor and Director of Nursing for follow through as needed (not applicable with visitor Incident);-The Licensed Nurse may complete a nurses' note and update the Resident Care Plan as needed (not applicable with visitor incident);-The Nurse's notes may contain the following documentation:-Clear objective facts of what occurred;-An Evaluation of the resident's condition at the time of the accident/incident may include a description of the resident, vital signs, and other physical characteristics apparent as a result of the accident/incident;-Any treatment provided;-Notification or attempts to notify the resident's physician, family, and/or legal representative, or any other health care professional or individuals involved with the resident's care;-The charge nurse's signature, date, & time of the documentation;-Note: If a Visitor accident/incident occurs, medical record documentation will not apply.-The Administrator/ Director of Nursing will notify the State Department of Health in accordance with Reporting Guidelines in the event the accident/incident is a reportable occurrence;-Accidents/Incidents will be reviewed as part of Quality Assurance and Quality Improvement (QAPI);-Report completion: Incident Report will be completed in the Electronic Medical Record (EMR);-In the event the computer is down paper copies of an incident report will be available. Review of Resident #10's face sheet, showed:-admitted on [DATE];-discharged on 8/25/25;-Diagnoses included cerebral infarction (stroke), posterior reversible encephalopathy syndrome (PRES, rare neurological disorder characterized by reversible brain swelling in the back part of the brain), hemiplegia (weakness on one side of the body) and hemiparesis following cerebral infarction, anemia (iron deficiency) and muscle weakness. Review of the resident's nursing admission evaluation and baseline care plan, dated 8/21/25, showed:-General appearance: Blank;-Vital signs: Blank;-Head, eyes, ears, nose and throat (HEENT): Blank;-Respiratory/chest: Blank;-Cardiac/circulation: Blank;-Gastrointestinal/bowel: Blank;-Genitourinary/bladder: Blank;-Skin: Blank;-Pain: Blank;-Extremities/Range of motion: Blank;-Functional abilities/self care: Blank;-Functional abilities/mobility: Blank;-Mobility devices: Blank;-Health conditions/special treatments: Blank;-Medications: Blank;-Medical conditions: Blank;-Physician orders: Blank;-Dietary/nutritional status: Blank;-Therapy: Blank;-Social Services: Blank;-Plan of care: Blank;-Baseline care plan review: Blank. Review of the resident's admission fall risk assessment, dated 8/21/25, showed:-Level of consciousness/mental state: Blank;-History of falls (past three months): Blank;-Ambulation/elimination status: Blank;-Vision status: Blank;-Gait/ balance: Blank;-Systolic blood pressure: Blank;-Medication: Blank;-Predisposing disease: Blank. Review of the resident's pain interview assessment, dated 8/21/25, showed:-Have you had pain or hurting at any time in the last five days: Yes;-How much of the time have you experienced pain or hurting over the last five days: Occasionally;-Pain effect on sleep: Occasionally;-Over the past five days, how often have you limited your participation in rehabilitation therapy sessions due to pain: Rarely or not at all;-Pain interference with day to day activities: Rarely or not at all;-Please rate your worst pain over the last five days on a zero to ten: Three out of Ten;-Please rate the intensity of your worst pain over the last five days: Mild;-Frequency with which resident complains or shows evidence of pain or possible pain: Indicators of pain (1 to 2 days);-Received scheduled pain medication regimen: No;-Received as needed (PRN) pain medications or was offered and declined: No;-Describe administration patterns, any side effects and effectiveness: Resident given PRN Tylenol;-Received non-medication intervention for pain: No;-Signed by Licensed Practical Nurse (LPN) on 8/29/25. Review of the resident's nursing evaluation, dated 8/21/25, showed:-Did the resident have major surgery during the 100 days prior to admission: No;-Recent surgery requiring active SNF care: No;-Persistent vegetative state/no discernible consciousness: No;-Ability to express ideas and wants, consider both verbal and non-verbal expression: No;-Understanding verbal content, however able (with hearing aid or device if used): Usually understands;-Does this resident have one or more unhealed pressure ulcers/injuries: No;-Skin and ulcer/injury treatments: Pressure reducing device for bed;-Respiratory status: Regular/unlabored;-The resident presents diagnosis of hemiplegia: -Right sided deficit/weakness: blank; -Left sided deficit/weakness: blank;-Has the resident had any falls since admission/entry or re-entry or the prior assessment: Yes;-Fall interventions in place: Yes;-Special treatments and programs: None;-Additional services provided: Observation/assessment; -Management and evaluation of resident care plan; -Therapy-Signed by LPN on 8/29/25. Review of the resident's Physician's Orders Sheet (POS), dated August 2025, showed:-An order, dated 8/21/25, acetaminophen tablet 325 mg, give one tablet via nasogastric tube (NG tube, thin, flexible tube inserted through the nose and into the stomach);-An order, dated 8/21/25, pain scale 1-10 every shift, document pain;-An order, dated 8/22/25, x-ray left arm and right shoulder, one time only for fall for two days;-An order, dated 8/22/25, portable x-ray left shoulder, humerus, forearm, wrist, elbow related to pain due to physical limitations;-An order, dated 8/22/25, acetaminophen tablet 325 milligram (gm), give one tablet by mouth every six hours as needed for pain. Review of the resident's progress notes, showed:-On 8/22/25 at 6:50 A.M., resident noted to have slid out of bed and on to the floor trying to ambulate without assistance. This nurse assessed resident for injury, bruising and redness, none noted at this time. Per resident he/she is having pain to left arm and right shoulder. New order for x-ray to both extremities. Given Tylenol 325 mg for pain. Resident placed back into bed by Certified Nurse Aide (CNA) x2. Bed locked and lowered for safety. Call light in reach;-On 8/22/25 at 6:30 P.M., resident's female family advocate at bedside request information regarding resident medication orders. Resident in bed aware/talkative with visitor and stated ok to speak with her/him. Resident son also present on the phone to verify information. Request resident to have x-ray left arm status/post (s/p) fall related to complaints of pain. Resident in bed with discomfort noted with care/repositioning. Physician made aware. Given new order x-ray lower upper extremities (LUE). X-ray company made aware;-On 8/22/25 at 8:01 P.M., X-ray tech here at this time to perform exam. Resident resting in bed. Cooperative with care. No acute distress noted;-On 8/23/25 at 7:12 A.M., rested safely/comfy in low bed. Aroused easily to stimuli. Voices needs. Continued left side weakness. Positioned comfortably with no acute distress noted. G-tube flushed without difficulty. Peri care provided with incontinence. No acute distress noted. Head of bed (HOB) elevated. Bed low. Call light in reach;-No IFU progress note each shift for 72 hours. Review of the resident's medical record on 8/28/25 and 8/29/25, showed no documentation of neuro checks, skin assessment completed after the resident's fall, or completed x-ray of the resident's right extremities. Review of the resident's Neurological Evaluation, dated 8/22/25, provided by the facility on 9/3/25 at 3:12 P.M. by email, showed:-Directions: Complete Post-Fall if resident hit head or unwitnessed fall: -Every (Q) 15 Minutes times (X) one hour; -Q 30 minutes X one hour; -Q Hour X two hours; -Q two hours X eight hours; -Q four hours X 12 hours; -Q shift X 72 hours;-Q 15 minutes X one hour: -8/22/25, 6:45 A.M., completed; -8/22/25, 7:00 A.M., completed; -8/22/25, 7:15 A.M., completed; -8/22/25, 7:30 A.M., completed;-Q 30 minutes X one hour: -8/22/25, 7:45 A.M., time incorrect, should be 8:00 A.M.; -8/22/25, 8:00 A.M., time incorrect, should be 8:30 A.M.;-Q Hour X two hours: -8/22/25, 10:00 A.M., time incorrect, should be 9:30 A.M.; -8/22/25, 12:00 P.M., time incorrect, should be 10:30 A.M.;-Q two hours X eight hours: -8/22/25, 9:00 P.M., time incorrect, should be 12:30 P.M.; -8/23/25, 5:00 A.M., date and time incorrect, should be 8/22/25 at 2:30 P.M.; -8/23/25, 1:00 P.M., date and time incorrect, should be 8/22/25 at 4:30 P.M.; -8/23/25, 9:00 P.M., date and time incorrect should be 8/22/25 at 6:30 P.M.;-Q four hours X 12 hours: -8/24/25, 9:00 A.M., date and time incorrect should be 8/22/25 at 10:30 P.M.; -8/24/25, 9:00 P.M., date and time incorrect should be 8/22/25 at 2:30 A.M.; -8/25/25 9:00 A.M., date and time incorrect should be 8/23/25 at 6:30 A.M.;-Q shift X 72 hours: -Blank: Should have been completed on 8/23/25 day shift (7:00 A.M. - 3:00 P.M.); -Blank: Should have been completed on 8/23/25 evening shift (3:00 P.M. - 11:00 P.M.); -Blank: Should have been completed on 8/23/25 night shift (11:00 P.M. - 7:00 A.M.); -Blank: Should have been completed on 8/24/25 day shift; -Blank: Should have been completed on 8/24/25 evening shift; -Blank: Should have been completed on 8/24/25 night shift; -Blank: Should have been completed on 8/25/25 day shift. Review of the resident's x-ray results, dated 8/22/25, showed:-History: Post fall;-Left elbow, two views: No acute fracture or dislocation;-Left humerus, 2+ views: No acute fracture or dislocation;-Left forearm, two views: No acute fracture or dislocation;-Left wrist, two views: No acute fracture or dislocation;-Left shoulder, complete 2+ views: No fractures or dislocation;-No documentation of x-ray result for the right extremities. Review of the resident's Medication Administration Record (MAR), dated August 2025, showed:-An order, dated 8/21/25, pain scale 1-10 every shift: -On 8/22/25 during 7:00 A.M. to 3:00 P.M. shift, 3; -On 8/22/25 during 3:00 P.M. to 11:00 P.M. shift: blank; -On 8/22/25 during 11:00 P.M. to 7:00 A.M. shift: blank; -On 8/23/25 during 7:00 A.M. to 3:00 P.M. shift, 3; -On 8/23/25 during 3:00 P.M. to 11:00 P.M. shift, 0; -On 8/23/25 during 11:00 P.M. to 7:00 A.M. shift, 0;-An order, dated 8/22/25, acetaminophen tablet 325 mg, Give one tablet by mouth every six hours as needed for pain, showed the medication was not administered between 8/22/25 through 8/28/25; -On 8/28/25, the medication was discontinued;-An order, dated 8/21/25, acetaminophen tablet 325 mg. Give one tablet via NG tube every six hours as needed for pain, showed the medications was not administered 8/21/25 through 8/22/25; -On 8/22/25, the medication was discontinued. Review of the progress notes, showed no entries for 8/24/25 and 8/25/25. Review of the resident's care plan, dated 8/25/25, showed:-Focus: The resident is at risk for falls, confusion, and deconditioning;-Goal: The resident will be free of minor injury;-Interventions: Anticipate and meet the resident's needs; -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; -Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; -Family request bed to be placed up against wall; -Low bed with fall mat; -Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident, family, caregiver, Interdisciplinary team (IDT) as to causes; -The resident needs activities that minimize the potential for falls while providing diversion and distraction. Review of the hospital emergency room record, dated 8/25/25, showed:-Alert and oriented;-Reported he/she fell Friday (8/22/25) and today;-Hematoma/abrasion on left forehead;-Patient reports headache and room is spinning. During an interview on 8/29/25 at 9:24 A.M., LPN C said if a resident had a fall, neuro checks are completed, regardless if it was witnessed or not. The Assistant Director of Nursing (ADON) makes sure it is completed. He/She believed it would be scanned into the medical record. They also complete pain and skin assessments. If there is an open area, they will notify the physician and receive treatment orders. During an interview on 8/29/25 at 9:29 A.M., the Administrator said neuro checks are completed on paper. Once the neuro checks are completed, it is scanned into the medical record. During an interview on 8/29/25 at 1:33 P.M., the Director of Nursing (DON) said she expected the fall assessment to be completed upon admission. The admitting nurse on the floor is responsible. She expected falls to be documented and neuro checks are expected to be completed immediately regardless if it was witnessed or unwitnessed. The skin and pain assessments are on the form called the fall risk assessment. It should be completed. The neuro checks are scanned in. It is not in the medical record, it was not scanned in. She expected staff to offer PRN pain medications and document in the medical record. She expected physician's orders to be followed and for staff to be knowledgeable of and follow facilities policies. 2599861

Based on observation, interview and record review, the facility failed to ensure a resident was free from additional harm after experiencing an unwitnessed fall. Staff transferred the resident back to his/her bed while the resident showed signs of injuries (Resident #8). The resident sustained fractures following the fall. In addition, the facility failed to transfer a resident (Resident #1) appropriately utilizing a mechanical lift. The sample size was 24. The census was 121. Review of the facility's Fall Management Policy, dated 2/28/23, showed: -Policy: To provide an environment that remains as free of accidents and hazards as possible. The Facility will complete a fall evaluation on Residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or reduce injuries; -Definition: -A Fall is a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object; -An unwitnessed fall occurs when a Resident is found on the floor and the Resident/Employee is unaware of how he/she got there; -Prevention/Treatment: -Prior to moving the Resident, the Charge Nurse will evaluate for injury; -If injury is known or suspected; -Provide emergency first aid treatment as applicable. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Cognitively intact; -No behaviors; -Required substantial/maximal assistance for mobility and transfers; -Diagnoses included anemia. Review of the resident's progress notes, showed: -2/13/25 at 9:16 P.M., the resident was found on the floor by staff. Resident stated he/she was trying to reach something on his/her bedside table and slipped out of bed. Resident denies pain at this time. No visible injuries. Denies hitting head. Resident refused to turn to be placed on Hoyer (mechanical lift) pad. Educated resident on the safety of using a Hoyer. Resident insisted to be lifted by two male staff to be placed back into bed. One male staff held his/her legs and other male staff held under his/her arms. Placed resident back to bed. Multiple staff present at the time. Resident refuses to have vitals taken. Notified doctor; -2/14/25 at 2:04 A.M., Doctor and evening shift supervisor notified. Resident is now having complaints of left arm pain, refusing to be changed by the Certified Nursing Assistant (CNA). Call made to physician for an x-ray. Resident notified; -2/14/25 at 8:55 A.M., X-ray to left arm/shoulder completed. Awaiting the results; -2/14/25 at 12:04 P.M., Received the x-ray results. This nurse called the doctor and reported the results. Resident has a non-displaced fracture involving the supracondylar left humerus (a break to the lower part of this bone, close to the elbow) that suggests metastatic disease. The doctor recommends sending the patient to the hospital. This nurse talked to the patient and explained that the doctor recommended he/she go to the hospital. Resident is alert and oriented and able to understand he/she has a fracture and is own responsible party. Resident declined going to the hospital and states he/she could wait and if it gets worse, then would go to the hospital; -2/14/25 at 3:24 P.M., the resident refused vital signs during this shift. Dr here and made aware. Continues to be assisted with activities of daily living; -2/14/25 at 9:23 P.M., the resident resiting in bed with the rise and fall of the chest. Resident complained of pain to the left arm. This writer offered resident a pain medication to help with pain. The resident declined pain medication. This writer had conversation with the resident on how he/she fell, and why he/she did not want to go to the hospital. Resident responded saying, I am afraid of what else they will find. This writer encouraged resident to go. Resident continues to decline offer stating is he/she changes his/her mind, he/she will let this writer know. Vital signs refused. Swelling noted. Offered to elevate arm. Resident declined medical doctor. Review of the resident's care plan, in use during the time of the investigation, revised 2/14/25, showed: -Focus: The resident is at risk for falls. 2/13/25 fall; -Goal: The resident will be free of minor injury through the review date; -Interventions: Anticipate and meet the resident's needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Review of the resident's progress note, showed: -2/15/25 at 2:38 A.M., resident requested to go to the hospital. Medical doctor made aware. Resident left facility via stretcher for complaints of pain to left hip radiating down his/her leg. Resident going to the hospital; -2/20/25 at 4:07 P.M., spoke with staff at the hospital. Diagnoses of left distal femur fracture (thigh bone just above the knee joint) and left humerus fracture. No anticipated discharge date available at this time. Review of the resident's hospital Discharge summary, dated [DATE] at 10:14 A.M., showed: -Left distal femur fracture-occurred after fall out of bed experiencing dizziness; -Left distal humerus fracture. During an interview on 5/30/25 at 2:33 P.M. and 6/2/25 at 7:27 A.M., the resident said on 2/13/25 around 10:00 P.M., he/she reached for something on the night stand and fell from the bed, onto the floor. He/She screamed in pain and for help because he/she could not get to the call light. Two female staff members came to the room to assist him/her back in bed. They did not offer a Hoyer to transfer the resident back into bed. The resident said, If they did offer it, I don't know how they would have gotten me on it because I was in so much pain and the way my body was positioned would not allow a Hoyer to lift me without causing further pain. I was in so much pain, I would have refused a Hoyer anyway. The resident was not sure who the two staff members were, only they were from an agency and not regular employees of the facility. The staff members did not complete range of motion on the resident. They did not take vitals. The two staff got in position to transfer the resident back to bed. The resident said, something did not feel right when the staff were about to lift the resident. He/She asked the two staff members to stop and requested two male staff members transfer him/her back to bed. The staff members texted the male CNAs to assist the resident back into bed. Approximately five minutes later, CNAs Q and T entered the resident's room to transfer him/her back into bed. CNA Q grabbed the resident's legs while CNA T grabbed the resident's arm. The resident said CNA T grabbed him/her by the arm, under his/her elbow. As they lifted the resident, the resident said he/she felt a crack in his/her arm and yelled out, ouch, my arm, my arm, my arm! They then transferred the resident into the bed. The female staff said, they did not do anything to your arm. Make sure to document that they did not do anything to his/her arm. The resident said he/she was in so much pain after being placed in bed. An aide entered his/her room shortly after and said he/she needed to take vitals. The resident refused and said he/she was in pain. The resident was also distrustful of the aide because he/she said the resident was not in pain and did not want to work with the aide. He/She did not have any vitals taken due to pain. The next day someone came in and took x-rays. Later, the resident found out he/she had a fracture. He/She was afraid to go to the hospital and initially declined. That evening, Licenced Practical Nurse (LPN) O arrived and the resident told him/her what happened as he/she trusts LPN O. LPN O convinced the resident to go to the hospital. During an interview on 6/2/25 at 4:52 A.M., LPN O said he/she arrived to work the following day after the resident fell. The resident told him/her what happened the night before. LPN tried providing care to the resident and the resident cried out in pain. He/She encouraged the resident to go to the hospital. LPN O was not sure who the staff were who worked with the resident. He/She believed they were agency staff. During an interview on 6/2/25 at 7:04 A.M., CNA R said he/she was present when the fall occurred. He/She heard the resident yelling and saw him/her on the floor. He/She immediately got the nurse and explained the resident needed a mechanical lift and was on the floor screaming out in pain. He/She could not recall the nurse and said the nurse worked for an agency and had not returned since the incident. The nurse did not get a chance to obtain vitals because the resident refused and kept saying I am hurt and insisting staff get him/her off the floor. CNA R and the unknown nurse educated the resident on the importance of using the mechanical lift. Again, the resident refused. As they were going to lift the resident, the resident asked for CNAs Q and T. The aides arrived and lifted the resident off the floor and placed him/her back in bed. The nurse said he/she would document in the progress note the resident refused a mechanical lift and vitals. Later that evening, CNA R returned to the resident's room to get vitals. The resident refused and said he/she was in pain. He/She did not return to follow up on vitals as this was close to 10:00 P.M. when it happened and the shift was almost over. During an interview on 6/2/25 at 9:02 A.M., CNA Q said he/she and CNA T received a text message from the nurse asking for assistance in getting a resident off the floor. When they arrived, the resident was on the floor screaming in pain saying, It hurts, it hurts, it hurts. The resident also said to get him/her off the floor. At first, CNA Q said he/she did not recall the nurse doing range of motion because the resident was in so much pain and insisted on being transferred back to bed. They did not use a pad to transfer the resident. He/She could not recall exactly how the resident was lifted. He/She grabbed the resident by the legs and CNA T, who has since been terminated, grabbed the resident by the arms. He/She could not recall how the resident's arms were grabbed and how his/her body was positioned prior to the transfer. After transferring the resident back to bed, CNA Q continued with his/her assignments. During an interview on 6/2/25 at 9:21 A.M., LPN S said if there was an unwitnessed fall, the resident should be assessed by the nurse prior to moving the resident. If the resident is alert and oriented, denies pain, range of motion performed, vitals taken and no visible signs of injury, the resident could be transferred back into bed using a lift or pad. This was after a full head to toe assessment. If the resident was in pain, or showed signs of pain, it would be unsafe to transfer the resident back into bed. Staff should call Emergency Medical Services (EMS) if a resident showed signs of injury following a fall. During an interview on 6/2/25 at 4: 15 P.M., the Director of Nursing (DON) said if the resident complained of pain after a fall, staff should not attempt to move the resident and should call EMS immediately. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse, Assistant Director of Nursing and Administrator said staff should have contacted EMS following the resident's fall if he/she showed signs of injury. They could not recall who the nurse was as he/she was through an agency and the facility has stopped utilizing agency staff. The Administrator was told the resident was not injured during the transfer. They staff should not have moved the resident following the fall. During an interview on 6/3/25 at 11:34 A.M., the facility's Medical Director said she was not familiar with the resident. However, staff should have contacted EMS prior to moving the resident if he/she showed signs of an injury. 2. Review of the facility's Total Lift Transfer policy, reviewed on 11/28/22, showed: -Policy: The facility will utilize a Total Lift Device on residents who are unable to assist with transfers; -Responsibility: Employees, nursing administration, Director of Nursing; -Procedure: -Measure resident for appropriate sling size according to Manufactures Guidelines; -Explain the procedure; -Ensure lifting device battery is charged; -Clear an unobstructed path for the lift device; -Ensure appropriate room to pivot the lift; -Position the lift near the receiving surface; -Place the lift at the correct height; -Lock the bed/chair wheels; -Inspect equipment; ensure in good condition (sling/straps); -Place sling under the resident; -Lower lift for easy attachment of the sling; -Position the sling under the resident with the base of the sling at the base of the resident's spine, top of the sling at the top of the head; cross straps prior to hooking the straps of the lift; -Match the corresponding colors on each slide of the sling and observe that all sling loops are securely connected; -Lift resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution; -Evaluate resident's level of comfort and observe for signs of pinching or pulling of the skin; -Standing next to the resident, press the up button on the lift controls to slowly raise the lift to the height necessary to clear the surface. maintain contact with the resident to guide/steady the resident during the lift transfer, as necessary; -Standing next to resident use the down button on the lift control to slowly lower the resident to the desired surface, guide/steady as necessary; -Detach the sling from the lift ensuring the bar of the lift does not touch resident; -Move the lift away from the resident; -Lifting from the chair: Lock the wheels of the chair; -Attach the sling to the lift using color coded straps; cross straps prior to securing to the lift; -Open the legs of the lift using the hand controls; -Raise resident using the hand controls; -Safely lower resident to the chair ensuring proper placement; -Unhook sling from lift ensuring the lift bar does not touch resident; -Lifting from the floor: Place the sling centered under resident; -Open the legs of the lift; -Attach the sling to the lift using color coded straps; cross sling straps prior to securing to the lift; -Raise resident from the floor to the desired surface. Review of Resident #1's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Wheelchair for mobility device; -Dependent to chair/bed-to-chair transfer; -Diagnoses included multiple sclerosis (MS, chronic disease of the central nervous system) and paraplegia (paralysis of the lower parts of the body). Review of the resident's care plan, in use at time survey, showed: -Focus: Limited physical mobility related to MS, paraplegia and needs assistance with meals; -Goals: Will demonstrate the appropriate use of adaptive devices to increase mobility; -Will remain free of complications related to immobility, including contractures, thrombus formation (blood clots), skin breakdown, fall related injury; -Interventions: Hoyer lift transfer with medium size sling, provide supportive care, assistance with mobility as needed, document assistance as needed; -Focus: Resident is at risk for falls related to deconditioning; -Goal: Resident will not sustain serious injury through the review date; -Interventions: Anticipate and meet the resident's needs, follow facility fall protocol. Observation on 6/2/25 at 5:05 A.M., showed CNA N and LPN O entered the resident's room to transfer the resident using a Hoyer lift. The Hoyer sling or pad was applied under the resident while in bed. The resident was not properly adjusted prior to lifting the resident. CNA N adjusted the resident's head and feet with one hand while controlling the lift and the resident was suspended in the air. The resident's wheelchair was placed away from the bed. The resident was dangling and spun around while the lift was wheeled closer to the wheelchair. LPN O did not spot and support the resident. The resident was lowered to the wheelchair without being adjusted and repositioned comfortably. During an interview 6/3/25 at 10:59 A.M., CMT (Certified Medication Technician) D said Hoyer lift transfers required two staff to provide residents' safety. The staff should make sure they were using the correct size of the sling or pad. One staff would operate the Hoyer while the other would make sure the resident would not slide out of the sling, and make sure to hold and support the resident's head and legs. The staff should make sure the resident was comfortable in the chair or bed after transfer. During an interview on 6/3/25 at 11:28 A.M., LPN C said two staff were required at all times to transfer residents using Hoyer lift. One staff can spot and keep the resident stable while the other operates the Hoyer. The resident's head, legs and body should be assisted and kept steady, and without flopping to the chair. The resident's wheelchair should be positioned parallel and close to the bed. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse said Hoyer-transferred residents should have two staff at all times, providing residents' safety. The staff should make sure the Hoyer's legs were opened when used, and the resident's body should be adjusted and leveled. The resident should be supported, avoiding being dangled in the air and providing a minimum distance from the bed when lifted up. She expected staff to provide the residents with safe transfer at all times and to follow their mechanical transfer policy. MO00238874 MO00237238 MO00254710

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to date and cover food. In addition, the facility also failed to discard outdated food and failed to ensure kitchen equipment was kept clean during four of five days of observation. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The sample was 24. The census was 121. 1. Observation of the kitchen on 5/28/25 at 10:12 A.M., 5/29/25 at 3:45 P.M., 5/30/25 at 3:29 P.M., and 6/3/25 at 11:45 A.M., showed: -Dry storage room: -A container of dry grits, with a best by date of 8/12/24; -A package of tortillas opened and exposed to air; -Two boxes of angel food cake mixes, both with expiration dates of 2/14/24; -A box of lasagna pasta noodles opened and without a date; -Walk in freezer: -A bag of French toast tied in a knot at the end, without a date; -A bag of hamburger patties tied in a knot at the end, without a date; -An opened box of turkey sausage patties exposed to air; -An opened box of sausage patties exposed to air; -An opened box of chicken breasts exposed to air. 2. Observation of the kitchen's dry storage room on 5/29/25 at 3:45 P.M., 5/30/25 at 3:29 P.M., and 6/3/25 at 11:45 A.M. showed a package of macaroni noodles wrapped in plastic and without a date. 3. Observation of the kitchen's walk-in freezer on 5/29/25 at 3:45 P.M., and 5/30/25 at 3:29 P.M., and 6/3/25 at 11:45 A.M., showed a package of waffles, opened and exposed to air and without a date. 4. Observation of the kitchen on 5/28/25 at 10:12 A.M., 5/29/25 at 3:45 P.M., 5/30/25 at 3:29 P.M., and 6/3/25 at 11:45 A.M., showed: -The stove: -Heavy caked-on stains along the front and sides of the stove; -The deep fryer: -Old grease in the fryer; -Old batter caked along the inside of the fryer; -Baked on grease on strainers and along the inside of the fryers; -Stove: -Caked-on stains along the front and on the sides of the stove; -Heavy caked-on stains along the front and on the side in between the grill; -Stand-alone oven: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, and sides of oven; -Tray had caked-on stains, and had various food particles on it. During an interview on 6/3/25 at 11:45 A.M., the Dietary Manager (DM) said it was her expectation that all food items were properly labeled, dated, covered and stored. Expired and outdated items were to be discarded. The general cleaning was done everyday. Deep cleaning was done weekly. The deep fryer was drained and cleaned weekly and as often as needed. It was the responsibility of her cooks every shift to go through and check to make sure that all food items were properly labeled, dated, stored and covered. The cooks were also expected to go through and make sure there were no expired items and to discard said items. The DM did not have a copy of the April 2025 and May 2025 cleaning schedules. She expected all kitchen equipment to be cleaned and in proper working condition.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to change gloves, wash or sanitize hands and wear gowns during care for residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) for four residents (Residents #105, #66, #47 and #1). In addition, the staff failed to disinfect the accucheck machine (used to test blood sugar) properly for one resident (Resident #47). Furthermore, staff placed unbagged dirty linens and briefs on the floor during care of two residents (Residents #105 and #66). Moreover, the facility failed to ensure newly hired employees completed the 2-step Mantoux tuberculin skin test (TST), used to test for latent tuberculosis (TB) infection, as required for 9 out of 10 employees residents sampled. The sample was 24. The census was 121. Review of the facility's Enhanced Barrier Precaution (EBP) sign, showed: -Everyone must clean their hands, including before entering and when leaving the room; -Providers and staff must also: wear gloves and gown for the following high contact resident care activities: -Transfers; -Providing hygiene; -Changing briefs or assisting with toileting; -Wound care: any skin opening requiring a dressing. Review of the facility's Hand Hygiene policy, reviewed on 4/28/22, showed: -Policy: The Facility will provide guidelines to Employees on proper handwashing and Hand Hygiene techniques that will aid in the prevention of the transmission of infections; -Responsibility: All Employees, Nursing, Nursing Administration, Director of Nursing; -Procedure: Employees will be trained and receive ongoing education on the importance of Hand Hygiene in preventing the transmission of Healthcare-Associated Infections (HAI); -Hand Hygiene should be performed following the Clinical Indications: -Before/After providing Care; -Before/After performing Aseptic Task (such as placing an indwelling device); -Contact with blood, body fluids, or contaminated surfaces; -Before/After applying/removing gloves/Personal Protective Equipment (PPE); -After handling soiled lines/items potentially contaminated with blood, body fluids, or secretions. Review of the facility's Handling Linen policy, reviewed on 7/2/24, showed: -Policy: Linen and laundry should be handled, transported, and stored to prevent the spread of infection; -Employees shall be educated in proper techniques to handle, store, and transport both soiled and clean linens and laundry. No policies for multi-use machines and employee's TB testing were provided following requests from the facility. 1. Review of Resident #105's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Moderately impaired cognition; -Feeding tube while a resident; -Frequently incontinent of bowel and bladder; -Required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene; -Diagnoses include medically complex condition and human immunodeficiency virus (HIV, a virus that attacks the body's immune system). Review of the care plan in use at the time of survey, showed: -Focus: Activities of Daily Living (ADL, grooming, dressing, bathing and personal hygiene) self-care performance deficit activity intolerance, fatigue, impaired balance; -Goal: ADL Function: resident requires assistance with ADL care and mobility. At facility on a skilled rehab stay to increase in strength, mobility, endurance, and independence; -Interventions included: toilet use: one assist. Observation on 6/2/25 at 5:45 A.M., showed an EBP sign and a caddy with PPE hanging on the resident's door. The resident lay in bed, Certified Nurse Aide (CNA) L entered the resident's room, performed hand hygiene and put on gloves. The CNA pulled the cover down and unfastened the brief and provided peri care (cleansing between the legs and buttocks area), the resident turned onto his/her side and the CNA finished cleaning the resident. The CNA removed the resident's brief and his/her gloves and placed them on the floor. He/She put a new pair of gloves on and put a new brief on the resident. Then, he/she made the resident comfortable in bed and picked up the soiled brief and gloves off the floor and put them in a trash bag and removed the trash from the room. The CNA failed to wear a gown while providing direct resident care. 2. Review of Resident #66's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia (decrease in number of red blood cells), high blood pressure, obstructive uropathy (any blockage or impediment that prevents the normal flow of urine through the urinary tract) and diabetes; -Indwelling catheter (a sterile tube inserted into the bladder to drain urine); -One Stage two pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue separating from living tissue), may also present as an intact or open/ruptured blister); -One Stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling); -Two unstageable wounds-slough and/or eschar (dead tissue): known but not stageable due to coverage of wound bed by slough and/or eschar; -One unstageable-deep tissue: suspected deep tissue injury in evolution. Review of the care plan, in use at the time of survey, showed: -Focus: resident had an unstageable pressure wound to left heel, Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) to right heel, unstageable to sacrum, Stage 3 to left buttock, and Stage 2 to right buttock; -Goal: to remain without complications over through the next review; -Interventions: provide treatment per current order. Observation on 6/2/25 at 7:05 A.M., showed an EBP sign and PPE on the resident's door. The resident lay in bed with his/her heel boots in place. The indwelling catheter was draining to gravity on the window side of the bed. Licensed Practical Nurse (LPN) K entered the room, performed hand hygiene and put gloves on, no gown was put on. He/She removed the resident's heel boots and changed the resident's dressing on both of his/her heels. LPN K removed the bed linens that were at the foot of the bed and placed them in a pile on the floor and said, I know linens should not be on the floor; it is what it is. The nurse moved the resident's urinary gravity bag to the other side of the bed and assisted the resident to roll onto his/her side. The nurse removed his/her gloves and left the room, to obtain more linens. When he/she returned to the room, he/she had on gloves, gown and a face mask on and said now that I'm all gowned up, I am good. The nurse provided peri care and wound care to the resident's buttocks. After care was provided, the nurse placed the dirty linens that were on the floor in a plastic bag and removed them from the room. 3. Review of Resident #47's admission MDS, dated [DATE], showed: -Cognitively intact; -Dependent (helper does all the effort. Resident does none of the effort to complete the activity) for chair/bed-to-chair-transfer; -Diagnosis of end stage renal disease (ESRD, chronic irreversible kidney failure); -Dialysis while a resident. Review of the care plan in use at the time of survey, showed: -Focus: ADL self-care and mobility performance deficit related to weakness and activity intolerance; -Goal: will maintain current level of function with ADLs through the review date; -Interventions included: transferring: dependent. Observation on 6/2/25 at 5:22 A.M., showed an EBP sign and a caddy with PPE hanging on the resident's door. LPN K and CNA L entered the resident's room and performed hand hygiene and put on gloves. The resident lay in bed, with a mechanical lift pad under him/her. The CNA and the nurse attached the lift cloth to the mechanical lift and transferred the resident from the bed to the chair. Then, they unfastened the lift cloth and positioned the resident in the chair. Both staff failed to wear a gown during the transfer. Observation on 5/29/25 at 8:00 A.M., showed LPN A removed the blood sugar machine from the medication cart and entered the resident room. He/She performed the blood sugar and returned the blood sugar machine to the medication cart without cleaning it. The blood sugar machine was placed on top of the medication cart without placing a barrier between the top of the cart and the machine. At 8:20 A.M., LPN A took the same blood sugar machine into another resident's room without cleaning it and performed the blood sugar. The blood sugar machine was placed on to the top of the medication cart, without cleaning it or placing a barrier between the blood sugar machine and the top of the cart. 4. During an interview on 6/3/25 at 2:05 P.M., the Assistant Director of Nursing (ADON) said multi-use equipment should be cleaned and sanitized with a Sani wipe or a bleach wipe before and after use. Residents who have a wound, a catheter, a feeding tube, an access port (an implanted device that allows healthcare providers to easily access a vein or other body cavity for administering medications, fluids, or other treatments, as well as for drawing blood), Clostridioides difficile (C. diff, a bacterium that can cause an infection of the colon), and certain infections require EBP. Staff should wear a gown and gloves and a mask if the resident had a viral infection, every time staff entered the resident's room. The Concierge was responsible for setting up the resident's room and placing the EBP signs on the doors. Soiled linens and trash should be placed in a plastic trash bag and not on the floor. 5. Review of Resident #1's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Wheelchair for mobility device; -Dependent to chair/bed-to-chair transfer; -Diagnoses included multiple sclerosis (MS, chronic disease of the central nervous system) and paraplegia (paralysis of the lower parts of the body). Review of the resident's care plan, in use at time survey, showed: -Focus: Resident had impaired skin integrity, had trauma-related wounds to dorsal 5th and an autoimmune-related wound to her left hand. Resident had unstageable wound to left heel, stage III right lateral ankle and right heel; -Goals: Resident will maintain or develop clean and intact skin; -Interventions: Perform treatment to wound per current treatment order. Assess wound for signs and symptoms of infection with each dressing change/treatment. Report positive findings of redness warmth, swelling increased drainage, increased pain; -Focus: Resident required suprapubic catheter (a urinary catheter inserted directly into the bladder) due to neuromuscular dysfunction of the bladder; -Goal: Resident will be/remain free from catheter-related trauma; -Interventions: Check tubing for kinks each shift, monitor/document for pain/discomfort due to catheter. Observation on 6/2/25 at 5:05 A.M., showed CNA N and LPN O entered the resident's room which had an EBP sign on the door, to transfer the resident using a Hoyer lift (mechanical device used to transfer dependent residents). Both staff failed to wear gowns on. CNA N operated the Hoyer lift, touched the resident's urinary catheter bag, then applied a cushion to the resident's right side, with the same gloves on. He/She then touched and adjusted the resident's head, while also touching her face with the same dirty gloves on. 6. During an interview on 6/3/25 at 11:30 A.M., LPN C said the residents who required EBP precautions are discussed daily in shift report. The resident would have a sign and PPE on their door. Residents who have catheters/dialysis, wounds would be on EBP precautions. Staff should wear the gowns, masks and gloves while providing direct care and when handling bodily fluids. High contact care areas would include dressing, transfers, proving peri care, catheter care or wound care. 7. Review of the admission Supervisor's employee record, showed: -Hired on 1/8/25; -First step TB received on 1/20/25; -No documentation of date and result of the first step TB; -No documentation of the second step TB was completed. 8. Review of CNA U's employee record, showed: -Hired on 8/20/24; -First step TB received on 8/20/24; -No documentation of date and results of the first step TB; -No documentation of the second step TB was completed. 9. Review of CNA V's employee record, showed: -Hired on 4/30/25; -No documentation of dates received and results of both the first and second steps TB. 10. Review of CNA V's employee record, showed: -Hired on 5/7/25; -No documentation of dates received and results of both the first and second steps TB. 11. Review of Receptionist X's employee record, showed: -Hired on 8/17/24; -First step TB received on 8/12/24; -No documentation of date and result of the first step TB; -No documentation of the second step TB was completed. 12. Review of [NAME] Y's employee record, showed: -Hired on 1/20/25; -First step TB received on 1/28/25; -No documentation of date and result of the first step TB; -No documentation of the second step TB was completed. 13. Review of Housekeeper Z's employee record, showed: -Hired on 12/5/24; -First step TB received on 12/4/24; -No documentation of date and result of the first step TB; -No documentation of the second step TB was completed. 14. Review of CMT AA's employee record, showed: -Hired on 5/21/25; -First step TB received on 5/21/25; -No documentation of date and result of the first step TB; -No documentation of the second step TB was completed. 15. Review of CNA BB's employee record, showed: -Hired on 4/15/25; -First step TB received on 4/15/25; -No documentation of date and result of the first step TB; -No documentation of the second step TB was completed. During an interview on 6/3/25 at 2:04 P.M., the ADON/Infection Control Preventionist (ICP) said the Human Resources (HR) would let any nurse know newly hired employees who needed the 2 step TB. The employees were provided with a form on which dates, results and lot numbers were to be documented. The ADON/ICP was responsible for keeping track of the newly hired employees' TB testing. 16. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse said she expected staff to follow the facility's infection control policies and procedures.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified eight medication carts and four medication rooms. Four of the eight carts and two of the four medication rooms were checked for medication storage. Issues were found in one of the medication rooms, and on two medication carts. The census was 121. Review of the facility's Storage of Medications policy, revised 11/2018, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -When the original seal of a manufacturer's container or vial is initially broken, it is recommended that a nurse write the date opened on the medication container or vial; -The nurse will check the expiration date of each medication before administering it; -No expired medication will be administered to a resident; -Medication and biologicals are stored at their appropriate temperatures and humidity according to the United Stated Pharmacopeia guidelines for temperature ranges; -Medications requiring refrigeration are kept in a refrigerator at temperatures between 20 C (Celsius) or 360 F (Fahrenheit) and 80 C or 460 F, with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored securely according to state regulations. Review of the manufacturer's insert for Tuberculin Purified Protein Derivative (PPD, (Mantoux) is a skin test to aid in diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease) showed: Store at 35° to 46°F. A vial of PPD (tubersol) which has been entered and in use for 30 days should be discarded. Do not use after expiration date. Review of the manufacture's insert for Lorazepam Oral Concentrate (liquid medication used to treat anxiety), showed: Store at 36° to 46°F. 1. Observation and interview on [DATE] at 11:15 A.M., showed the refrigerator inside the medication room on the [NAME] Hall had a multidose vial of Flucelvax (flu vaccine) 2024-2025 formula that was open and undated. Licensed Practical Nurse (LPN) A said the vial should be dated when opened by whomever opened it. 2. Observation of the nurse's medication cart on the [NAME] Hall on [DATE] at 11:30 A.M., showed one opened and undated vial of PPD. A bottle of Lorazepam concentrate was stored in the locked box. 3. Observation and interview on [DATE] at 11:50 A.M., showed the nurse's medication cart on the Tranquility Hall with two out of nine insulin pens in the top drawer which were opened and undated. LPN B said whomever opened the insulin pen was responsible for dating them. Lorazepam Concentrate and PPD should be stored in the refrigerator. 4. During an interview on [DATE] at 4:15 P.M. the Director of Nursing said multidose vials and insulin should be dated when they are opened by the person who opened it. Liquid Lorazepam and PPD should be stored in the refrigerator. She would expect medications to be stored per manufacturer's recommendations. 5. During an interview on [DATE] at 5:25 P.M., the Corporate Nurse said she would expect medications to be stored per manufacturer's guidelines.

Based on interview and record review, the facility failed to implement their policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for two of five residents sampled for medication review (Residents #35 and #62). The sample was 24. The facility census was 121. Review of the facility's Medication Regimen Review, revised 8/17, showed: -Policy: The pharmacist performs a comprehensive review of each resident's medical record at least monthly. The medication regimen review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. While conducting the MRR the pharmacist may also collaborate with members of the Interdisciplinary Team (IDT), the resident, the resident's family, and/or resident representative. Irregularities, findings and recommendations are reported at a minimum to the Director of Nursing (DON), attending physician, and the Medical Director; -The ACP reviews the medical record of each resident at least monthly; -The pharmacist or designee; clinical pharmacist at the provider pharmacy, works with facility personnel and electronic records to gather pertinent information related to the resident's status and/or request for consultation; -The findings are phoned, faxed, or e-mailed within 1 business day of monthly MRR completion (or as agreed upon by facility) to the DON or designee and are documented and stored with the other pharmacist recommendations in the resident's active record; -The prescriber and/or Medical Director is notified if needed; -Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the DON, attending physician and the Medical Director; -Recommendations are acted upon and documented by the facility staff and/or the prescriber. 1. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/19/25, showed: -Intact cognition; -Diagnoses included cancer, anxiety, depression, and respiratory failure. Review of the resident's care plan in use at time of survey, showed: -Focus: Resident has been prescribed psychotropic medications; -Goal: Maximize resident's functional potential and well-being while minimizing the hazards associated with drug-related side effects; -Interventions: Administer medications per order and monitor for effectiveness, monitor for drug-related side effects. Review of the resident's active order summary, showed: -An order dated, 12/10/24, for Hydroxyzine HCl (used to help control anxiety), give 25 milligrams (mg) by mouth every 6 hours as needed (PRN) for anxiety; -An order dated, 3/25/25, for Lorazepam Intensol Oral Concentrate (antianxiety medication), 2 mg per milliliter (ml), to give 0.25 ml by mouth every 4 hours as needed for shortness of breath and anxiety; -No stop date or notes indicating the continued use of PRN psychotropic medications. Review of the resident's MRR, dated 3/25/25, showed recommendations to discontinue the PRN use of Hydroxyzine and Lorazepam, or reorder for the specific number of days in accordance with the state and federal guidelines, that psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, then he/she should document the rationale in the resident's medical record and indicate the duration for the PRN order. The form showed no notes of the physician or provider addressing the pharmacist recommendation. Review of the resident's medical record showed no documentation of the physician or provider addressed the pharmacist's recommendation. 2. Review of Resident #62's annual MDS, dated [DATE], showed: -Intact Cognition; -Diagnoses included high blood pressure, diabetes, arthritis, fracture, anxiety disorder, depression, maniac depression (other than bipolar disorder), chronic obstruction pulmonary disease (COPD, lung disease), and respiratory failure. Review of the resident's care plan, in use during survey, showed: -Focus: Resident uses antipsychotic medications related to bipolar disorder; -Goal: Resident will reduce the use of antipsychotic medication through the review date; -Interventions: Administer antipsychotic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. Monitor/document/report any PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia (involuntary movements), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms, not usual to the person. Monitor/record occurrence for behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.), and document per facility protocol. Review of the resident's physician orders, showed an order dated 11/19/ 24, for quetiapine fumarate (antipsychotic) 25 mg. Give one tablet by mouth at bedtime related to bipolar disorder. Review of the resident's April and May's 2025 MARs, showed an order, dated 11/19/ 24, for quetiapine fumarate, 25 mg to give one tablet by mouth at bedtime related to bipolar disorder. Review of the resident's medical record, showed a monthly MRR, dated 4/25/25, resident has been taking quetiapine 25 mg at bedtime since 11/29/24 without a gradual dose reduction (GDR), could an attempt at a dose reduction at this time be done to verify if the resident was on the lowest possible dose? If not, please indicate a response. Review of the resident's medical record showed no documentation of the physician's response to the MRR, dated 4/25/25. 3. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse and Administrator said they expected the staff to notify the physician regarding the monthly MRR and make sure they document in the residents' records. They expect the staff to follow their policy for the monthly MRR.

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice when the facility failed to perform/document post-fall neurological assessment (an assessment that checks the resident's mental status, level of consciousness, pupil reaction, motor (movement) response to stimulation, and sensation) and complete post fall assessments per policy for one resident (Resident #105). The sample was 24. The census was 121. Review of the facility's Fall Management policy, date 2/28/23, showed: -An un-witnessed fall occurs when a resident is found on the floor and resident/employee is unaware how he/she got there; -Prior to moving the resident, the charge nurse will evaluate for injury; -Complete neurological evaluation post-fall on residents with potential head injury or unwitnessed fall; -Implement Post-Fall Evaluation/Documentation, all shift evaluation/documentation X72 Hours. -Potential Head Injury: charge nurse shall complete a neurological evaluation per instructions on resident's post-fall with potential head injury/unwitnessed. Review of Resident #105's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/14/25, showed: -Moderately impaired cognition; -Frequently incontinent of bowel and bladder; -Required substantial/maximal assistance (helper does more than half the effort) for activities of daily living (grooming, bathing, dressing, toileting, and transfers); -No functional limitation in range of motion (ROM); -Mobility device: wheelchair; -Diagnoses include medically complex condition. Review of the resident's care plan in use during survey, showed: -Focus: The resident is at risk for falls confusion, deconditioning, gait balance problems 3/12/25 fall, 3/24/25 fall, 3/29/25 fall, 4/17/25 fall no injury, 4/21/25 fall no injury, 4/28/25 fall no injury, 4/30/25 fall no injury, 5/13/25 fall without injury (slid out of wheelchair); -Goal: The resident will be free of minor injury through the review date; -Interventions included: -On 3/12/25, ensure personal items are within reach prior to leaving room; -On 3/24/25, bed in low position, call light within reach. Reminders to call for assistance prior to attempting to transfer or reaching for out of reach items; -On 3/29/25, room moved closer to nurses' station for closer observation; -On 4/18/25, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; -On 4/21/25, encourage and reminded to ask staff for assist with hygiene to prevent falls and maintain safety; -On 4/30/25, staff to ensure personal items are within reach; -On 5/14/25, physical therapy (PT) evaluate and treat as ordered or as needed. Review of the resident's progress notes dated 3/12/25 through 5/28/25, showed: -On 3/12/2025 at 9:30 A.M., during rounds, the nurse was informed by the certified nurse aide (CNA) that resident was on the floor after he/she slid off the bed while trying to grab some of his/her belongings from the bedside table. Assessed for potential injuries, none found. Checked for ROM, no issues, resident able to move all extremities. Neurological check done, resident alert and oriented x 3 (person, place, time), Pupils equal, round, and reactive to light and accommodation (PERRLA). Vital signs as follows: blood pressure (BP, normal was 130/80 through 90/60) 129/94, pulse (P, normal 60 through 100) 95, Respirations (R, normal 12 through 18) 19, temperature (Temp, normal 97.8 through 99.1) 97.7, Oxygen saturation (02 sat, normal 95 through 100%) 98% on room air. Assisted resident back to bed. Medical Doctor (MD)/Resident Representative (RR) notified: -Eight out of nine every shift post fall documentation, blank; -On 3/24/25 at 7:15 A.M., during shift change, the nurse was informed by the CNA (Certified Nurse Aide) that resident was on the floor after he/she slid off the bed while reaching for his/her stuff from the bedside table. Assessed for potential injuries, none found. Checked for ROM, no issues, resident able to move all extremities. Neurological check done, resident alert and oriented x 1 (person), PERRLA. Vital signs as follows: BP 118/75, P 77, R 18, Temp 98.0, 02 sat 97% on room air. Assisted resident back to bed, advised to use call light for assistance. MD/RR notified; -Eight out of nine every shift post fall documentation, blank; -On 3/29/25 at 2:37 P.M., BP 116/75, P 91, Temp 97.0, O2 sat 93% on room air, upon assessment patient observed lying on abdomen on the floor next to his/her bed. Patient was asked why he/she was lying on the floor next to his/her bed and patient stated that he/she was trying to get up and take his/ herself to the restroom. Patient was asked did he/she hit his/her head and patient stated that he/she did not. Patient was asked if he/she was in any pain and patient stated that he/she was not in any pain. patient's extremities were observed and no limitations. Patients skin was intact with no new changes. Patient's level of consciousness was intact. Patient alert and able to voice needs. Patient was assisted up from floor with two people assist and a gait belt and placed back into his/her bed patient received a shower and cleaned up and placed back in his/her bed with call light within reach and operable. MD made aware and gave orders for neurological checks. Neurological checks started and will be passed along to the oncoming nurse: -Eight out of nine every shift post fall documentation, blank; -On 4/3/25 at 8:03 A.M., patient was observed on the floor at about 2:15 this morning, by shift supervisor, patient was helped back into bed, assessment done, vitals within normal limits. Patient able to move all extremities without any facial grimace, patient did not voice any pain. MD and family member notified: -Six out of nine every shift post fall documentation, blank; -On 4/14/2025 at 4:30 A.M., on rounds resident noted on the floor at bedside. Positioned lying on his/her back. Bed in low position. No injury/abrasion noted. ROM within normal limits. Assisted back to bed without difficulty stated, I was going out. Oriented to place and time with some understanding noted. Denies any acute pain/discomfort. No acute distress noted. BP 134/81, P-93, R-18, O2 sat-98% on room air, Neurological check in place. Vital signs stable: -Eight out of nine every shift post fall documentation, blank; -On 4/17/25 at 1:30 P.M., patient's vitals obtained and noted. Neurological checks, ROM within normal limits. Patient denies pain, no apparent injuries noted, significant other, MD and Assistant Director of Nursing (ADON) made aware of fall: -Six out of nine every shift post fall documentation, blank; -On 4/21/25 at 3:30 P.M., Situation, Background, Assessment, Recommendation SBAR, is a structured communication tool used to improve communication between healthcare professionals, particularly when discussing a patient's condition or other urgent matters), showed: the change in condition/reported was falls, at the time of evaluation resident/patient vital signs was BP 137/97, P 92, R 18, Temp 97.3: -Five out of nine every shift post fall documentation, blank; -On 4/28/25 at 11:56 A.M., CNA called to go to room, resident on floor, beside his/her bed, lying supine, alert, confusion present. Active passive range of motion (APROM) done x4 extremities, denies pain, no injuries noted. MD and RR made aware. BP-121/82, P- 92, R- 20. DON made aware. At 3:32 P.M., resident remains on incident follow up (IFU) for prior fall, complains of aches all over. Tylenol given as ordered, neurological checks within normal limits for this resident, no injury noted: -Five out of six every shift post fall documentation, blank; -On 4/30/25 at 12:00 P.M., during rounds, the nurse was informed by therapist that resident was on the floor after he/she slid off the bed while reaching for his/her phone. Assessed for potential injuries, none found. Checked for ROM, no issues, resident able to move all extremities. Neurological check done, resident alert and oriented x2, PERRLA. Vital signs as follows: BP 112/83, P 82, R 19, Temp 97.8, 02 sat 97% on room air. Assisted resident back to bed, advised to use call light for assistance. MD/RR notified: -Four out of nine every shift post fall documentation, blank; -On 5/7/25 at 8:59 A.M., resident was found on the floor at approximately 8:45 this morning. His/Her vital signs are stable, and he/she did not hit his/her head and there is no bruising or skin tears at this time. MD and family informed: -Five out of nine every shift post fall documentation, blank. During an interview on 6/3/25 at 11:30 A.M., Licensed Practical Nurse (LPN) C said for unwitnessed falls, he/she would assess the resident from head to toe checking for injury, pain, a change in ROM. He/She would ask the resident what happened and document the fall. The MD would be notified and the RR. Neurological checks would be completed per the scale on the form for 72 hours. During an interview on 6/3/25 at 12:20 P.M., the Administrator said the facility did not have any of the resident's neurological check sheets. The staff documented they were done but she could not find them. The Administrator would expect for staff to follow the facility's policy for falls and if the resident had any issues notify the supervisor. During an interview on 6/2/25 at 4:15 P.M., the DON said if the resident had an unwitnessed fall, she would expect for staff to follow the facility's policies and procedures, and notify the MD, RR. During an interview on 6/3/25 at 5:25 P.M. with the ADON, Corporate Nurse and the Administrator, the Corporate Nurse said she would expect neurological checks to be completed per the facility's policy and she would expect for staff to follow the facility's policies and procedures. MO00254710

Based on interview and record review, the facility failed to ensure a resident was administered Triumeq (Abacavir-Dolutegravir-Lamivudine, a prescription medication used to treat human immunodeficiency virus (HIV, a virus that attacks the body's immune system)) as ordered (Resident #105). In addition, the facility failed to ensure the prescribing Infectious Disease (ID) physician was notified timely when the medication was not available. The facility failed to have a process in place to follow up timely on prior authorizations resulting in the resident missing multiple doses. The sample was 24. The census was 121. Review of the facility's Medication Administration - Prep and General Guidelines policy, dated 12/17, showed: -If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the Medication Administration Record (MAR) for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record; -If a vital medication is withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response; - If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed and may differ slightly from the procedures for using paper MARs. Review of the facility's Physician Orders Policy, dated last reviewed 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Physician orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners (NP) and Physician Assistants (PA)) authorized to prescribe orders; -Medications will be ordered from the pharmacy to ensure prompt delivery. Review of Resident #105's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/14/25, showed: -Moderately impaired cognition; -No behaviors or rejection of care; -Diagnoses included HIV. Review of the care plan in use at the time of survey showed: -Focus: The resident has impaired immunity related to acquired immunodeficiency syndrome (AIDS, late stage of HIV that occurs when the body's immune system is badly damaged because of the virus); -Goal: The resident will not display any complications related to immune deficiency; -Interventions included: -Encourage fluid intake and adequate rest to boost the immune system; -Monitor/document and report as needed any signs and symptoms of infection: fever; redness; drainage or swelling around wounds or catheter sites (site where a catheter enters the body); cough, respiratory symptoms; dysuria (painful urination), hematuria (blood in the urine), flank pain (discomfort felt in the body between the ribs and the hips) and foul smelling urine; -Monitor/document and report as needed abnormal laboratory values; -Monitor/document and report to the Medical Doctor (MD) signs and symptoms of delirium: changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle; -The resident is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infection away. During an interview on 5/28/25 at 3:10 P.M. and 5/30/25 at 2:25 P.M., the resident and the resident representative (RR) said the resident admitted to the facility on [DATE] and the facility did not start the Triumeq until 3/14/25. The facility went through their pharmacy to get the medication. The resident went for a doctor's appointment on 5/20/25 and had labs drawn. When the labs came back it showed the viral load (the amount of virus present in a person's blood or other bodily fluids) was over one million and the CD4 (specific type of white blood cell that plays a critical role in the immune system) was low. This should have been the opposite if the medications were being administered. The ID office tried to call the facility on 5/22/25, but they were unable to reach the nurse. PA I called the RR who told the Director of Nursing (DON), and she called the ID office. The ID office was able to get the medications covered and sent over to the facility on 5/23/25. The resident did not receive his/her medications for a month and half. The RR was told there was an issue with the insurance. The facility did not notify the RR the medications were not being administered. The facility told the RR not to bring any medications, whatever the resident needed would be provided by the facility. Review of the transfer orders for the receiving facility, dated expected discharge date [DATE], showed: -A physician order for Triumeq, take one tablet by mouth once daily; -A physician order for Triumeq, take one tablet by mouth once daily. Review of the MAR, dated 3/7/25 through 3/14/25, showed: -A physician order for Triumeq 600-50-300 mg, give two tablets via (percutaneous endoscopic gastrostomy (peg)-tube (feeding tube)) in the morning for antiviral. Order date was 3/8/25 and discontinued on 3/14/25; -On 3/8 through 3/10 and 3/12/25 staff documented NA (not administered see nurses notes); -On 3/11 and 3/13/25 staff documented as administered; -On 3/14/25 staff documented OO (out of facility); Review of the progress notes dated 3/7/25 through 3/14/25, showed: -On 3/7/25 at 8:29 P.M., resident was admitted today at 7:50 P.M. from hospital with diagnoses of AIDS and neutropenia acute respiratory failure (a serious condition where the lungs are unable to adequately oxygenate the blood). Medications verified with primary physician, no new orders; -On 3/8/25 at 11:13 A.M., Triumeq, new admit, medication on order; -On 3/9/25 at 10:12 A.M., Triumeq, new admit, medication on order; -On 3/9/25 at 11:44 A.M., Triumeq, called pharmacy regarding status, requires approval due to high cost, DON aware; -On 3/10/25 at 10:20 A.M., Triumeq, awaiting pharmacy delivery; -On 3/10/25 at 7:21 P.M., NP note, showed chief complaint: Resident was a new admit to facility. The NP did not document the medication was on order; -On 3/11/25 at 2:50 P.M., Triumeq, medication needs approval before they (the pharmacy) will send it out; -On 3/12/25 at 9:01 A.M., Triumeq, awaiting pharmacy delivery; -On 3/14/25 at 12:48 P.M., resident came back from MD appointment. Update regarding medication dosage, Triumeq one tablet once daily via gastrostomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication). MD notified; -There was no documentation showing the RR was made aware there was a gap in the medication being administered. Review of the ID office notes, showed on 3/14/25 at 3:23 P.M., the ID office called the facility on Tuesday 3/11/25 to ensure patient was receiving medications properly. Waited on call for close to two hours. Was told at that time that patient had yet to receive Triumeq. ID office attempted to call on 3/13/25 and waited on hold for approximately 40 minutes. Was unable to speak with a nurse at that time. Patient brought paperwork from facility to appointment today. According to paperwork patient began taking all medications upon admission on [DATE]. Called facility and asked to speak with a Nurse Supervisor. Nurse Supervisor pulled dispense report and reported the Triumeq was started on 3/13/25. Two tablets of Triumeq were given instead of one. Gave a verbal order to decrease dosing to one pill of Triumeq once daily. Review of the MAR, dated 3/15/25 through 3/31/25, showed: -A physician order for Triumeq 600-50-300 mg, give one tablet via peg tube in the morning for HIV; -On 3/15 and 3/30/25 staff documented NA. Review of the progress notes dated 3/15/25 through 3/31/25, showed on 3/15/25 at 8:30 A.M. and on 3/30/25 at 11:18 A.M., were left blank. Review of the ID office notes, showed, date of service 3/20/25 at 2:54 P.M., RR, called earlier this week with concerns that the resident had decompensated. According to the RR, the resident was transitioned back to nothing by mouth (NPO) as he/she was not swallowing, and he/she was unable to participate in therapy due to both physical and mental decline. Spoke with the Nurse Supervisor as well as the resident's nurse on 3/19/25. The Nurse Supervisor stated that the resident was seen on 3/18/25 by the Medical Director who did not have any concerns and did not place any new orders. Verified the resident was getting medications as prescribed. Review of the MAR dated 4/1/25 through 4/30/25, showed: -A physician order for: Triumeq 600-50-300 mg, give one tablet via peg tube in the morning for HIV; -No documentation by staff on 4/11/25; -On 4/20, 4/22 through 4/27 and on 4/30/25, staff documented NA. Review of the progress notes dated 4/1/25 through 4/30/25 showed: -On 4/11/25, there was no documentation for the medication; -On 4/20/25 at 11:22 A.M. Triumeq, on order; -On 4/21/25 at 3:07 P.M., NP in to see resident, new orders obtained, diet consult, count meal consumption for next three days and change tube feeding from continuous to on at 7:00 P.M. and off at 7:00 A.M. The note did not show the NP was aware the medication was on order; -On 4/21/25 at 6:32 P.M., NP note did not show the medication was on order; -On 4/22/25 at 3:25 P.M., Triumeq, unavailable; -On 4/23/25 at 8:08 A.M., Triumeq, drug unavailable, on order; -On 4/24/25 at 7:00 A.M., Triumeq, on order; -On 4/24/25 at 5:56 P.M., NP note did not show the medication was on order; -On 4/25/25 at 9:30 A.M., Triumeq, medication not available; -On 4/26/25 at 9:23 A.M. Triumeq, note was blank; -On 4/27/25 at 11:22 A.M., Triumeq, on order; -On 4/28/25 at 6:21 P.M., NP Notes/ Findings: Resident has an extensive past medical history. Resident seen today for compliance with medication and effectiveness of treatment, on exam today resident denies any acute findings and no acute finding noted, resident maintains Triumeq one daily; Plan: Maintain Triumeq one daily, to follow up with Infectious disease; -On 4/30/25 at 9:06 A.M. Triumeq, medication not available, on order; -Staff did not document the ID physician was notified the medication was not being administered as ordered; -Staff did not document the resident or RR were made aware the medication was not being administered. Review of the MAR dated 5/1/25 through 5/26/26, showed: -A physician order for Triumeq 600-50-300 mg, give one tablet via peg tube in the morning for HIV; -On 5/3 through 5/6, 5/8 through 5/10, 5/12, 5/17 through 5/22/25 staff documented NA; -On 5/7/25 staff left blank. Review of the progress notes dated 5/1/25 through 5/26/25, showed: -On 5/1/25 at 6:45 P.M., NP note did not show the medication was on order; -On 5/3/25 at 11:07 A.M., Triumeq, high-cost medication, n/a; -On 5/4/25 at 9:10 A.M., Triumeq, note was blank; -On 5/5/25 at 8:47 A.M., Triumeq, high-cost medication not available; -On 5/6/25 at 9:57 A.M., Triumeq, on order; -On 5/8/25 at 10:37 A.M., Triumeq, med not available; -On 5/9/25 at 8:59 A.M., Triumeq high-cost medication not available; -On 5/10/25 at 10:01 A.M., Triumeq note was blank; -On 5/12/25 at 9:19 A.M., Triumeq, high-cost medication not available; -On 5/17/25 at 8:39 A.M., Triumeq high-cost medication not available; On 5/18/25 at 9:58 A.M., Triumeq high-cost medication not available, called pharmacy regarding status, not covered by insurance, MD made aware; -On 5/19/25 at 9:01 A.M., Triumeq, high-cost medication not available; -On 5/20/25 at 9:56 A.M., Triumeq, medication not available; -On 5/21/25 at 10:43 A.M., Triumeq, high-cost medication not available; -On 5/22/25 at 10:16 A.M., Triumeq, high-cost medication not available; -Staff did not document the ID physician , the resident/RR were notified the medication was not administered. Review of the ID office notes, showed: Visit date: 5/22/25, no time was documented, Concerns were brought to our attention that patient's insurance was not covering Triumeq anymore. A script for Triumeq was sent to hospital pharmacy to look into claim and any Issues that would arise. Triumeq at hospital pharmacy: $4,676. 91 rejections for cost exceeds maximum. Requested a maximum cost override on the Triumeq. A maximum cost override would be required every single month for pharmacy benefits. Insurance cannot tell ID office what the maximum cost is or why a monthly override was needed on a chronic disease medication. The representative confirmed that there have been zero paid claims on Triumeq for 2025 under the patient's pharmacy benefits. Override was approved and pharmacy processed for $0.00. Patient's viral load came back at over 1 million. Called facility this morning at approximately 8:15 A.M. The facility was able to tell PA I Triumeq was on patient's medication list. The facility was not able to provide the ID office with a dispense report. The facility claimed there was an insurance problem and patient last received his/her Triumeq on 5/17/25. The individual on the phone asked that PA I call back to speak with the DON. Called the facility and asked to be transferred to the DON. Sent to the voice mail, left a message. Immediately called back and asked to speak with an available nurse. Was transferred which went directly to voice mail, left a message. PA I attempted to call facility to inquire about fill history and dispense report as resident's recent HIV viral load resulted as over one million. Waited on hold for 20 minutes. A nurse answered and responded I don't have time for that. I am giving hand off. Was put back on hold. Waited an additional 15 minutes prior to hanging up and calling back. Called the facility again and told the individual at the front desk that it was an urgent matter. The individual said he/she paged the DON, but didn't hear back from anyone and proceeded to hang up the phone. Called the RR with patient's test results. Explained that the results are very concerning because this means patient has been off his/her Antiretroviral therapy (ART, combination of medication that manages and suppresses HIV). RR drove to the facility, found the DON and had her call the ID office. Explained patient's test results to DON and explained that it would be PA I's assumption that the patient has been off his/her ART for over a month. This is extremely concerning due to patient's current status and recent past medical history. The prescribing physician at the ID office was not made aware of any delays or gaps in treatment. The RR was not made aware either. The DON said there was a cost concern with the drug. Stated that their physician did a peer to peer and that the drug was denied. Explained that our facility was able to send the drug to our pharmacy and that it was processed with a $0.00 co-pay. PA I would like to send a courier with the medication to ensure patient was re-started on the medication ASAP. PA I will need to know exactly how long the patient was without his/her ART. The DON said the patient last took Triumeq on 5/2/25. Requested the facility fax a fill history, complete dispense report and any documented communication regarding the drug Triumeq. The Assistant Director of Nursing (ADON) called this office at approximately 4:00 P.M. and stated the patient and RR were made aware of patient's gap in medication and were informed on multiple occasions outside medication was needed to be brought into the facility. It is noted that the patient does not have capacity at this point in time. RR stated he/she was never made aware patient was not receiving ART and in fact had noted concerns about patient's increased confusion and steps backwards. During an interview on 5/29/25 at 7:40 A.M. and 12:12 P.M., Certified Medication Technician (CMT) D said if a medication was not available, he/she would reorder the medication using the computer system. If the medication was a stock medication, he/she would go to the supply room and obtain the medication. If the medication was a prescription medication, he/she would try to obtain the medication from the emergency (e) kit. If the medication was not in the e-kit, he/she would tell the nurse, and the nurse would call the pharmacy and the doctor. The past two weeks or so, the resident had been getting his/her medication. Prior to that, the nurses were administering the medication. During an interview on 5/29/25 at 9:15 A.M., CMT G said if a medication was not available, he/she would check the stat kit. If the medication was not available in the e-kit, he/she would call the pharmacy and report it to the nurse and do what the nurse told him/her to do. During an interview on 5/29/25 at 11:50 A.M. Registered Nurse (RN) H said if a medication was not available for two doses, he/she would document it on the MAR, call the pharmacy and notify the physician. Initially the pharmacy provided the resident's medication. After that, there was an issue with the insurance. He/She placed a call to notify the doctor, but he/she could not recall if the doctor called back or if he/she passed it on to the next shift. He/She did not notify the RR because the RR came late to the facility. He/She did not know if the resident was currently receiving his/her medications or not. During an interview on 5/29/25 at 10:24 A.M. Pharmacist F said new orders are submitted to the pharmacy electronically. If a medication was not available, the facility would usually call the pharmacy, and they will trouble shoot the problem. Medications were refilled through the computer system. If a medication needed a script the facility could notify the physician themselves or call the pharmacy who would notify the physician. On 3/12/25 the pharmacy sent out the order for two tablets every morning for a 15-day supply. Triumeq was not available in the facility emergency kit (e-kit, a limited supply of medications for immediate use in case of emergencies when pharmacy services are not readily available). Pharmacist F said the resident had a second order, Triumeq one tablet every morning. The order was stuck in the prior authorization batch and was not sent out. During an interview on 5/29/25 at 10:50 A.M., PA I said she was aware there would be a delay in the facility obtaining the resident's medication initially. This was because the resident was admitted to the facility on a Friday and Triumeq was not a medication the pharmacy usually had on their shelves. The pharmacy would need to order the medication, but they would expect the medication to be at the facility by Monday or Tuesday. PA I called the facility to verify the medications had been received and was told the medication had been started. The facility never called and reported there was a gap in the resident's medication. On May 20, 2025, the residents' labs were drawn and showed his/her viral load was 1.2 million. If the resident was receiving his/her medication the viral load should be fully suppressed, but in the resident's case the viral load could be 100-200 over. As the prescribing doctor for the medication, he/she would have expected to have been notified when the medication was not administered. If the facility would have notified her the office's pharmacy access specialist, who worked with the pharmacy to get the medications, could have looked into it. Once the ID office was made aware the resident was not receiving his/her medication, the medication was delivered to the facility within a few hours. The facility said their pharmacist talked with their doctor and the pharmacy was waiting on the doctor to sign off on the medication. The doctor said she signed off on the medication. The facility said they told the resident he/she was not receiving the medication. PA I did not believe the RR was aware the resident was not receiving his/her medications because the RR knew the ID office had resources to obtain the medications. If the RR knew the resident was not receiving the medication he/she would have contacted the office. During an interview on 5/29/25 at 1:21 P.M., and on 6/3/25 at 11:10 A.M., Physician J said if a medication was not available, she would expect the nurse to call the pharmacy to find out the reason and notify the DON and to notify her. Staff could notify her after two or three missed does up to a week, depending on the medication. It was not acceptable for staff to document NA, without documenting what they did, such as calling the pharmacy. Documenting was important for better communication so the next nurse would know what had been done. The resident was admitted with Medicare A services and was supposed to discharge home. The DON called her and asked if they could change the medication to something else. Physician J told the facility to contact the ID office as she was not an HIV specialist. Another time, she spoke with the nurse who said the resident was receiving his/her medication and the ID office did not want to change the medication. Later, she was told insurance would not pay for the medication. This medication was very expensive and she did not expect for the facility to have to pay for it. It took time to submit an appeal to try to get the medication covered and/or get the resident set up with a clinic. The facility did not have to notify the ID office if they notified Physician J the resident did not receive his/her medications. Physician J would expect the staff to follow physician orders. If the viral load was one million that could indicate the resident was not receiving his/her medications, but she did not know the resident's prior viral load. The facility could have set up an appointment with ID. During an interview on 5/29/25 at 1:55 P.M., with the DON, ADON and the Administrator, the DON said if a medication was not available, staff should check the pyxis (an automated medication dispensing system) to see if the medication could be pulled and given. If the medication was not available, the nurse should call the pharmacy and notify the doctor after one missed dose. After the doctor was notified, the nurse would not have to notify the doctor for each missed dose, depending on the medication. This may be be documented. Sometimes staff did not document if the doctor or NP was at the facility. Staff should document NA for not administered on the MAR and the reason it was not administered. Notification of the RR would depend on if the resident was their own responsible party or not. The resident brought his/her own medication from home and the facility used it until they found out they could not use it. The resident's RR was going to bring in the medication, then he/she did not bring it in. The RR would say he/she was going to bring it in. The facility's doctor was working with the facility's pharmacy, and the doctor signed off on the medication. The medication was ordered from the facility's pharmacy. The RR was aware there was a delay in the resident's medication in April and that's when he/she was supposed to bring the medication in from home. On 5/8/25 the ADON said she texted the facility's doctor to update her, and the doctor said to follow up with ID office. The ADON said she talked with ID office, and they said they would pay for the medication. The medication was sent out on 5/22/25. These communications were not documented. The DON said if a resident did not receive his/her antiviral medication, she would suspect it could increase the viral load. The Administrator said the facility knew the cost of the medications when they accepted a resident. If they accepted a resident, it was their responsibility to pay for the medications. When staff documented on a high-cost medication, the computer automatically entered high-cost medication because it was prepopulated. The DON said she felt the facility did everything correct on their end. They notified the doctor, the pharmacy, the RR and ID office. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse said she would expect for the staff to follow physician orders and the facility's policies and procedures. On 5/30/25 and on 6/3/25, the surveyor requested any text messages the facility had showing the physician/ID office was notified the resident was not receiving the medication per MD order. As of 6/3/25 at 6:00 P.M. no documentation was provided.

Based on observation, interview and record review, the facility failed to follow their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to obtain a physician order for dialysis and failed to document assessments for two residents (Residents #32 and #217) and failed to ensure the blood pressure was not obtained in the same arm as the dialysis access site (e.g. arteriovenous (AV, a surgically created connection between an artery and a vein, for dialysis shunt or graft (a synthetic tube used to create the connection)) for one resident (Resident #27). The facility identified 24 residents who received dialysis services, four residents were sampled, and issues were found with three. The sample was 24. The census was 121. Review of the facility's undated Hemodialysis policy, showed: -Policy: this facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis; -The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications; -The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit (a whooshing sound heard through a stethoscope), and palpating for a thrill (a vibration felt ). If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist (kidney doctor); -The resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access device is located; -Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled. Change dressing to site only per the dialysis facility's direction. 1. Review of Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/23/25, showed: -Cognitively intact; -End stage renal disease (ESRD, chronic irreversible kidney failure); -Received dialysis while a resident. Review of the care plan, in use at the time of survey, showed; -Focus: the resident needed hemodialysis related to renal failure; -Goal: the resident will have no signs and symptoms of complications from dialysis through the review date; -Interventions: check and change dressing daily at access site. Document. During an interview on 5/28/25 at 11:23 A.M., the resident said he/she received his/her dialysis at an outside location on Tuesdays, Thursdays and Saturdays. His/Her access site was located on the right side of his/her upper chest. The facility checked his/her vital signs before dialysis, but after dialysis no one checked the resident's vital signs or the access site. Review of the physician order summary (POS), dated 5/30/25, showed: -A physician order for: Monitor right chest central venous catheter (CVC, a long flexible tube inserted into a large vein in the neck, chest, arm or groin) for signs and symptoms of infection, edema, bleeding. Inform medical doctor and call 911; -A physician order to hold medications while in dialysis. Give once a day medication upon return to the floor; -There was no physician order for dialysis. Review of the Treatment Administration Record (TAR), dated 5/1/25 through 5/31/25, showed no documentation of the status of the resident's access site upon return from the dialysis treatment or that the dialysis catheter was assessed every shift to ensure the catheter dressing was intact. Review of the progress notes, dated 5/1/25 through 5/29/25 showed no documentation of the status of the resident's access site upon return from the dialysis or the assessment of the dialysis catheter every shift to ensure the catheter dressing was intact. During an interview on 6/2/25 at 3:35 P.M., Registered Nurse (RN) H said for residents who received dialysis services, staff monitored their vital signs, the access site, urine output, if they were still urinating, intake and the bruit and thrill. This was documented on the Medication Administration Record (MAR)/TAR. When residents went for dialysis, a pre-dialysis assessment was completed and documented on the dialysis communication sheet. This sheet was sent with the resident to dialysis and the dialysis center completed their section and sent it back with the resident. The facility completed a post dialysis assessment, and documented it on the MAR. The resident should have a physician order for dialysis, and it should include the frequency the resident received dialysis. Resident #217's dialysis access cite was in his/her left arm. 2. Review of Resident #217's medical record, showed: -Alert and oriented times one to three (to person, place and time); -Had a dialysis port in left upper chest; -Diagnoses included ESRD, dependence on renal dialysis; -There was no physician order for dialysis or for checking the bruit and thrill. Review of the care plan, in use at the time of survey, showed: -Focus: the resident needs hemodialysis related to renal failure; -Goal: The resident will have immediate intervention should any signs and symptoms of complications from dialysis occur through the review date; -Interventions included: Check and change dressing daily at access site, document. Encourage resident to attend all hemodialysis treatments as ordered. Patient received hemodialysis in facility three times a week. Review of the Inpatient Discharge Summary for discharge date [DATE], showed chronic ESRD, left upper extremity fistula (a connection made between an artery and a vein for dialysis access) for dialysis access. Observation on 5/29/25 at 7:25 A.M., showed the resident in bed and wore a gown. Therapy was in the room assisting the resident with morning care. A dressing was seen on the resident's left upper arm. Therapy staff said it was the resident's dialysis access site. Review of the TAR, dated 5/24/25 through 5/31/25, showed no documentation the bruit and thrill were checked every shift or the status of the resident's access site. Review of the progress notes, dated 5/24/25 through 5/28/25, showed no documentation the bruit and thrill were checked every shift or the status of the resident's access site. 3. Review of Resident #27's annual MDS, dated [DATE], showed: -Cognitively intact; -Special treatment: dialysis; -Diagnoses included ESRD, heart failure, high blood pressure, high cholesterol and diabetes mellitus. Review of the resident's care plan, in use during the survey, showed: -Focus: The resident has a diagnosis of chronic renal failure (slow decline in renal function), and receives hemodialysis. He/She is at risk for complications. The resident receives hemodialysis three times weekly on Tuesdays, Thursdays, and Saturdays at 9:00 A.M., -Goal: The resident will be transported to dialysis on time as scheduled; -Intervention: Maintain no blood pressures, IMs (intramuscular, referring to an injection directly into a muscle), or IVs (injection directly into the vein) to shunt extremity. Ensure No blood draws from access site (other than from dialysis staff). Review of the resident's POS, showed an order, dated 12/1/22 for the resident to receive dialysis on Tuesdays, Thursdays, and Saturdays with a pick up time at 10:00 A.M. Review of the resident's blood pressures taken from 4/1 through 4/30/25, showed: -The resident's blood pressure taken 16 out of 24 opportunities in the resident's right arm; -The resident's blood pressure taken eight out of 24 opportunities in the resident's left arm. Review of the resident's blood pressures taken from 5/1 through 5/31/25 showed: -The resident's blood pressure taken 11 out of 21 opportunities in the resident's right arm; -The resident's blood pressure taken 10 out of 21 opportunities in the resident's left arm. 4. During an interview on 6/2/25 at 3:45 P.M. and 6/3/25 at 11:30 A.M., Licensed Practical Nurse (LPN) C said the nurse completed the pre-dialysis assessment and documented it on the dialysis communication form. The form was sent with the resident to dialysis and dialysis would complete their portion and send it back with the resident. Once the resident returned to the facility, LPN C checked the resident's blood pressure to be sure it did not drop and documented it on the dialysis communication sheet and under vital signs tab in the computer. Documentation for the bruit and thrill and checking the dialysis access site was documented on the MAR. Residents who received dialysis needed a physician order. During an interview on 6/3/25 at 3:00 P.M., RN M said the dialysis center did the post weight. After dialysis, staff should check the bandages on the fistulas and a resident's blood pressure to determine if it was low. 5. During an interview on 6/2/25 at 4:15 P.M., the Director of Nursing (DON) said the nurses did a pre-dialysis assessment and documented it on the dialysis communication form and the form was sent with the resident to dialysis. The dialysis center completed their section and sent it back to the facility. If the dialysis center did not send the form back, the facility would call the dialysis center. If something was out of the ordinary, the dialysis center was good about calling the facility. The facility did not do a post assessment unless there was something out of the ordinary documented on the communication form. The bruit and thrill along with the monitoring of the access site were documented on the skilled therapy form. Residents should have a physician order for dialysis. 6. During an interview on 6/3/25 at 5:20 P.M. and 5:25 P.M., the Corporate Nurse said residents who receive dialysis services should have a physician order for dialysis. They did not want the dressing to the access sites changed daily. She expected staff to follow physician orders and follow the facility policies and procedures. The Corporate Nurse also said blood pressures should not be taken on the same arm where the dialysis port was located for dialysis residents.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were followed up on for the final accounting within 30 days for residents who expired. This affected two of two sampled residents who expired and had money in their resident trust account. (Residents #267 and #268). The census was 121. 1. Review of Resident #267's resident trust fund account, showed: -Resident expired on [DATE]; -A balance of $8297.87; -TPL completed and mailed [DATE]. 2. Review of Resident #268's resident trust fund account, showed: -Resident expired on [DATE]; -A balance of $2798.79; -TPL completed and undated time of mailing. 3. During an interview on [DATE] at 2:30 P.M., the Regional Business Office Manager and the Business Office Manager said they just sent the TPL letters for both residents on [DATE]. They were aware the letters were required to be sent within 30 days of a residents' death. The Business Office employee, who was responsible for sending out the letters, was terminated last week. Prior to that, they did not have someone in the department since January. The Business Office Manager was not involved in sending TPLs after a resident's death. 4. During an interview on [DATE] at 5:25 P.M., the Administrator said TPL forms should be sent within 30 days of a resident's death.

Based on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left medication in one resident's room. (Resident #105). In addition, an inhaler was observed at the bedside table of a resident who did not have a physician order for self-administration or for medications to be left at the bedside. (Resident #62) . The sample was 24. The census was 121. Review of the facility's Self-Administration of Medications policy, dated 12/17, showed: -Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. -For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition; -Similar reviews of administration technique is conducted for other dosage forms such as inhalers, sublingual (udner the tongue) tablets, eye drops, injections, etc.; -The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered. 1. Review of Resident #105's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/14/25, showed: -Moderately impaired cognition; -No functional limitation in range of motion in the upper extremities; -Diagnoses include medically complex condition. Review of the care plan in use at the time of survey, showed staff did not address if the resident could self-administer his/her medications. Review of the medical record, showed there was no self-administer assessment competed and there was not a physician order for the resident to self-administer his/her medications. Observation and interview on 6/2/25 at 4:45 A.M., showed the resident was awake lying in bed playing on his/her phone. On the over bed table next to the resident was a cup of water and a small clear medication cup with two white round pills and one oval pill inside. The resident said if he/she was doing something, the nurse would say here are your meds and I would say okay. Observation on 6/2/25 at 5:20 A.M., showed the cup with the medications in it was gone. The resident said the medications were thrown away. Observation of the trash can in the room showed there was no medications in the trash. During an interview on 6/3/25 at 2:00 P.M., Certified Medication Technician (CMT) D said medications should not be left at the bedside. The resident can pour the medications into his/her mouth himself/herself, but staff should stay with him/her until the medications were taken. 2. Review of Resident #62's annual MDS, dated [DATE], showed: -admitted to facility on 7/5/23; -No cognitive impairment; -Diagnoses included hypertension (HTN, high blood pressure), diabetes mellitus (DM, metabolic disease), arthritis, other fracture, anxiety disorder, depression, maniac depression (other than bipolar disorder), chronic obstruction pulmonary disease (COPD, lung disease), and respiratory failure. Review of the resident's care plan, in use at the time of survey, showed no documentation the resident was assessed as able to self-administer his/her medications or take his/her medications without supervision. Review of the resident's medical record showed no self-administration of medication assessment. Review of the resident's electronic physician order summary for May 30, 2025, showed: -No order for a self-administration of medication assessment; -No order for the resident to self-administer medications. Observation and interview on 5/28/25 at 12:36 P.M. showed the resident lying in bed with his/her eyes opened. An Albuterol Sulfate Aerosol HFA inhaler was lying on his/her bedside table. He/She said it was an emergency inhaler. He/She wasn't sure if the facility staff were aware that he/she had the inhaler or not. 3. During an interview on 6/2/25 at 4:15 P.M., the Director of Nursing said residents who self-administer their medications should have a self-administration assessment completed, and they would need a physician order to self-administer their medications. This would be documented on their care plan. Staff should not leave medications at the bedside. The DON would expect for staff to follow the facility's policies and procedures. 4. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse said residents who self-administer their medications need a physician order.

Based on observation, interview and record review the facility failed to provide care consistent with professional standards of practice, when staff failed to timely administer or document treatment orders and failed to document a description of the wounds on admission for one resident. (Resident #215). The sample was 24. The census was 121. Review of the facility's Wound Management Policy, dated 11/15/22, showed: Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Charge nurse will notify physician in the absence of treatment orders; -Wound characteristics/documentation: -Location of the wound pressure injury & stage; -Size (Shape, Depth, Tunneling and/or Undermining). Volume & Exudate (drainage) characteristics; -Pain evaluation; -Presence of infection/bioburden. -Condition of the wound bed & wound edges. condition of the peri-wound (area around the wound); -Treatments will be documented on the Treatment Administration Record (TAR). Review of the facility's Skin Integrity policy, dated 7/5/24, showed: Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity. Review of the facility's Nursing Admission/readmission Checklist, undated, showed: Complete skin assessment and initial wound user defined assessment (UDA). Interdisciplinary team (IDT) documentation should include notifying the medical doctor (MD), resident representative (RR) and Registered Dietitian (RD), of skin condition, preventative measures in treatment regimen. Review of Resident #215's baseline care plan dated 5/10/25, showed, note all skin issues was blank. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 5/13/25, showed: -admission date was 5/9/25; -Cognitively intact; -No behaviors or rejection of care; -Diagnoses included: anemia (decrease in number of red blood cells), heart failure, high blood pressure, diabetes, paraplegia (paralysis of the legs and lower body), renal failure; -Number of unstageable-deep tissue: suspected deep tissue injury (DTI) in evolution: Two, present on admission; -Number of Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough (dead tissue separating from living tissue) or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining (wound open underneath the border of the wound) and tunneling (a deep, narrow channel that extends from the surface of a wound into the underlying tissues)): One, present on admission. Review of the care plan in use at the time of survey, showed: -Focus: The resident was admitted to facility with DTI to bilateral heels and a healing Stage IV to sacrum (a triangular bone at the base of the spine) related to immobility; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date; -Interventions included: Administer treatments as ordered and monitor for effectiveness. During an interview on 5/22/25 at 7:51 A.M., Physician P said the resident's main wound was located on his/her sacrum. The wound had been present since April 2025. When the resident was discharged to the facility and subsequently returned to the hospital, the ulcer was quite a bit larger. They could see via imaging that the infection had spread deeper. The resident would require six weeks of Intravenous (IV, administered into a vein) antibiotics. There was a lot of dead necrotic (dead) tissue on top of the wound bed. The resident would be undergoing surgical debridement (a procedure that involves the removal of dead or damaged tissue from a wound). Review of the hospital discharge summary for date of services 5/9/25, showed: Pertinent Consultations and Follow up Recommendations: Wound care, patient needs follow up for Stage IV sacral pressure ulcer. Recommend cleanse with wound cleanser or normal saline. Recommend apply triad (wound dressing) twice daily and as needed. Leave open to air or cover with secondary dressing. Air seat cushion for pressure injury on sacrum. Review of the progress notes dated 5/9/25 through 5/15/25, showed: -On 5/9/25 at 6:18 P.M., Alert and oriented times three (person, place and time). Skin: normal color, texture, no rashes or lesions; -On 5/10/25 at 10:09 P.M., 5/12/25 at 3:10 A.M., 5/15/25 at 1:09 A.M. and 5/16/25 at 2:42 A.M., Skilled evaluations: Skin, left blank. Review of the Wound Care Team notes, dated 5/13/25, showed: -Chief complaint: Resident presents with wounds on his/her sacrum, right heel and left heel; -Unstageable DTI of the right heel, undetermined thickness; -Wound size: 5.1 length by (X) 6 (width) by not measured (depth) centimeters (cm) -Treatment plan: Betadine, gauze sponge sterile and wrap with gauze roll and tape every two days and as needed if saturated, soiled or dislodged; -Unstageable DTI of the left heel undetermined thickness; -Wound size: 5 X 5.5 X not measured cm; -Treatment plan: Betadine, gauze sponge sterile and wrap with gauze roll and tape every two days and as needed if saturated, soiled or dislodged; -Stage IV pressure wound sacrum full thickness; -Wound size: 4.9 X 7 X not measured cm. Depth is unmeasured due to presence of nonviable tissue and necrosis; -Treatment Plan: Hypochlorous acid solution apply twice daily and as needed if saturated, soiled, or dislodged. Gauze sponge sterile apply twice daily and as needed if saturated, soiled or dislodged. Gauze island with bordered gauze (bdr) apply twice daily as needed if soiled. -Surgical excisional debridement, remove thick adherent eschar and devitalized tissue (no longer living), remove necrotic tissue and establish the margins of viable tissue. Additional note: Post debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level (connection tissue), which had been obscured by necrosis prior to this point. This wound has now revealed itself to be Stage IV pressure injury. This is not a wound deterioration. Review of the resident's progress notes, showed on 5/15/25 at 9:37 P.M., seen by wound care team this week, new orders received and implemented to the TAR. RR and physician made aware will continue with new plan. Review of the physician order sheet, dated active as of 5/17/25, showed: -A physician order for wound consult as needed to evaluate and treat, start date was 5/10/25; -A physician order for unstageable DTI right heel, cleanse with wound cleanser, air/pat and dry, add betadine gauze sponge sterile wrap with gauze every two days and as needed for wound care. Start date was 5/15/25; -A physician order for unstageable DTI left heel, cleanse with wound cleanser, air/pat and dry, add Betadine (antiseptic) gauze sponge sterile wrap with gauze every two days and as needed for wound care. Start date was 5/15/25; -A physician order for pressure wound sacrum cleanse with wound cleanser, air/pat dry, skin prep to peri wound (the area of skin surrounding a wound), add wet to dry dressing (a type of wound dressing where saline-soaked gauze is placed in the wound, allowed to dry, and then removed) with Hypochlorous Acid Solution (antimicrobial) solution twice daily and as needed cover with island gauze dressing, if saturated, soiled, or dislodged for wound care. Start date was 5/16/25. Review of the progress notes dated 5/17/25 through 5/20/25, showed: -On 5/17/25 at 10:40 A.M., Skilled skin evaluation: Skin warm and dry, skin color within normal limits and turgor is normal; -On 5/19/25 at 4:52 P.M. Resident was sent to the hospital; -Staff did not document any description of the wounds upon admission. Review of the TAR, dated 5/9/25 through 5/20/25, showed -A physician order for Stage IV sacral pressure ulcer. Cleanse with wound cleanser or normal saline. Apply Triad(a sterile protective coating designed to be applied directly from the tube on to broken skin and/or the wound without the need of a secondary dressing) twice a day (BID) and as needed. Leave open to air or cover with secondary dressing. Every evening shift for wound care, start date was 5/10/25 and discontinued on 5/11/25; -No documentation for 5/10 and 5/11/25; -A physician order for unstageable sacral pressure ulcer, cleanse with wound cleanser or normal saline, skin prep to peri wound, apply Xeroform (petrolatum-impregnated gauze dressing), Calcium Alginate (wound dressing) cover with foam dressing everyday shift and as needed for wound care start date 5/13/25, discontinued on 5/15/25; -Staff documented the treatment was completed once daily. -A physician order for pressure wound sacrum cleanse with wound cleanser, air/pat dry, skin prep to peri wound, add Wet to Dry dressing with Hypochlorous Acid Solution twice daily and as needed cover with island gauze dressing, if saturated, soiled, or dislodged for wound care, start date was 5/16/25; -No documentation on 5/17/25 at 8:00 P.M. through 11:00 P.M.; -A physician order for unstageable DTI Right Heel, cleanse with wound cleanser, air/pat and dry, add betadine gauze sponge sterile wrap with gauze every two days and as needed, start date was 5/15/25 -No documentation on 5/15 and 5/17/25. On 5/19/25, staff documented OO (out of facility); -A physician order for unstageable DTI Left Heel, cleanse with wound cleanser, air/pat and dry, add Betadine Gauze sponge sterile wrap with Kerlix (a brand of gauze bandage rolls widely used in wound care) every two days and as needed, start date was 5/15/25; -No documentation on 5/15 and 5/17/25. On 5/19/25, staff documented OO; -A physician order for pressure wound sacrum cleanse with wound cleanser, air/pat dry, skin prep to peri wound, add Wet to Dry dressing with Hypochlorous Acid Solution twice daily and as needed cover with island gauze dressing, if saturated, soiled, or dislodged for wound care, start date was 5/16/25; -No documentation on 5/17/25 at 8:00 P.M. through 11:00 P.M. Review of the progress notes dated 5/13/25 through 5/19/25, showed no documentation the treatment was changed or the physician was made aware there was a delay in the treatment being administered per physician order. During an interview on 6/2/25 at 5:18 A.M. Licensed Practical Nurse (LPN) K said the nurses on the floor were responsible for completing the treatments. Treatments are documented on the TAR. During an interview on 6/3/25 at 11:30 A.M., LPN C said when a resident was admitted to the facility usually one nurse would do the paperwork (enter all the orders into the computer and set up follow up appointments, etc.) and the other nurse completed the head-to-toe body assessment and vital signs. The skin assessments were documented in the computer under skin observation tool. There was a human diagram on the skin assessment and the nurse would document the location of any wounds and define what the issue was from the drop-down box . LPN C would describe what the wound looked like, the location, the stage and note if there was any tunneling. The physician would be notified, and orders would be obtained if the resident did not have orders from the hospital. The resident would be seen by the Wound Doctor on her next visit. When treatments were completed, they should be documented on the TAR. A blank on the TAR meant it was not done. During an interview on 6/2/25 at 8:45 A.M., the Wound Nurse said the floor nurses were responsible for providing the wound care. She scheduled the treatments and rounded weekly with the Wound Doctor. She was responsible for the weekly wound documentation. If the floor nurses noted a new wound or a change in the resident's wounds, they would notify her, and she would obtain the treatment orders. Or, whoever found the wound or change in the wound could call the physician and obtain orders. If the nurse was unable to complete a treatment, they would pass it on to the next shift or if she was at the facility they could notify her. Then, she would complete the treatment. The nurse should document on the TAR when the treatment was completed. If the treatment was not completed it should be documented and the reason why wound care was not provided. A blank on the TAR meant the treatment was not done. If NA (not applicable) was documented, the treatment still needed to be completed. During an interview on 6/2/25 at 4:15 P.M., the Director of Nursing (DON) said the facility did not always receive the discharge paperwork from the hospital at the time residents were admitted . A skin assessment should be completed on admission by the floor nurse. Any nurse could do a skin assessment. The Wound Nurse would see the resident the next day she was in the facility. The nurse should document a description of what the wound looked like. The nurses did not stage or measure wounds. If the resident came to the facility with a treatment order, the nurse should enter the treatment into the computer. If the resident did not have a treatment order, the Wound Nurse would see the resident the next day and call the physician to get an order. The floor nurse could also call the physician and get a treatment order. The facility had protocols in place for treatments until the resident could be seen by the Wound Doctor. The Wound Doctor visited the facility weekly. A blank on the TAR meant the item was not addressed. Staff should document if the treatment was administered or enter a code if it was not administered. The DON did not know why the resident's sacrum treatment was not documented as administered until 5/13/25 or why his/her heel treatments were not documented as administered until 5/19/25. The DON would expect for staff to follow the physician orders and the facility policies and procedures. During an interview on 6/3/25 at 4:28 P.M., the Wound Doctor said if a resident was admitted to the facility or a wound was found between her visits to the facility, the nurse should notify the facility's Wound Nurse and notify the resident's physician to obtain treatment orders. She visited the facility weekly, and her notes were uploaded into the facility computer system. The Wound Nurse and the DON had access to her notes. The Wound Doctor only saw the resident once and she ordered a simple dressing change to his/her heels to be changed every two days. The resident had a large necrotic area on his/her sacrum, and she order the dressing to be changed twice daily. The Wound Doctor was not aware the wound on the resident's sacrum was not documented until 5/13/25 or that there was no documentation for his/her heels until 5/19/25. The Wound Doctor would expect for staff to follow the physician orders and the facility's policies and procedures. During an interview on 6/3/25 at 5:25 P.M., the Corporate Nurse said when the facility received report from the hospital, the hospital would notify staff if the resident had a wound. If the resident did not have a treatment for the wound, the Wound Nurse would obtain the order. A description of the wound should be documented, which would include measurements, the stage of the wound, location and the type of treatment. A blank on the TAR meant staff did not check it off or they did not do the treatment. She would expect for staff to follow physician orders and follow the facility policies and procedures. MO00254618

See Event ID 0WE512. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/18/24. Based on interview and record review, the facility failed to ensure staff were readily available to respond to residents' needs as evidenced by not answering call lights timely. One resident, with a history of bypass surgeries (Resident #24) was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. Emergency Medical Services (EMS) responded but could not find facility staff until they found one staff member curled up on the couch asleep. The resident was admitted to the hospital with atrial fibrillation (a-fib, abnormal heart rhythm characterized by a rapid and irregular heartbeat). Another resident (Resident #25) was returning from the hospital with EMS at the same time that Resident #24 was having chest pains and that EMS crew could not find staff readily available. In addition, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). The sample was 30. The census was 118.

See Event ID 0WE512. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. When EMS responded, they were unable to find facility staff, until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time Resident #25 was having chest pains and that EMS crew also could not find staff readily available. In addition, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118.

See Event ID 0WE512. Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. The facility also failed to provide fresh ice water to three residents (Resident #31, #46 and #45). The census was 118.

Based on observation, interview and record review, the facility failed to follow their policy by failing to ensure residents received care consistent with professional standards. Staff failed to follow physician orders and perform wound treatments for three of three residents sampled (Residents #10, #8 and #1). The facility also failed to assess a resident at the time of admission for one of three sampled residents (Resident #18). The census is 129. Review of the facility Wound Management policy, last reviewed on 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Procedure: Wound Management: -Wound treatment will be provided in accordance with physician's orders: Cleansing method, type of dressing and frequency of dressing change; -Charge Nurse will notify physician in the absence of treatment orders; -Wound dressings will be applied in accordance with manufacturer's recommendations; -Wound Characteristics/Documentation: Location of the wound. Size (shape, depth, tunneling and/or undermining), volume and drainage characteristics. Pain evaluation. Condition of the wound bed. Condition of the peri-wound (skin surrounding the wound); -Guidelines for Dressing Selection: Obtain physician's order; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of the treatments will be monitored through ongoing evaluation of the wounds. Review of the facility Physician Orders policy, last reviewed on 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Responsibility: Licensed Nursing, Administration, and Director of Nursing (DON); -Procedure: Orders must be recorded in the medical record by the Licensed Nurse authorized to transcribe such orders. Physician orders must be documented clearly in the medical record. Physician orders must be documented clearly in the medical recorded. Physician orders will be transcribed to the appropriate administration record electronic medication administration record (eMAR) or electronic treatment administration record (eTAR). Review of the facility's Admission/Readmission Assessment policy revised 1/24/19, showed; -Policy: Residents are to be evaluated upon admission or readmission; -Procedure: Complete the section for skin. Review of the Licensed Practical Nurse (LPN) job description, revised 5/2022, showed: Essential Functions of LPN: Assesses and documents the resident's condition and nursing needs. Performs treatments for assigned residents. Documents treatments as required. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/21/24, showed: -admitted [DATE]; -Diagnoses included high blood pressure, peripheral vascular disease (lack of blood flow to the legs), diabetes, high cholesterol and stroke; -Cognitively intact; -Wounds. Review of the resident's eTAR, dated September 2024, showed: -An order, dated 9/7/24, at 3:00 P.M., both lower extremities cleanse with wound cleanser, apply betamethasone valerate 0.1% ointment (a steroid that treats inflammation), cover with silicone dressing gauze and wrap with kerlix (gauze) every evening shift, every other day; -On 9/15/24 the treatment was documented as completed. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's treatment to both lower extremities. Observation on 9/16/24 at 6:52 A.M., showed the resident lay in bed. The resident said the dressings on his/her legs were not being done like the doctor said. The resident pulled the cover back and there were three dressings: left knee dated 9/14, dressing to right lower extremity dated 9/14 and left lower extremity dated 9/14. Certified Nursing Assistant (CNA) C read the dates on the dressing and confirmed the dates. Observation on 9/17/24 at 6:59 A.M., showed the resident lay in bed. The resident said the nurse came in and changed his/her dressings that morning around 5:30 A.M. The resident pulled the covers back and all three dressings were dated for 9/16. Observation on 9/17/24 at 3:49 P.M., showed the resident informed the wound doctor and wound nurse the dressing had not been changed on schedule. The wound nurse said the date showed 9/16, but the resident said the dressings were done that morning around 5:30 A.M. Observation on 9/18/24 at 8:08 A.M., showed the resident lay in bed. He/She reiterated the dressings were changed yesterday morning, and he/she remembered the nurse's name. During an interview on 9/18/24 at 8:15 A.M., LPN D said he/she changed the dressings on the resident the morning of 9/17/24, but could not recall the time. During an interview on 9/18/24 at 12:22 P.M., LPN E said dressings should be done as ordered by the physician and should be dated and initialed when the dressing was applied. During an interview on 9/18/24 at 1:22 P.M., the DON said the expectation was the nurses performed wound dressing changes as ordered to, initialed and dated the dressing when completed, and document the treatment had been completed. 2. Review of Resident #8's admission face sheet, showed: -admitted [DATE]; -Diagnoses of cellulitis (a bacterial skin infection) of left lower limb, malignant (cancerous) melanoma (skin cancer) of the left lower limb, high blood pressure and renal (kidney) disease. Review of the resident's skin observation tool, located in the electronic medical record (EMR), showed: -Date: 9/9/24 at 3:25 P.M., and Lock Date 9/16/24 at 3:30 P.M.: No documentation about a skin tear on the resident's left wrist/hand area. Review of the resident's progress note, located in the EMR, showed on 9/12/24 at 11:58 P.M., LPN G documented the resident slid to the floor onto his/her bottom while attempting to ambulate with walker to the restroom. Resident stated he/she became weak and slid to the floor. Zero complaints of pain or discomfort upon assessment. The documentation did not show the resident sustained any injuries as a result of the incident. Observation on 9/16/24 at 7:03 A.M., showed the resident lay in bed with a dressing on his/her left wrist/hand. The dressing was dated 9/12/24. The resident said the skin tear occurred when he/she fell a few days ago. No one had changed the dressing since 9/12/24. Review of the resident's Physician's Order Summary (POS) and TAR on 9/17/24, showed no order for a skin tear to the resident's left wrist/hand. During an interview on 9/17/24 at 10:35 A.M., LPN G said the resident fell on [DATE], and obtained a skin tear on his/her left wrist/hand. He/She cleaned the skin tear, applied a dressing and wrote the date 9/12 on the dressing. He/She should have contacted the physician and got an order and entered the order on the POS and TAR. LPN G got busy and forgot. The resident was admitted to the hospital yesterday and was not available for observation of the skin tear. During an interview on 9/18/24 at 12:47 P.M., the DON said LPN G should have assessed the resident's skin tear, called the physician, obtained an order and entered the order on the POS and TAR. All of that should have been documented. Normally a skin tear treatment would be ordered to be changed daily. If the order was not entered on the TAR, the EMR system would not alert the nurses to change the dressing. 3. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Diagnoses of Alzheimer's Disease, anxiety disorder and depression. Review of the resident's POS, showed: -An order dated 8/24/24, to cleanse right lateral forearm, clean with wound cleanser. Apply A&D ointment (a skin protectant that helps treat and/or prevent diaper rash/chapped skin) and wrap with kerlix, change every other day; -An order dated 8/29/24, to right proximal (located close/nearby) posterior (located behind) leg, clean with wound cleanser. Apply A&D ointment and wrap with kerlix, change dressing every other day. Review of the resident's TAR, showed the treatments initialed as completed every other day. Observation on 9/16/24 at 7:05 A.M., showed the resident had an undated dressing to the right lower extremity and right upper extremity. During an interview on 9/18/24 at 12:22 P.M., LPN E said dressings should be done as ordered by the physician and should be dated and initiated when the dressing is applied. During an interview on 9/18/24 at 1:22 P.M., the DON said the expectation was for nurses to perform wound dressing changes as ordered and initial and date the dressing when completed, and document the treatment had been completed. 4. Review of Resident #18's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact. Review of the resident's medical record, showed diagnoses included hip fracture, high cholesterol, diabetes and anxiety disorder. Review of the resident's admission nursing assessment, dated 9/5/24, showed no assessment of a surgical wound to the right hip. Review of the resident's POS, showed no order for a dressing to the surgical incision to the right hip. Review of the resident's telephone hospital discharge summary to the nurse, not dated, showed: -Gauze dressing as needed; -Bruising to the right leg. Observation and interview on 9/16/24 at 6:52 A.M., showed the resident had an undated dry dressing to the right hip. The dressing appeared to be old and the tape was soiled. The resident said that he/she did ask the nurses about the dressing this morning because he/she had a follow up with the orthopedic surgeon today. The response from the nurse was to let the doctor remove the dressing. Observation and interview on 9/16/24 at 7:14 A.M., showed the resident had an undated dry dressing to his/her right hip. The dressing appeared to be old and the tape was soiled. The resident said the nurses had not changed the dressing since he/she arrived at the facility. During an interview on 9/18/24 at 12:22 P.M., LPN E said a resident should be assessed from head to toe during an admission assessment and any dressings or surgical wounds should be noted on the assessment. If a resident has a dressing in place during the assessment and there is no order, the nurse should call the doctor for clarification. Surgical wounds should be assessed daily for drainage and infection. During an interview on 9/18/24 at 1:22 P.M., the DON said the expectation is the nurses perform a complete skin assessment when a resident admits to the facility. The nurses should note any dressings and wounds and clarify with the physician for treatment orders. Surgical wounds should be looked at daily and documented. MO00240093 MO00241424 MO00241889

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect. Facility staff failed to provide prompt and adequate incontinence care. Four out of four sampled residents, who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), were observed with two incontinence briefs on, both of which were saturated and with strong odors of urine and feces. Three residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take several hours for staff to answer call lights. Additionally, facility staff neglected to respond to a call light for one resident, with a history of bypass surgeries (Resident #24) who was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. Emergency Medical Services (EMS) responded but could not find facility staff until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time that Resident #24 was having chest pains and that EMS crew could not find staff readily available. Additionally, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118. 1. Review of Resident #34's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/31/24, showed: -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheelchair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers; and -At risk for pressure ulcers. -Diagnoses included stroke, heart failure, and diabetes mellitus. Review of the resident's Braden Scale, dated 7/31/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast. Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder. Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -A strong odor of urine emitting from the room into the hall. -The resident lay in his/her bed on a low air loss mattress. -Registered Nurse (RN) D pulled the resident's bed covers down to show the resident wore two briefs. -The resident's outer brief was soaked with urine, with the padding in the brief in clumps. -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24 at 4:35 A.M., RN D said: -He/She did not think the resident was changed over the night shift. -He/She verified the resident wore two briefs, both soaked with urine, and lay in urine extending up to his/her shoulders. During an interview on 10/28/24 at 5:49 A.M., Certified Nurse Aide (CNA) E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day. -He/She was the only CNA assigned to care for the resident on the hall. -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care. -He/She had just provided incontinence care to the resident. -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident lay on a wet absorbent pad before he/she gave the resident incontinence care. 2. Review of Resident #33's admission MDS, a federally mandated assessment instrument completed by facility staff, dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Eating, oral hygiene, upper body dressing: Partial moderate assistance; -Always incontinent of bowel and bladder; -Risk of pressure ulcers, yes; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 9/4/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's current care plan, showed: -Focus: Activities of daily living (ADLs, bathing, toileting, dressing, etc.) self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; -Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date; -Interventions: -Assist resident to bathroom as desired/indicated, offer toileting before meals, after meals and at bedtime; -Clean peri-area with each incontinence episode; -Focus: Resident has the potential for impaired skin integrity; -Goal: Resident will maintain or develop clean and intact skin by the review date; -Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. During an observation and interview on 10/28/24 at 4:23 A.M., RN D said residents do not get changed often on night shift because there isn't enough staff to get everything done. The resident lay in bed on his/her right side. RN D pulled the white quilt back and pulled the resident's sweatpants down, showing the resident had two briefs on. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with urine and dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. During an observation and interview on 10/28/24 at 5:54 A.M., with CNA E and Assistant Director of Nursing (ADON) M, CNA E said the resident takes himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it from the resident and pulled the resident's sweatpants down, showing the resident had two briefs on. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident has the outer brief over the pull up because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she was walking down the hall because the resident takes himself/herself to the bathroom. CNA E said he/she glanced/peeked at the resident when he/she was walking down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees and the resident's shirt was wet up to his/her waist below his/her elbows. CNA E walked and guided the resident to the bathroom. Once CNA E entered the bathroom, there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet and then had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet and the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. During an interview on 10/28/24 at 6:05 A.M., CNA E said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident was walking the halls last night; -CNA E checked for incontinence by peeking in the resident's brief and by touching the resident's brief on the outside of his/clothes on his/her lower buttocks. If the CNA felt the brief was hard that meant the resident was incontinent and needed care. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. ADON M said it is inappropriate to feel the resident's brief through his/her clothing while they are walking down the hall to see if the resident is soiled. ADON M expected staff to provide privacy and to visually check the residents brief to see if the resident is soiled. It is inappropriate to place a brief on top of a pull up to prevent a resident from removing the pull up. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition. -Wheelchair for locomotion. -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed. -Dependent on staff for chair/bed-to-chair transfers. -Always incontinent of bowel and bladder. -At risk for pressure ulcers. -Moisture Associated Skin Damage (MASD) present. -Pressure reducing device for bed. -Diagnoses included morbid obesity, depression, anxiety, metabolic encephalopathy (chemical imbalance in the blood that affects brain function) and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility. Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections. Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility. Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Observation on 10/28/24 at 4:50 A.M., showed: -A strong odor of urine and bowel movement emitting from the room into the hall. -The odor of urine and feces was so strong upon entry into the room, the surveyor's eyes burned. -The resident lay in his/her bed on a low air loss mattress. -The resident wore two briefs which were soaked with urine. -The resident lay on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine. -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine-soaked areas. -The resident wore a hospital gown that was also urine soaked. -The resident had dried feces on his/her buttocks and inside of the inner brief. -The resident's mattress was visibly wet with urine. -The resident's bilateral buttocks were reddened. -The resident's inner thighs were reddened. During an interview on 10/28/24 at 4:52 A.M. and at 5:06 A.M., the resident said: -He/She had not received incontinence care since the evening before around 6:00 P.M. (eleven hours). -The staff did not usually provide incontinence care during the night shift. -Lying in a pool of urine on the wet sheet was annoying to the resident. -He/She did not like wearing two briefs at once, as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24 at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected Moisture Associated Dermatitis (MASD). -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24 at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M. -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care. -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time. -He/She only put two briefs on residents if they asked for them. -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet. -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff. -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. During observation and interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time early this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had two briefs on. The resident said it depends on what staff changes him/her if they put one or two briefs on. The resident said it seems like they put two on all the time. The resident said he/she is changed and repositioned one time each shift and said he/she needed changed and repositioned more often. When he/she turns his/her call light on, it takes an hour to an hour and a half before staff respond to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid that had approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had two briefs on and the briefs were soaked with urine. RN D said it is not appropriate for any resident to have two briefs on. If a resident has two briefs on, the staff might think the resident is dry by only looking at the outer brief. If residents are left soiled for an extended period of time, it can cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., showed: -The resident wore two briefs which were both visibly soaked with urine. -He/She did not like to wear two briefs, as they were uncomfortable, were too tight between his/her legs and cut into his/her groin. Review of the resident's weekly skin assessment, dated 10/29/24 at 12:01 P.M., showed the resident had redness at his/her buttocks and groin. 4. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting and personal hygiene: substantial maximal assistance; -Shower transfer, dependent; -Frequently incontinent of bladder; -Always incontinent of bowel; -Risk of pressure ulcers, yes; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day (almost 12 hours). The resident said he/she had not been changed all night. The resident had two briefs on. The inner brief was brown and was saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she does not like to be soiled for extended periods of time. The resident also said his/her family gets ice water for him/her on the days they are at the facility. On days the family is not at the facility, he/she does not get offered ice water. Observation and interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., showed: -There was a cup with approximately 4 inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -He/She was last checked on by staff around 6:00 A.M. that morning and he/she was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup, as that sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident lay on an absorbent pad that was saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings which extended up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J, who was sitting in the hallway, and asked CNA J who had the resident. CNA J said the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. ADON M said it was not appropriate for a resident to not be changed from 10:00 P.M. until 6:30 A.M. the following day. Night shift starts at 11:00 P.M. and the resident was not changed for the entire night shift. ADON M said he/she spoke to the night shift charge nurse and CNA J was the CNA responsible for completing rounds and changing the resident. ADON M said he/she did not have an opportunity to speak with CNA J before he/she left. ADON M said CNA J reported to ADON M that the resident was on another CNA's assignment. ADON M said he/she expected staff to be knowledgeable of and follow the facility' policies. ADON M expected staff to make rounds on the residents every two hours and know what residents they are responsible for each shift. 5. Review of Resident #31's quarterly MDS, dated [DATE], showed the resident: -Cognitively intact. -Rejection of care not exhibited. -Frequently incontinent of bowel and bladder. -At risk for pressure ulcers. -Diagnoses included need for assistance with personal care, abnormalities of gait and mobility, muscle weakness and reduced mobility. Review of the resident's current care plan, showed: -Focus: ADL self-care performance deficit. -Goal: Resident requires assistance with ADL care and mobility. -Interventions: -Bed mobility requires staff assistance to turn and reposition in bed. -Toilet use requires staff assistance of one. -Transfer requires staff assistance of one. -Encourage use of call light. During an interview on 10/28/24 at 8:08 A.M., the resident said staff do not come in and offer to change him/her when he/she is soiled. The resident said he/she must get out of bed and change himself/herself and put the soiled briefs in the trash can next to his/her bed. The trash was just changed and was overflowing with soiled briefs and the staff member who came in and took the trash, threw a fit wanting to know why all the briefs were in the trash can. The resident then became tearful and said he/she is doing the best he/she can. The resident said it would be helpful if the staff would assist him/her in changing his/her brief when he/she is soiled but said staff will not assist him/her because there was not enough staff. The resident said it takes up to two hours for staff to answer his/her call light, if they come at all. The resident said staff do not pass or offer ice water. The resident said he/she has a small green cooler he/she keeps on his/her walker and the resident fills this small cooler up himself/herself. 6. Review of Resident #43's annual MDS, dated [DATE], showed: -Adequate hearing. -Clear speech - distinct intelligible words. -Makes Self Understood: Understood. -Ability To Understand Others: Understands - clear comprehension. -Cognitively intact. -Always incontinent of bowel and bladder. -Diagnoses of anxiety and depression. Review of the resident's current care plan, showed: -11/9/21: Focus -ADL self-care performance deficit. Goal - Resident requires assistance with ADL care and mobility. Interventions: Personal hygiene, one assist. Toilet use, utilize check and change to manage incontinence; -10/23/24: Focus - Frequently incontinent bowel and bladder. Goal - Will remain free from skin breakdown. Interventions: Incontinent - Check and change for incontinence. During an interview on 10/30/24 at 7:47 A.M., the resident said he/she is incontinent of bowel and urine. Most nights, staff check him/her for incontinence one time, which is not enough. Staff tell him/her there is not enough help to check him/her more than once. If he/she turns on his/her call light, it can take hours for staff to answer it, or they will answer it, turn the call light off, then leave without taking care of him/her. It makes him/her feel bad when he/she is left wet for long periods. 7. Review of Resident #44's annual MDS, dated [DATE], showed: -Adequate hearing. -Clear speech - distinct intelligible words. -Makes Self Understood: Understood. -Ability To Understand Others: Understands - clear comprehension. -Cognitively intact. -Always incontinent of bowel and bladder. -Diagnoses of anxiety and depression. Review of the resident's current care plan, showed: -8/22/23: Bladder incontinence related to impaired mobility. Goal: Will remain from skin breakdown due to incontinence and brief use. Interventions: Check as required for incontinence. During an interview on 10/30/24 at 7:37 A.M., the resident said he/she is incontinent of bowel and bladder. Most night shifts, staff will check and change him/her twice at the most, sometimes only once, and in the past couple of weeks, there had been some nights no one came to check him/her at all. When he/she is checked once or not at all, he/she lays in a puddle of urine. Most nights, he/she is unable to turn on his/her call light because staff do not leave the call light where he/she can reach it. When the call light is in reach and he/she turns it on, it can take hours for someone to answer it. He/She feels ignored by staff. 8. Review of Resident #24's electronic medical record (EMR), showed: -Diagnoses of high blood pressure and a-fib. -A progress note, dated 9/27/24 at 3:47 A.M., and documented by Licensed Practical Nurse (LPN) N: This nurse was notified that resident called 911 stating he/she was having chest pain. His/Her chest felt like it was filling with water. EMS arrived asking resident why he/she did not turn on his/her call light for this nurse to evaluate him/her. Resident stated he/she just wanted to go to the hospital. Resident transferred to stretcher going to hospital for evaluation. No signs or symptoms noted. Review of the staffing schedule for the night shift of 9/26/24 (the shift started at 11:00 P.M. on 9/26/24 and ended at 7:00 A.M. on 9/27/24), showed one nurse working on the two units on the first floor where Resident #24 resided. Review of the resident's Des [NAME] Department of Public Safety report (EMS/ambulance report) dated 9/27/24, showed: -911 Caller: Resident #24. -Alarm: 3:15 A.M. Dispatched: 3:17 A.M. Arrived: 3:21 A.M. -3:34 A.M.: Had to wake up staff to locate the resident. -3:36 A.M.: Caller (resident) states he/she has been having chest pains for 45 minutes. -3:37 A.M.: Attempted to contact staff two times no answer to locate resident's room number. -3:38 A.M.: EMS has been on the scene for over 10 minutes at the front door. -3:40 A.M.: Staff was contacted a third time and finally picked up. Dispatch advised that DSFD (Des [NAME] Fire Department) was on scene and ambulance was there for over 10 minutes. Staff was asked to check a resident name for a room number. They advised they would have to go downstairs and look for it. -Narrative: Upon arrival, observed Resident #24 laying supine (on the back) in bed. The resident could speak without deficit and appeared to be stable. The resident advised he/she was having substernal (behind the breastbone) chest pain that did not radiate for approximately and hour and a half. Resident advised he/she tried to call staff for approximately one hour however, no one would answer his/her call light. It should be noted, staff was found sleeping in the hallway wrapped in blankets sleeping and other staff members coming in from their vehicles in the parking lot. An ECG was conducted at which time A-fib was observed. The resident was provided with 324 milligram aspirin orally. During transport (to the hospital) no changes in the resident's vitals were observed. -Call closed at 4:12 A.M. During an interview on 9/27/24 at 7:29 A.M., Emergency Medical Technician (EMT) AA said they had been at the facility for 10 minutes and could not find any staff. Dispatch called the facility and did not get an answer. Upon entrance to the facility, several call lights were flashing and there was no staff in sight. While walking around trying to find the resident's room, the paramedics saw a someone curled up on the couch, asleep. Resident #24 said he/she yelled for help for 10 minutes. When they didn't respond, he/she called 911. Two staff eventually appeared, and several staff were seen exiting their cars and returning to the building. The lights were off at the nurse's station and one of the staff had to restart the computer to get the resident's face sheet. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she worked on the night shift of 9/26/24. He/She worked on the same floor, but not the same unit where the resident resided. During that shift EMS was in the building and said they had been looking for staff because the resident had called them and said he/she was having chest pain. He/She also saw a policeman in the building at the same time EMS was in the building. He/She was not sleeping on duty and did not see other staff sleeping. 9. Review of Resident #25's EMR, showed: -admission date of 9/8/24. -Diagnoses of syncope (fainting), vertigo (light headed/dizziness), A-fib and cognitive communication deficit; -A progress noted dated 9/26/24 at 8:36 P.M.: Resident complained of feeling like he/she did when he/she had a brain bleed. He/She said he/she wants to go to the hospital for evaluation. Physician and DON notified. -A progress note dated 9/27/24 at 3:37 A.M.: Resident returned from hospital. Family arrived with resident. During an interview on 9/27/24 1:50 P.M., Family Member (FM) MM said he/she arrived at the facility from the hospital on 9/27/24 at 3:30 A.M. The Des [NAME] Police Department (PD) and ambulance were in the building. The paramedic said they had been walking around trying to find staff and the resident who called the police for 20 minutes. There were call lights going off. Another resident was having chest pain, had his/her call light on, and when no one answered it, he/she called 911. FM M walked around with the paramedics for an additional 20 minutes before staff came out of a dark room. During an interview on 10/31/24 at 8:17 A.M., the Director of Nursing (DON) said no one told her the paramedics and police could not locate staff when they responded to Resident #24's emergency call or when Resident #25 returned to the facility. No one told her a staff member was found sleeping by the EMS crew. If they would have called her, she would have come in at that time and began an investigation as to why the staff could not be found and why a staff member was sleeping on duty. 10. Review of Resident #20's EMR, showed: -admission date of 9/9/24. -Diagnoses included: Heart failure, below the knee amputation (BKA) of right leg and diabetes mellitus. Review of the resident's progress notes, showed: -On 9/11/24, at 7:15 P.M., Fire and Ambulance arrived, making nurse aware 911 had been called for the resident's room. This nurse approached room noting this resident in bathroom on toilet. Two EMTs entered the restroom to assess resident. Resident stated he/she would like to be transported to ED for eval for pain. Resident left facility at this time remaining alert and able to make needs known. During an interview on 9/27/24 at 12:09 P.M., EMT AA said EMS was dispatched to the facility on Labor Day weekend and staff were seen sleeping. The residents were complaining they had not received their medication. The agency staff said there was not a nurse in the building, and they didn't pass meds, because the residents were new admits and they had not received their meds from the pharmacy. Review of the resident's hospital ED records, showed: -Arrival Date/Time: 9/11/24 at 6:20 P.M -Chief Complaint: [TRUNCATE

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. When EMS responded, they were unable to find facility staff, until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time Resident #25 was having chest pains and that EMS crew also could not find staff readily available. In addition, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118. Review of the Facility Assessment, dated 8/2/24, showed: -Purpose: The Facility Assessment is a complete review of the internal human and physical resources required by the facility to care for residents competently during day to day (including nights and weekends) and emergency operations. The facility assessment identifies your capabilities as a skilled nursing services provider. The Facility Assessment will be the basis for surveyors to ascertain whether your are prepared to competently take care of the population you have identified that you serve; -There are three components to the review: -1. Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethic/cultural/religious factors that impact care; -2. Services and care offered based on resident needs; -3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, and education and training; -The assessment is not intended to be a static tool but is intended to be a living document. It should include the business plan, staffing plan, the types of resident served, and the resources and physical plant required to competently care for the identified populations; -People Involved in Completing: Administrator, Director of Nursing (DON), Maintenance Director, Human Resources/Payroll Director, Activities Supervisor, Social Services Director and Medical Director; -Resident Profile: Average daily census - 120-130; -Special Treatments and Conditions (a daily average): Radiation - 0-2, Oxygen Therapy - 20-30, Suctioning - 0-5, Tracheostomy Care - 0-5, Behavioral Health Needs (including wandering, aggression, anxiety, depression, socially inappropriate) - 50-60, Active or Current Substance Use Disorders - 15-25, Intravenous (IV) Medications - 10-15, Injections - 20-30, Advanced Wound Care Needs - 10-20, Dialysis - 10-20, Ostomy Care - 0-5, Hospice Care - 0-10, and Isolation or Quarantine for Active Infectious Disease - 0-20; -Assistance with Activities of Daily Living (ADLs): Bed Mobility Sit to Lying - Supervision/Partial/Moderate Assist (86 residents) and Dependent/Maximum Assist (15), Mobility Sit to Stand - Supervision/Partial/Moderate Assist (92) and Dependent/Maximum Assist (19), Bathing - Supervision/Partial/Moderate Assist (96) and Dependent/Maximum Assist (34), Transfers - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (14), Eating - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (6), Toileting - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (12); -Current Staff on Payroll: Licensed Nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)) 20-28, Nurse Aides (Certified Nursing Assistants (CNAs)) 30-40, Other nursing personnel (e.g., Administrative Duties) 7; -The assessment did identify how many nurses and/or CNAs were needed to provide prompt and adequate care by shift (day shift 7:00 A.M. - 3:00 P.M., evening shift 3:00 P.M. - 11:00 P.M. and night shift 11:00 P.M. - 7:00 A.M.). Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care. Incontinent care will include a skin evaluation of the resident; promoting hygiene and skin prevention with infection/irritation; -Responsibility: Nursing Assistant, Licensed Nurses, Nursing Administration, Infection Control Preventionist and Director of Nursing. Review of the facility's CNA job description, revised 1/2024, showed: -Facilitates all care and service in a friendly customer-driven approach; assures Residents are treated with dignity and respect at all times; -Provides for activities of daily living by assisting with serving meals; feeding Residents as necessary; and ambulating, turning. and positioning Residents; toileting assistance; and providing fresh water and nourishment between meals; -Provides Residents with hygiene supports including nail care, light hair or other grooming, oral hygiene, bathing, and incontinence care; -Follows all company policies and procedures. 1. Observation during the initial tour of the facility on 10/28/24 at 4:00 A.M., showed two nurses on duty (one nurse was assigned to the two units downstairs, and one nurse was assigned to the two units upstairs) and five CNAs on duty (two CNAs assigned downstairs and three CNAs assigned upstairs). Review of the facility census report, dated 10/27/24, showed the following: -Joliet (downstairs unit): 22 residents; -[NAME] (downstairs unit): 38 residents; -[NAME] (upstairs unit): 31 residents; -Tranquility (upstairs unit): 27 residents. During an interview on 10/28/24 at 4:10 A.M., RN D said: -He/She worked the night shift from 11:00 P.M. until 7:00 A.M. last night; -There were only two CNAs for 58 residents and one nurse during his/her shift; -He/She did not feel the residents were getting appropriate care as there was not enough staff to care for them and the residents were neglected; -He/She did not feel the staffing ratio to residents was safe for the employees or the residents; -Sometimes it took them over an hour to answer call lights and the residents were left wet for all that time because there were so many residents who required two people for direct care. During an interview on 10/28/24 at 5:17 A.M., and 5:30 A.M., CNA F said he/she began work yesterday around 11:00 P.M. He/She worked on one of the two upstairs units. He/She was the only CNA working that unit, which is not unusual. It was difficult to give care to all his/her residents last night due to the lack of staff. If it's just him/her working, he/she cannot check the residents every two hours or answer the call lights timely. He/She can only check the residents two times at the most. When there are two CNAs on the unit, he/she is able to check the residents every two hours and is able to answer the call lights more promptly. During an interview on 10/28/24 at 6:13 A.M., Assistant Director of Nursing (ADON) M said there should be three to four CNAs working upstairs and downstairs on night shift and there should be one to two nurses upstairs and downstairs for night shift. ADON M said he/she was on call last night and did not receive any calls regarding staffing concerns. ADON M said he/she was not aware the facility only had one nurse upstairs and downstairs and two CNAs upstairs and downstairs. ADON M said if staff would have contacted him/her, he/she would have come into the facility to assist or would have given staff extra directions. ADON M said if the facility does not have the appropriate amount of staff, it could cause a deficit to resident care. During an interview on 10/30/24 at 7:00 A.M., CNA K said he/she worked the day shift, 7:00 A.M. until 3:00 P.M. When he/she started to get residents ready after first arriving on duty, it was not uncommon to find several residents wearing two incontinent briefs soaked through with urine. This occurred several times a week. He/She did not think those residents could possibly have been checked and changed every two to three hours. He/She had not told the nurses because it would not do any good. During an interview on 10/30/24 at 7:22 A.M., CNA F said night shift is from 11:00 P.M. to 7:00 A.M. and rounds are completed two times before 5:00 A.M. When he/she comes in at 11:00 P.M., he/she makes rounds with the evening shift CNA. During rounds, CNA F checks to see if the resident needs ice water, remote, call light, see if the residents need changed or taken to the bathroom and to make sure the residents are breathing. If a resident has on two briefs, it is not good for the resident because the outer brief can look dry and the inner brief could be wet. CNA F would be reluctant to change them if the resident looked dry. If residents are not changed, it can cause them to get red bottoms or bed sores. CNA F said when there is only one CNA on each side and one nurse, it takes a long time to answer call lights. CNA F said if four to five call lights are on, he/she will quickly go to each person with a call light on to make sure there is not an emergency like they are slipping off the bed or have fallen. CNA F will then start changing the first resident who had the call light on. It takes up to 20 minutes to change one resident because he/she has to go to the room see what he/she needs, then go to the clean utility closet and get supplies, and then go back to the resident's room to clean and change the resident. CNA F said it can take up to an hour and forty minutes to answer a call light at times. CNA F said sometimes when you go back to the resident who had the call light on, they have called 911 and say nobody was answering their call light. CNA F said sometimes staff on night shift will fall asleep and when it happens the first time, they are given a warning. If it happens a second time, they would get fired. CNA F said sometimes when sitting in a chair if it is quiet at night, staff can doze off but it does not happen often. If a resident is a two person assist, then CNA F has to go and find another staff member to assist and the resident has to wait on care to be provided. During an interview on 10/30/24 at 7:27 A.M., CNA L said he/she worked the day shift. When he/she reported to work, he/she started to get residents ready for the day. He/She frequently found residents heavily saturated in urine. Sometimes, some residents wore two incontinence briefs, and they were saturated with urine. He/She did not feel those residents could possibly have been checked for incontinence every two hours. During an interview on 10/30/24 at 11:30 A.M., the Administrator said based on current resident acuity levels identified in the Facility Assessment, the facility needs the following number of staff on the midnight shift: -One nurse on all four units for a total of 4 nurses; -Three CNAs for the two units downstairs (one on each unit and to one split between the two units); -Four CNAs on the two units upstairs (two on each unit) for a total of seven CNAs on night shift. Four nurses and seven CNAs total are needed to ensure residents receive appropriate care in a timely manner. There should always be at least one staff member on each unit at all times. Review of the facility nursing staffing reports (staff in/out time punches) for the midnight shifts from 10/14/24 through 10/29/24, showed the facility failed to provide the Administrator's expected staffing (four nurses) on the following dates: 10/16, 10/17, 10/18, 10/19, 10/21, 10/22, 10/23, 10/24, 10/25 and 10/27/24. Review of the facility nursing staffing reports for the midnight shift from 10/14/24 through 10/29/24, showed the facility failed the Administrator's expected staffing (seven CNAs) on the following dates: 10/14, 10/16, 10/18, 10/19, 10/23, 10/24, 10/25, 10/26, 10/27 and 10/28/24. During an interview on 10/31/24 at 6:09 A.M., LPN A said he/she worked the night shift last night. He/She was the only nurse working the two downstairs units. There is supposed to be one nurse for each unit. If he/she is covering just one unit, he/she can get everything done even if something unexpected happens. If he/she is covering both units, he/she can get everything done, but it may not be timely. If something unexpected happens while he/she is covering two units, he/she may not be able to get everything done. It is not too often that three CNAs are scheduled for the two downstairs units. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. 2. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Eating, oral hygiene, upper body dressing: Partial moderate assistance; -Always incontinent of bowel and bladder; -Risk of pressure ulcers, yes; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 9/4/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's current care plan, showed: -Focus: Activities of daily living (ADLs, bathing, toileting, dressing, etc.) self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; -Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date; -Interventions: -Assist resident to bathroom as desired/indicated, offer toileting before meals, after meals and at bedtime; -Clean peri-area with each incontinence episode; -Focus: Resident has the potential for impaired skin integrity; -Goal: Resident will maintain or develop clean and intact skin by the review date; -Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. During an observation and interview on 10/28/24 at 4:23 A.M., RN D said residents do not get changed often on night shift because there isn't enough staff to get everything done. The resident lay in bed on his/her right side. RN D pulled the white quilt back and pulled the resident's sweatpants down, showing the resident had two briefs on. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with urine and dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. During an observation and interview on 10/28/24 at 5:54 A.M., with CNA E and ADON M, CNA E said the resident takes himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it from the resident and pulled the resident's sweatpants down, showing the resident had two briefs on. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident has the outer brief over the pull up because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she was walking down the hall because the resident takes himself/herself to the bathroom. CNA E said he/she glanced/peeked at the resident when he/she was walking down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees and the resident's shirt was wet up to his/her waist below his/her elbows. CNA E walked and guided the resident to the bathroom. Once CNA E entered the bathroom, there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet and then had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet and the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. CNA E did not change the resident during the night shift. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. - this interview is listed under #1. During an interview on 10/28/24 at 6:05 A.M., CNA E said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident was walking the halls last night. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheelchair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers; -At risk for pressure ulcers; -No skin issues present; -Pressure reducing device for bed; -Diagnoses included stroke, heart failure, and diabetes mellitus. Review of the resident's Braden Scale, dated 7/31/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast. Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder. Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -There was a strong odor of urine emitting from the room into the hall; -The resident lay in his/her bed on a low air loss mattress; -RN D pulled the resident's bed covers down to show the resident wore two briefs; -The resident's outer brief was soaked with urine, with the padding in the brief in clumps; -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24 at 4:35 A.M., RN D said: -He/She did not think the resident was changed over the night shift; -He/She verified the resident wore two briefs, both soaked with urine, and lay in urine extending up to his/her shoulders. During an interview on 10/28/24 at 5:49 A.M., CNA E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day; -He/She was the only CNA assigned to care for the resident on the hall; -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care; -He/She had just provided incontinence care to the resident; -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident lay on a wet absorbent pad before CNA E gave the resident incontinence care. 4. Review of Resident #45's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Moderately impaired cognition; -Wheelchair for locomotion; -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed; -Dependent on staff for chair/bed-to-chair transfers; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -Moisture Associated Skin Damage (MASD) present; -Pressure reducing device for bed; -Diagnoses included morbid obesity, depression, anxiety, metabolic encephalopathy (chemical imbalance in the blood that affects brain function) and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility. Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections. Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility. Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Observation on 10/28/24 at 4:50 A.M., showed: -There was a strong odor of urine and bowel movement emitting from the room into the hall; -The odor of urine and feces was so strong upon entry into the room, the surveyor's eyes burned; -The resident lay in his/her bed on a low air loss mattress; -The resident wore two briefs which were soaked with urine; -The resident lay on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine; -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine soaked areas; -The resident wore a hospital gown that was also urine soaked; -The resident had dried feces on his/her buttocks and inside of the inner brief; -The resident's mattress was visibly wet with urine; -The resident's bilateral buttocks were reddened; -The resident's inner thighs were reddened. During an interview on 10/28/24 at 4:52 A.M. and at 5:06 A.M., the resident said: -He/She had not received incontinence care since the evening before around 6:00 P.M.; -The staff did not usually provide incontinence care during the night shift; -Lying in a pool of urine on the wet sheet was annoying to the resident; -He/She did not like wearing two briefs at once, as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24 at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected Moisture Associated Dermatitis (MASD); -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24 at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M.; -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care; -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time; -He/She only put two briefs on residents if they asked for them; -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet; -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff; -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. Review of the resident's weekly skin assessment, dated 10/28/24 at 12:43 P.M., showed there was no documentation found of skin issues at the resident's buttocks or groin. During observation and interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time in the early this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had two briefs on. The resident said it depends on what staff changes him/her if they put one or two briefs on. The resident said it seems like they put two on all the time. The resident said he/she is changed and repositioned one time each shift and said he/she needed changed and repositioned more often. When he/she turns his/her call light on, it takes an hour to an hour and a half before staff respond to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid that had approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had two briefs on and the briefs were soaked with urine. RN D said it is not appropriate for any resident to have two briefs on. If a resident has two briefs on, the staff might think the resident is dry by only looking at the outer brief. If residents are left soiled for an extended period of time, it can cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., showed: -The resident wore two briefs which were both visibly soaked with urine; -He/She did not like to wear two briefs, as they were uncomfortable, were too tight between his/her legs and cut into his/her groin. Review of the resident's weekly skin assessment, dated 10/29/24 at 12:01 P.M., showed the resident had redness at his/her buttocks and groin. 5. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting, shower, upper and lower body dressing, put on and take off footwear, personal hygiene, and roll left and right: substantial maximal assistance; -Shower transfer, dependent; -Frequently incontinent of bladder; -Always incontinent of bowel; -Risk of pressure ulcers, yes; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. Review of the resident's forms list on 10/31/24 at 12:44 P.M., showed no Braden assessment completed for the resident in 2024. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day. The resident said he/she had not been changed all night. The resident had two briefs on. The inner brief was brown and was saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she does not like to be soiled for extended periods of time. The resident also said his/her family gets ice water for him/her on the days they are at the facility. On days the family is not at the facility, he/she does not get offered ice water. Observation and interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., showed: -There was a cup with approximately 4 inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -He/She was last checked on by staff around 6:00 A.M. that morning and he/she was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup, as that sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident lay on an absorbent pad that was saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings which extended up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J, who was sitting in the hallway, and asked CNA J who had the resident. CNA J said the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. ADON M said it was not appropriate for a resident to not be changed from 10:00 P.M. unit 6:30 A.M. the following day. Night shift starts at 11:00 P.M. and the resident was not changed for the entire night shift. ADON M said he/she spoke to the night shift charge nurse and CNA J was the CNA responsible for completing rounds and changing the resident. ADON M said he/she did not have an opportunity to speak with CNA J before he/she left. ADON M said CNA J reported to ADON M that the resident was on another CNA's assignment. ADON M said he/she expected staff to be knowledgeable of and follow the facility' policies. ADON M expected staff to make rounds on the residents every two hours and know what residents they are responsible for each shift. During an interview on 10/2

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. When EMS responded, they were unable to find facility staff, until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time Resident #25 was having chest pains and that EMS crew also could not find staff readily available. In addition, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118. Review of the Facility Assessment, dated 8/2/24, showed: -Purpose: The Facility Assessment is a complete review of the internal human and physical resources required by the facility to care for residents competently during day to day (including nights and weekends) and emergency operations. The facility assessment identifies your capabilities as a skilled nursing services provider. The Facility Assessment will be the basis for surveyors to ascertain whether your are prepared to competently take care of the population you have identified that you serve; -There are three components to the review: -1. Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethic/cultural/religious factors that impact care; -2. Services and care offered based on resident needs; -3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, and education and training; -The assessment is not intended to be a static tool but is intended to be a living document. It should include the business plan, staffing plan, the types of resident served, and the resources and physical plant required to competently care for the identified populations; -People Involved in Completing: Administrator, Director of Nursing (DON), Maintenance Director, Human Resources/Payroll Director, Activities Supervisor, Social Services Director and Medical Director; -Resident Profile: Average daily census - 120-130; -Special Treatments and Conditions (a daily average): Radiation - 0-2, Oxygen Therapy - 20-30, Suctioning - 0-5, Tracheostomy Care - 0-5, Behavioral Health Needs (including wandering, aggression, anxiety, depression, socially inappropriate) - 50-60, Active or Current Substance Use Disorders - 15-25, Intravenous (IV) Medications - 10-15, Injections - 20-30, Advanced Wound Care Needs - 10-20, Dialysis - 10-20, Ostomy Care - 0-5, Hospice Care - 0-10, and Isolation or Quarantine for Active Infectious Disease - 0-20; -Assistance with Activities of Daily Living (ADLs): Bed Mobility Sit to Lying - Supervision/Partial/Moderate Assist (86 residents) and Dependent/Maximum Assist (15), Mobility Sit to Stand - Supervision/Partial/Moderate Assist (92) and Dependent/Maximum Assist (19), Bathing - Supervision/Partial/Moderate Assist (96) and Dependent/Maximum Assist (34), Transfers - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (14), Eating - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (6), Toileting - Supervision/Partial/Moderate Assist (105) and Dependent/Maximum Assist (12); -Current Staff on Payroll: Licensed Nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)) 20-28, Nurse Aides (Certified Nursing Assistants (CNAs)) 30-40, Other nursing personnel (e.g., Administrative Duties) 7; -The assessment did identify how many nurses and/or CNAs were needed to provide prompt and adequate care by shift (day shift 7:00 A.M. - 3:00 P.M., evening shift 3:00 P.M. - 11:00 P.M. and night shift 11:00 P.M. - 7:00 A.M.). Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care. Incontinent care will include a skin evaluation of the resident; promoting hygiene and skin prevention with infection/irritation; -Responsibility: Nursing Assistant, Licensed Nurses, Nursing Administration, Infection Control Preventionist and Director of Nursing. Review of the facility's CNA job description, revised 1/2024, showed: -Facilitates all care and service in a friendly customer-driven approach; assures Residents are treated with dignity and respect at all times; -Provides for activities of daily living by assisting with serving meals; feeding Residents as necessary; and ambulating, turning. and positioning Residents; toileting assistance; and providing fresh water and nourishment between meals; -Provides Residents with hygiene supports including nail care, light hair or other grooming, oral hygiene, bathing, and incontinence care; -Follows all company policies and procedures. 1. Observation during the initial tour of the facility on 10/28/24 at 4:00 A.M., showed two nurses on duty (one nurse was assigned to the two units downstairs, and one nurse was assigned to the two units upstairs) and five CNAs on duty (two CNAs assigned downstairs and three CNAs assigned upstairs). Review of the facility census report, dated 10/27/24, showed the following: -Joliet (downstairs unit): 22 residents; -[NAME] (downstairs unit): 38 residents; -[NAME] (upstairs unit): 31 residents; -Tranquility (upstairs unit): 27 residents. During an interview on 10/28/24 at 4:10 A.M., RN D said: -He/She worked the night shift from 11:00 P.M. until 7:00 A.M. last night; -There were only two CNAs for 58 residents and one nurse during his/her shift; -He/She did not feel the residents were getting appropriate care as there was not enough staff to care for them and the residents were neglected; -He/She did not feel the staffing ratio to residents was safe for the employees or the residents; -Sometimes it took them over an hour to answer call lights and the residents were left wet for all that time because there were so many residents who required two people for direct care. During an interview on 10/28/24 at 5:17 A.M., and 5:30 A.M., CNA F said he/she began work yesterday around 11:00 P.M. He/She worked on one of the two upstairs units. He/She was the only CNA working that unit, which is not unusual. It was difficult to give care to all his/her residents last night due to the lack of staff. If it's just him/her working, he/she cannot check the residents every two hours or answer the call lights timely. He/She can only check the residents two times at the most. When there are two CNAs on the unit, he/she is able to check the residents every two hours and is able to answer the call lights more promptly. During an interview on 10/28/24 at 6:13 A.M., Assistant Director of Nursing (ADON) M said there should be three to four CNAs working upstairs and downstairs on night shift and there should be one to two nurses upstairs and downstairs for night shift. ADON M said he/she was on call last night and did not receive any calls regarding staffing concerns. ADON M said he/she was not aware the facility only had one nurse upstairs and downstairs and two CNAs upstairs and downstairs. ADON M said if staff would have contacted him/her, he/she would have come into the facility to assist or would have given staff extra directions. ADON M said if the facility does not have the appropriate amount of staff, it could cause a deficit to resident care. During an interview on 10/30/24 at 7:00 A.M., CNA K said he/she worked the day shift, 7:00 A.M. until 3:00 P.M. When he/she started to get residents ready after first arriving on duty, it was not uncommon to find several residents wearing two incontinent briefs soaked through with urine. This occurred several times a week. He/She did not think those residents could possibly have been checked and changed every two to three hours. He/She had not told the nurses because it would not do any good. During an interview on 10/30/24 at 7:22 A.M., CNA F said night shift is from 11:00 P.M. to 7:00 A.M. and rounds are completed two times before 5:00 A.M. When he/she comes in at 11:00 P.M., he/she makes rounds with the evening shift CNA. During rounds, CNA F checks to see if the resident needs ice water, remote, call light, see if the residents need changed or taken to the bathroom and to make sure the residents are breathing. If a resident has on two briefs, it is not good for the resident because the outer brief can look dry and the inner brief could be wet. CNA F would be reluctant to change them if the resident looked dry. If residents are not changed, it can cause them to get red bottoms or bed sores. CNA F said when there is only one CNA on each side and one nurse, it takes a long time to answer call lights. CNA F said if four to five call lights are on, he/she will quickly go to each person with a call light on to make sure there is not an emergency like they are slipping off the bed or have fallen. CNA F will then start changing the first resident who had the call light on. It takes up to 20 minutes to change one resident because he/she has to go to the room see what he/she needs, then go to the clean utility closet and get supplies, and then go back to the resident's room to clean and change the resident. CNA F said it can take up to an hour and forty minutes to answer a call light at times. CNA F said sometimes when you go back to the resident who had the call light on, they have called 911 and say nobody was answering their call light. CNA F said sometimes staff on night shift will fall asleep and when it happens the first time, they are given a warning. If it happens a second time, they would get fired. CNA F said sometimes when sitting in a chair if it is quiet at night, staff can doze off but it does not happen often. If a resident is a two person assist, then CNA F has to go and find another staff member to assist and the resident has to wait on care to be provided. During an interview on 10/30/24 at 7:27 A.M., CNA L said he/she worked the day shift. When he/she reported to work, he/she started to get residents ready for the day. He/She frequently found residents heavily saturated in urine. Sometimes, some residents wore two incontinence briefs, and they were saturated with urine. He/She did not feel those residents could possibly have been checked for incontinence every two hours. During an interview on 10/30/24 at 11:30 A.M., the Administrator said based on current resident acuity levels identified in the Facility Assessment, the facility needs the following number of staff on the midnight shift: -One nurse on all four units for a total of 4 nurses; -Three CNAs for the two units downstairs (one on each unit and to one split between the two units); -Four CNAs on the two units upstairs (two on each unit) for a total of seven CNAs on night shift. Four nurses and seven CNAs total are needed to ensure residents receive appropriate care in a timely manner. There should always be at least one staff member on each unit at all times. Review of the facility nursing staffing reports (staff in/out time punches) for the midnight shifts from 10/14/24 through 10/29/24, showed the facility failed to provide the Administrator's expected staffing (four nurses) on the following dates: 10/16, 10/17, 10/18, 10/19, 10/21, 10/22, 10/23, 10/24, 10/25 and 10/27/24. Review of the facility nursing staffing reports for the midnight shift from 10/14/24 through 10/29/24, showed the facility failed the Administrator's expected staffing (seven CNAs) on the following dates: 10/14, 10/16, 10/18, 10/19, 10/23, 10/24, 10/25, 10/26, 10/27 and 10/28/24. During an interview on 10/31/24 at 6:09 A.M., LPN A said he/she worked the night shift last night. He/She was the only nurse working the two downstairs units. There is supposed to be one nurse for each unit. If he/she is covering just one unit, he/she can get everything done even if something unexpected happens. If he/she is covering both units, he/she can get everything done, but it may not be timely. If something unexpected happens while he/she is covering two units, he/she may not be able to get everything done. It is not too often that three CNAs are scheduled for the two downstairs units. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. 2. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Eating, oral hygiene, upper body dressing: Partial moderate assistance; -Always incontinent of bowel and bladder; -Risk of pressure ulcers, yes; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 9/4/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's current care plan, showed: -Focus: Activities of daily living (ADLs, bathing, toileting, dressing, etc.) self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; -Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date; -Interventions: -Assist resident to bathroom as desired/indicated, offer toileting before meals, after meals and at bedtime; -Clean peri-area with each incontinence episode; -Focus: Resident has the potential for impaired skin integrity; -Goal: Resident will maintain or develop clean and intact skin by the review date; -Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. During an observation and interview on 10/28/24 at 4:23 A.M., RN D said residents do not get changed often on night shift because there isn't enough staff to get everything done. The resident lay in bed on his/her right side. RN D pulled the white quilt back and pulled the resident's sweatpants down, showing the resident had two briefs on. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with urine and dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. During an observation and interview on 10/28/24 at 5:54 A.M., with CNA E and ADON M, CNA E said the resident takes himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it from the resident and pulled the resident's sweatpants down, showing the resident had two briefs on. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident has the outer brief over the pull up because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she was walking down the hall because the resident takes himself/herself to the bathroom. CNA E said he/she glanced/peeked at the resident when he/she was walking down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees and the resident's shirt was wet up to his/her waist below his/her elbows. CNA E walked and guided the resident to the bathroom. Once CNA E entered the bathroom, there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet and then had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet and the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. CNA E did not change the resident during the night shift. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. - this interview is listed under #1. During an interview on 10/28/24 at 6:05 A.M., CNA E said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident was walking the halls last night. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheelchair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers; -At risk for pressure ulcers; -No skin issues present; -Pressure reducing device for bed; -Diagnoses included stroke, heart failure, and diabetes mellitus. Review of the resident's Braden Scale, dated 7/31/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast. Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder. Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -There was a strong odor of urine emitting from the room into the hall; -The resident lay in his/her bed on a low air loss mattress; -RN D pulled the resident's bed covers down to show the resident wore two briefs; -The resident's outer brief was soaked with urine, with the padding in the brief in clumps; -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24 at 4:35 A.M., RN D said: -He/She did not think the resident was changed over the night shift; -He/She verified the resident wore two briefs, both soaked with urine, and lay in urine extending up to his/her shoulders. During an interview on 10/28/24 at 5:49 A.M., CNA E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day; -He/She was the only CNA assigned to care for the resident on the hall; -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care; -He/She had just provided incontinence care to the resident; -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident lay on a wet absorbent pad before CNA E gave the resident incontinence care. 4. Review of Resident #45's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Moderately impaired cognition; -Wheelchair for locomotion; -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed; -Dependent on staff for chair/bed-to-chair transfers; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -Moisture Associated Skin Damage (MASD) present; -Pressure reducing device for bed; -Diagnoses included morbid obesity, depression, anxiety, metabolic encephalopathy (chemical imbalance in the blood that affects brain function) and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility. Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections. Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility. Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Observation on 10/28/24 at 4:50 A.M., showed: -There was a strong odor of urine and bowel movement emitting from the room into the hall; -The odor of urine and feces was so strong upon entry into the room, the surveyor's eyes burned; -The resident lay in his/her bed on a low air loss mattress; -The resident wore two briefs which were soaked with urine; -The resident lay on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine; -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine soaked areas; -The resident wore a hospital gown that was also urine soaked; -The resident had dried feces on his/her buttocks and inside of the inner brief; -The resident's mattress was visibly wet with urine; -The resident's bilateral buttocks were reddened; -The resident's inner thighs were reddened. During an interview on 10/28/24 at 4:52 A.M. and at 5:06 A.M., the resident said: -He/She had not received incontinence care since the evening before around 6:00 P.M.; -The staff did not usually provide incontinence care during the night shift; -Lying in a pool of urine on the wet sheet was annoying to the resident; -He/She did not like wearing two briefs at once, as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24 at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected Moisture Associated Dermatitis (MASD); -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24 at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M.; -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care; -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time; -He/She only put two briefs on residents if they asked for them; -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet; -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff; -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. Review of the resident's weekly skin assessment, dated 10/28/24 at 12:43 P.M., showed there was no documentation found of skin issues at the resident's buttocks or groin. During observation and interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time in the early this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had two briefs on. The resident said it depends on what staff changes him/her if they put one or two briefs on. The resident said it seems like they put two on all the time. The resident said he/she is changed and repositioned one time each shift and said he/she needed changed and repositioned more often. When he/she turns his/her call light on, it takes an hour to an hour and a half before staff respond to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid that had approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had two briefs on and the briefs were soaked with urine. RN D said it is not appropriate for any resident to have two briefs on. If a resident has two briefs on, the staff might think the resident is dry by only looking at the outer brief. If residents are left soiled for an extended period of time, it can cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., showed: -The resident wore two briefs which were both visibly soaked with urine; -He/She did not like to wear two briefs, as they were uncomfortable, were too tight between his/her legs and cut into his/her groin. Review of the resident's weekly skin assessment, dated 10/29/24 at 12:01 P.M., showed the resident had redness at his/her buttocks and groin. 5. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting, shower, upper and lower body dressing, put on and take off footwear, personal hygiene, and roll left and right: substantial maximal assistance; -Shower transfer, dependent; -Frequently incontinent of bladder; -Always incontinent of bowel; -Risk of pressure ulcers, yes; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. Review of the resident's forms list on 10/31/24 at 12:44 P.M., showed no Braden assessment completed for the resident in 2024. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day. The resident said he/she had not been changed all night. The resident had two briefs on. The inner brief was brown and was saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she does not like to be soiled for extended periods of time. The resident also said his/her family gets ice water for him/her on the days they are at the facility. On days the family is not at the facility, he/she does not get offered ice water. Observation and interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., showed: -There was a cup with approximately 4 inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -He/She was last checked on by staff around 6:00 A.M. that morning and he/she was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup, as that sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident lay on an absorbent pad that was saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings which extended up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J, who was sitting in the hallway, and asked CNA J who had the resident. CNA J said the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. ADON M said it was not appropriate for a resident to not be changed from 10:00 P.M. unit 6:30 [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. The facility also failed to provide fresh ice water to three residents (Resident #31, #46 and #45). The census was 118. Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care. Incontinent care will include a skin evaluation of the resident; promoting hygiene and skin prevention with infection/irritation; -Responsibility: Nursing Assistant, Licensed Nurses, Nursing Administration, Infection Control Preventionist and Director of Nursing (DON). Review of the facility's Certified Nurse Aide (CNA) job description, revised 1/2024, showed: -Facilitates all care and service in a friendly customer-driven approach; assures Residents are treated with dignity and respect at all times; -Provides for activities of daily living by assisting with serving meals; feeding Residents as necessary; and ambulating, turning. and positioning Residents; toileting assistance; and providing fresh water and nourishment between meals; -Provides Residents with hygiene supports including nail care, light hair or other grooming, oral hygiene, bathing, and incontinence care; -Follows all company policies and procedures. 1. Review of Resident #33's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Always incontinent of bowel and bladder; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's care plan during the survey, showed: -Focus: ADL, self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; During an interview and observation on 10/28/24 at 4:23 A.M., the resident lay in bed on his/her right side. Registered Nurse (RN) D said residents do not get changed often on the night shift. RN D pulled the white quilt back and pulled the resident's sweatpants down. Observation showed the resident wore two briefs. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. Before exiting the room, RN D went to wash his/her hands in the resident's bathroom and there was a large amount of dried feces on the left side of the toilet seat. During an interview and observation on 10/28/24 at 5:54 A.M., with CNA E and Assistant Director of Nursing (ADON) M, CNA E said the resident took himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it. He/She pulled the resident's sweatpants down which showed the resident wore two briefs. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident had the outer brief over the pull up, because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she walked down the hall because the resident took himself/herself to the bathroom. CNA E said he/she glanced, peeked at the resident when he/she walked down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees. The resident's shirt was wet up to his/her waist and below his/her elbows. CNA E walked and guided the resident to the bathroom. When CNA E entered the bathroom there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet. ADON M had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet as the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. The resident had no open areas or red areas. CNA E did not change the resident during the night shift. During an interview on 10/28/24, at 6:05 A.M., CNA E, said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident walked the halls last night; -CNA E checked for incontinence by peeking in the resident's brief. He/She also touched the resident's brief on the outside of his/clothes, on his/her lower buttocks. If the CNA felt the brief was hard it meant the resident was incontinent and needed care. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. ADON M said it was inappropriate to see if the resident was soiled by feeling the resident's brief through his/her clothing while the resident walked down the hall. ADON M expected staff to provide privacy and to visually check the resident's brief to see if the resident was soiled. It was inappropriate to place a brief on top of a pull up to prevent a resident from removing the pull up. 2. Review of Resident #34's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheel chair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast; -Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder; -Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -There was a strong odor of urine emitting from the resident's room into the hall; -The resident lay on his/her bed on a low air loss mattress; -RN D pulled the resident's bed covers down to show the resident wore two briefs; -The resident's outer brief was soaked with urine, with the padding in the brief in clumps; -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24, at 4:35 A.M., RN D said: -He/She did not think the resident was changed during the night shift; -He/She verified the resident wore two briefs, both soaked with urine, and was lying in urine extending up to his/her shoulders. During an interview on 10/28/24, at 5:49 A.M., CNA E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day; -He/She was assigned to care for the resident; -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care; -He/She had just provided incontinence care to the resident; -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident was lying on a wet absorbent pad before CNA E gave the resident incontinence care. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Wheelchair for locomotion; -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed; -Dependent on staff for chair/bed-to-chair transfers; -Always incontinent of bowel and bladder. Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility; -Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections; -Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility; -Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Review of the resident's progress notes, showed no documentation the PCP or RRP was alerted to a change in the resident's skin or that a new order for treatment was obtained. Review of the resident's weekly skin assessment, dated 10/21/24, showed no new skin issues noted. There was no documentation to show existing skin issues. Observation on 10/28/24 at 4:50 A.M., showed: -A strong odor of urine and feces emitting from the resident's room into the hall; -The odor of urine and feces was strong upon entry into the room; -The resident was lying in his/her bed on a low air loss mattress; -The resident wore two briefs which were soaked with urine; -The resident was lying on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine; -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine soaked areas; -The resident was wearing a hospital gown that was also urine soaked; -The resident had dried feces on his/her buttocks and inside the inner brief; -The resident's mattress was visibly wet with urine; -The resident's bilateral buttocks were reddened; -The resident's inner thighs were reddened. During an interview on 10/28/24, at 4:52 A.M. and at 5:06 A.M., the resident, said: -He/She had not received incontinence care since the evening before around 6:00 P.M.; -The staff did not usually provide incontinence care during the night shift; -Lying in a pool of urine on the wet sheet was annoying to the resident; -He/She did not like wearing two briefs at once as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24, at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected moisture associated skin damage (MASD); -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24, at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M.; -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care; -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time; -He/She only put two briefs on residents if they asked for them; -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet; -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff; -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. Review of the resident's weekly skin assessment, dated 10/28/24 at 12:43 P.M., showed no documentation of skin issues at the resident's buttocks or groin. During an interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time earlier this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had on two briefs. The resident said it depended on what staff changed him/her if they put one or two briefs on. The resident said it seemed like they put two briefs on all the time. The resident said he/she was changed and repositioned one time each shift, but needed changed and repositioned more often. The resident said when he/she turned his/her call light on it took an hour to an hour and a half before staff responded to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid with approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed out each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had on two briefs and the briefs were soaked with urine. RN D said it was not appropriate for any resident to have on two briefs. If a resident wore two briefs, staff could think the resident was dry by only looking at the outer brief. If residents were left soiled for an extended periods of time it could cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., with the resident, showed: -He/She wore two briefs which were both visibly soaked with urine; -He/She did not like to wear two briefs as they were uncomfortable, too tight between his/her legs and cut into his/her groin. During an interview on 10/31/24 at 7:23 A.M., ADON M expected residents to be rounded on every two hours. ADON M expected residents to only have one brief on. The resident's skin integrity was at risk due to the moisture. It could cause skin break down because the briefs did not allow for oxygen to get to the skin. It was imperative to only use one brief on residents. 4. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting, shower, upper and lower body dressing, put on and take off footwear, personal hygiene, and roll left and right: substantial maximal assistance; -Shower transfer, dependent; -Eating and oral hygiene: Partial moderate assistance (helper does less than half the effort); -Frequently incontinent of bladder; -Always incontinent of bowel; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day. The resident said he/she had not been changed all night. The resident wore two briefs. The inner brief was brown and saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she did not like to be soiled for extended periods of time. The resident also said his/her family got ice water for him/her on the days they were at the facility. On days the family was not at the facility, the resident was not offered ice water. During an interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., the resident, said: -There was a cup with approximately four inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -Staff last checked on the resident around 6:00 A.M. that morning. The resident was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup as it sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief, and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident was lying on an absorbent pad that was also saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings extending up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J who was sitting in the hallway and asked CNA J who had the resident. CNA J responded the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. He/She said it was not appropriate for a resident to not be changed from 10:00 P.M. unit 6:30 A.M. the following day. He/She said night shift started at 11:00 P.M. and the resident was not changed for the entire night shift. ADON M said he/she spoke to the night shift charge nurse and CNA J was the CNA responsible for completing rounds and changing the resident but he/she did not have an opportunity to speak with CNA J before he/she left. ADON M said CNA J reported the resident was on another CNA's assignment. ADON M said he/she expected staff to be knowledgeable of and follow the facility's policies. ADON M said he/she expected staff to make rounds on residents every two hours and know what residents they were responsible for each shift. 5. Review of Resident #43's annual MDS, dated [DATE], showed: -Adequate hearing; -Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses of anxiety and depression. Review of the resident's care plan, located in the electronic medical record (EMR), showed: -11/9/21, Focus: ADL self-care performance deficit; -Goal, Resident requires assistance with ADL care and mobility; -Interventions: Personal hygiene, one assist. Toilet use, utilize check and change to manage incontinence; -10/23/24, Focus: Frequently incontinent bowel and bladder; -Goal: Will remain free from skin breakdown; -Interventions: Incontinent. Check and change for incontinence. During an interview on 10/30/24 at 7:47 A.M., the resident said he/she was incontinent of bowel and bladder. It was not uncommon for staff to put two incontinent briefs on him/her on the night shift, which he/she did not mind. Most nights staff checked him/her for incontinence one time, which was not enough. Staff told the resident there was not enough help to check him/her more than once. If he/she turned on his/her call light it could take hours for staff to answer it. Or, they would answer it, turn the call light off and leave without taking care of him/her. It made him/her feel bad when he/she was left wet for long periods. 6. Review of Resident #44's annual MDS, dated [DATE], showed: -Adequate hearing; -Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses of anxiety and depression. Review of the resident's care plan, located in the EMR, showed: -8/22/23, Focus: Bladder incontinence related to impaired mobility; -Goal: Will remain from skin breakdown due to incontinence and brief use; -Interventions: Check as required for incontinence. During an interview on 10/30/24 at 7:37 A.M., the resident said he/she was incontinent of bowel and bladder. Most night shifts, staff would check and change him/her twice at the most; sometimes only once. In the past couple of weeks there had been some nights no one came to check him/her at all. Sometimes staff put two incontinent briefs on him/her but he/she would prefer only one. When he/she was checked once or not at all, he/she laid in a puddle of urine. Most nights he/she was unable to turn on his/her call light because staff did not leave the call light where he/she could reach it. When the call light was in reach and he/she turned it on, it could take hours for someone to answer it. He/She felt ignored by staff. 7. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Rejection of care not exhibited; -Frequently incontinent of bowel and bladder; -Diagnosis included need for assistance with personal care, abnormalities of gait and mobility, muscle weakness, and reduced mobility. Review of the resident's care plan during the survey, showed: -Focus: ADL self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Bed mobility requires staff assistance to turn and reposition in bed; -Toilet use requires staff assistance of one; -Transfer requires staff assistance of one; -Encourage use of call light. During an interview on 10/28/24 at 8:08 A.M., the resident said staff did not come in and offer to change him/her when he/she was soiled. The resident said he/she must get out of bed and change himself/herself and put the soiled briefs in the trash can next to his/her bed. The resident said the trash was just changed and was overflowing with soiled briefs. The staff member who came in and took the trash threw a fit and wanted to know why all the briefs were in the trash can. The resident then became tearful and said he/she was doing the best he/she could. The resident said it would be helpful if the staff assisted him/her to change his/her brief when soiled, but said staff would not assist him/her. The resident said it took up to two hours for staff to answer his/her call light if they came at all. The resident said staff did not pass or offer ice water. The resident said he/she had a small green cooler he/she kept on his/her walker. The resident filled this small cooler up himself/herself. 8. During an observation on 10/31/24 at 6:44 A.M. a resident walked up to the ice chest next to the nurse's station and opened the lid and said there was no ice in the cooler. The cooler was half full of water at that time. The resident made the comment that he/she last received ice before he/she went to bed. 9. During an interview on 10/28/24, at 4:10 A.M., RN D, said: -He/She worked the night shift from 11:00 P.M. until 7:00 A.M. last night; -There were two CNAs for 58 residents and one nurse during his/her shift; -He/She did not feel the residents were getting appropriate care as there was not enough staff to care for them; -Sometimes it took them over an hour to answer call lights and the residents were left wet for all that time because there were so many residents who required two people for direct care; -He/She had not told the Administrator or DON, as he/she understood they were already aware; -He/She had to wake CNA F around 1:00 A.M. to answer call lights. CNA F was sleeping at the nurses' station in a chair with a blanket; -He/She found CNA E asleep in a bed in an un-occupied resident room at 3:30 A.M.; -The CNAs typically started to round on residents at 5:00 A.M. to clean up the residents before day shift came in. During an interview on 10/28/24 at 5:18 A.M., CNA F said rounds should be completed every two hours. While making rounds residents were checked to see if they need to be changed, repositioned, trash was checked to see if it needed to be taken out and see if the residents needed fresh ice and water. CNA F said he/she completed rounds on night shift between 11:30 P.M. and 12:00 P.M., 2:00 A.M. and 5:00 A.M. CNA F said if residents wore two briefs, it helped the urine not go all the way to the resident's back. CNA F said it was not normal to put two briefs on residents. He/She would only put two briefs on a resident if they requested it. CNA F said when a resident had two briefs on it was hard to determine if the resident was wet. During an interview on 10/30/24 at 7:22 A.M., CNA F said night shift was from 11:00 P.M. to 7:00 A.M. and rounds were completed two times before 5:00 A.M. When he/she came in at 11:00 P.M. he/she made rounds with the evening shift CNA. During rounds he/she checked to see if residents needed ice water, tv remote, call light, if the residents needed to be changed or taken to the bathroom and made sure the residents were breathing. If a resident had on two briefs it was not good because the outer brief could look dry and the inner brief could be wet. He/She would be reluctant to change them if the resident looked dry. If residents were not changed it could cause them to get red bottoms or bed sores. CNA F said when there was only one CNA on each side and one nurse it took a long time to answer call lights. CNA F said if four to five call lights were on he/she would quickly go to each person with a call light on to make sure there was not an emergency like slipping off the bed or a fall. CNA F said he/she would then start changing the first resident that had the call light on. It took up to 20 minutes to change one resident because he/she had to go to the room see what he/she needed, then go to the clean utility closet and get supplies, then go back to the resident's room to clean and change the resident. CNA F said it could take up to an hour and forty minutes to answer a call light at times. During an interview on 10/30/24 at 7:00 A.M., CNA K said he/she worked the day shift, 7:00 A.M. until 3:00 P.M. When he/she started to get residents ready after first arriving on duty, it was not uncommon to find several residents wearing two incontinent briefs soaked through with urine. This occurred several times a week. He/She did not think those residents could possibly have been checked and changed every two to three hours. He/She had not told the nurses. During an interview on 10/30/24 at 7:27 A.M., CNA L said he/she worked the day shift. When he/she reported to work he/she started to get residents ready for the day. He/She frequently found residents heavily saturated in urine. Sometimes some residents wore two incontinent briefs, and they were saturated with urine. He/She did not feel those residents could possibly have been checked for incontinence every two hours. During an interview on 10/30/24 at 11:16 A.M., the Administrator and DON said they expected call lights to be answered within 15 to 20 minutes. They said it was not appropriate for residents wait for a call light to be answered over the period of one to two hours. If a resident waited one to two hours for a call light to be answered there was a risk if the resident needed to use the restroom, they could attempt to take themselves and fall. They wanted call lights answered as promptly as possible because the staff did not know what the resident needed. Ice water should be passed every shift at a minimum and more if needed. It was not appropriate to feel a resident's brief through the resident's clothing in the hallway to check and see if the resident was soiled. MO00242946 MO00241933 MO00243961

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect. Facility staff failed to provide prompt and adequate incontinence care. Four out of four sampled residents, who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), were observed with two incontinence briefs on, both of which were saturated and with strong odors of urine and feces. Three residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take several hours for staff to answer call lights. Additionally, facility staff neglected to respond to a call light for one resident, with a history of bypass surgeries (Resident #24) who was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. Emergency Medical Services (EMS) responded but could not find facility staff until they found one staff member curled up on the couch asleep. Another resident (Resident #25) returned from the hospital with EMS at the same time that Resident #24 was having chest pains and that EMS crew could not find staff readily available. Additionally, another resident's hospital Emergency Department (ED) report showed the resident called 911 and said staff had left him/her on the toilet for three hours, causing stiffness and pain (Resident #20). This had the potential to affect all residents. The census was 118. 1. Review of Resident #34's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/31/24, showed: -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheelchair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers; and -At risk for pressure ulcers. -Diagnoses included stroke, heart failure, and diabetes mellitus. Review of the resident's Braden Scale, dated 7/31/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast. Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder. Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -A strong odor of urine emitting from the room into the hall. -The resident lay in his/her bed on a low air loss mattress. -Registered Nurse (RN) D pulled the resident's bed covers down to show the resident wore two briefs. -The resident's outer brief was soaked with urine, with the padding in the brief in clumps. -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24 at 4:35 A.M., RN D said: -He/She did not think the resident was changed over the night shift. -He/She verified the resident wore two briefs, both soaked with urine, and lay in urine extending up to his/her shoulders. During an interview on 10/28/24 at 5:49 A.M., Certified Nurse Aide (CNA) E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day. -He/She was the only CNA assigned to care for the resident on the hall. -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care. -He/She had just provided incontinence care to the resident. -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident lay on a wet absorbent pad before he/she gave the resident incontinence care. 2. Review of Resident #33's admission MDS, a federally mandated assessment instrument completed by facility staff, dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Eating, oral hygiene, upper body dressing: Partial moderate assistance; -Always incontinent of bowel and bladder; -Risk of pressure ulcers, yes; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 9/4/24, showed the resident was at high risk for developing pressure ulcers. Review of the resident's current care plan, showed: -Focus: Activities of daily living (ADLs, bathing, toileting, dressing, etc.) self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; -Goal: Resident will remain free from skin breakdown due to incontinence and brief use through the review date; -Interventions: -Assist resident to bathroom as desired/indicated, offer toileting before meals, after meals and at bedtime; -Clean peri-area with each incontinence episode; -Focus: Resident has the potential for impaired skin integrity; -Goal: Resident will maintain or develop clean and intact skin by the review date; -Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. During an observation and interview on 10/28/24 at 4:23 A.M., RN D said residents do not get changed often on night shift because there isn't enough staff to get everything done. The resident lay in bed on his/her right side. RN D pulled the white quilt back and pulled the resident's sweatpants down, showing the resident had two briefs on. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with urine and dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. During an observation and interview on 10/28/24 at 5:54 A.M., with CNA E and Assistant Director of Nursing (ADON) M, CNA E said the resident takes himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it from the resident and pulled the resident's sweatpants down, showing the resident had two briefs on. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident has the outer brief over the pull up because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she was walking down the hall because the resident takes himself/herself to the bathroom. CNA E said he/she glanced/peeked at the resident when he/she was walking down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees and the resident's shirt was wet up to his/her waist below his/her elbows. CNA E walked and guided the resident to the bathroom. Once CNA E entered the bathroom, there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet and then had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet and the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. During an interview on 10/28/24 at 6:05 A.M., CNA E said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident was walking the halls last night; -CNA E checked for incontinence by peeking in the resident's brief and by touching the resident's brief on the outside of his/clothes on his/her lower buttocks. If the CNA felt the brief was hard that meant the resident was incontinent and needed care. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she works the night shift. About 70% of the time, there are two CNAs scheduled to work the downstairs units instead of three. When there is one CNA on each unit, he/she cannot check and change residents every two hours. He/She can only do two checks per his/her eight-hour shift. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. ADON M said it is inappropriate to feel the resident's brief through his/her clothing while they are walking down the hall to see if the resident is soiled. ADON M expected staff to provide privacy and to visually check the residents brief to see if the resident is soiled. It is inappropriate to place a brief on top of a pull up to prevent a resident from removing the pull up. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition. -Wheelchair for locomotion. -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed. -Dependent on staff for chair/bed-to-chair transfers. -Always incontinent of bowel and bladder. -At risk for pressure ulcers. -Moisture Associated Skin Damage (MASD) present. -Pressure reducing device for bed. -Diagnoses included morbid obesity, depression, anxiety, metabolic encephalopathy (chemical imbalance in the blood that affects brain function) and polyneuropathy (damage to nerves causing pain, discomfort and mobility difficulties). Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility. Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections. Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility. Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Observation on 10/28/24 at 4:50 A.M., showed: -A strong odor of urine and bowel movement emitting from the room into the hall. -The odor of urine and feces was so strong upon entry into the room, the surveyor's eyes burned. -The resident lay in his/her bed on a low air loss mattress. -The resident wore two briefs which were soaked with urine. -The resident lay on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine. -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine-soaked areas. -The resident wore a hospital gown that was also urine soaked. -The resident had dried feces on his/her buttocks and inside of the inner brief. -The resident's mattress was visibly wet with urine. -The resident's bilateral buttocks were reddened. -The resident's inner thighs were reddened. During an interview on 10/28/24 at 4:52 A.M. and at 5:06 A.M., the resident said: -He/She had not received incontinence care since the evening before around 6:00 P.M. (eleven hours). -The staff did not usually provide incontinence care during the night shift. -Lying in a pool of urine on the wet sheet was annoying to the resident. -He/She did not like wearing two briefs at once, as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24 at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected Moisture Associated Dermatitis (MASD). -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24 at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M. -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care. -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time. -He/She only put two briefs on residents if they asked for them. -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet. -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff. -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. During observation and interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time early this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had two briefs on. The resident said it depends on what staff changes him/her if they put one or two briefs on. The resident said it seems like they put two on all the time. The resident said he/she is changed and repositioned one time each shift and said he/she needed changed and repositioned more often. When he/she turns his/her call light on, it takes an hour to an hour and a half before staff respond to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid that had approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had two briefs on and the briefs were soaked with urine. RN D said it is not appropriate for any resident to have two briefs on. If a resident has two briefs on, the staff might think the resident is dry by only looking at the outer brief. If residents are left soiled for an extended period of time, it can cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., showed: -The resident wore two briefs which were both visibly soaked with urine. -He/She did not like to wear two briefs, as they were uncomfortable, were too tight between his/her legs and cut into his/her groin. Review of the resident's weekly skin assessment, dated 10/29/24 at 12:01 P.M., showed the resident had redness at his/her buttocks and groin. 4. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting and personal hygiene: substantial maximal assistance; -Shower transfer, dependent; -Frequently incontinent of bladder; -Always incontinent of bowel; -Risk of pressure ulcers, yes; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day (almost 12 hours). The resident said he/she had not been changed all night. The resident had two briefs on. The inner brief was brown and was saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she does not like to be soiled for extended periods of time. The resident also said his/her family gets ice water for him/her on the days they are at the facility. On days the family is not at the facility, he/she does not get offered ice water. Observation and interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., showed: -There was a cup with approximately 4 inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -He/She was last checked on by staff around 6:00 A.M. that morning and he/she was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup, as that sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident lay on an absorbent pad that was saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings which extended up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J, who was sitting in the hallway, and asked CNA J who had the resident. CNA J said the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. ADON M said it was not appropriate for a resident to not be changed from 10:00 P.M. until 6:30 A.M. the following day. Night shift starts at 11:00 P.M. and the resident was not changed for the entire night shift. ADON M said he/she spoke to the night shift charge nurse and CNA J was the CNA responsible for completing rounds and changing the resident. ADON M said he/she did not have an opportunity to speak with CNA J before he/she left. ADON M said CNA J reported to ADON M that the resident was on another CNA's assignment. ADON M said he/she expected staff to be knowledgeable of and follow the facility' policies. ADON M expected staff to make rounds on the residents every two hours and know what residents they are responsible for each shift. 5. Review of Resident #31's quarterly MDS, dated [DATE], showed the resident: -Cognitively intact. -Rejection of care not exhibited. -Frequently incontinent of bowel and bladder. -At risk for pressure ulcers. -Diagnoses included need for assistance with personal care, abnormalities of gait and mobility, muscle weakness and reduced mobility. Review of the resident's current care plan, showed: -Focus: ADL self-care performance deficit. -Goal: Resident requires assistance with ADL care and mobility. -Interventions: -Bed mobility requires staff assistance to turn and reposition in bed. -Toilet use requires staff assistance of one. -Transfer requires staff assistance of one. -Encourage use of call light. During an interview on 10/28/24 at 8:08 A.M., the resident said staff do not come in and offer to change him/her when he/she is soiled. The resident said he/she must get out of bed and change himself/herself and put the soiled briefs in the trash can next to his/her bed. The trash was just changed and was overflowing with soiled briefs and the staff member who came in and took the trash, threw a fit wanting to know why all the briefs were in the trash can. The resident then became tearful and said he/she is doing the best he/she can. The resident said it would be helpful if the staff would assist him/her in changing his/her brief when he/she is soiled but said staff will not assist him/her because there was not enough staff. The resident said it takes up to two hours for staff to answer his/her call light, if they come at all. The resident said staff do not pass or offer ice water. The resident said he/she has a small green cooler he/she keeps on his/her walker and the resident fills this small cooler up himself/herself. 6. Review of Resident #43's annual MDS, dated [DATE], showed: -Adequate hearing. -Clear speech - distinct intelligible words. -Makes Self Understood: Understood. -Ability To Understand Others: Understands - clear comprehension. -Cognitively intact. -Always incontinent of bowel and bladder. -Diagnoses of anxiety and depression. Review of the resident's current care plan, showed: -11/9/21: Focus -ADL self-care performance deficit. Goal - Resident requires assistance with ADL care and mobility. Interventions: Personal hygiene, one assist. Toilet use, utilize check and change to manage incontinence; -10/23/24: Focus - Frequently incontinent bowel and bladder. Goal - Will remain free from skin breakdown. Interventions: Incontinent - Check and change for incontinence. During an interview on 10/30/24 at 7:47 A.M., the resident said he/she is incontinent of bowel and urine. Most nights, staff check him/her for incontinence one time, which is not enough. Staff tell him/her there is not enough help to check him/her more than once. If he/she turns on his/her call light, it can take hours for staff to answer it, or they will answer it, turn the call light off, then leave without taking care of him/her. It makes him/her feel bad when he/she is left wet for long periods. 7. Review of Resident #44's annual MDS, dated [DATE], showed: -Adequate hearing. -Clear speech - distinct intelligible words. -Makes Self Understood: Understood. -Ability To Understand Others: Understands - clear comprehension. -Cognitively intact. -Always incontinent of bowel and bladder. -Diagnoses of anxiety and depression. Review of the resident's current care plan, showed: -8/22/23: Bladder incontinence related to impaired mobility. Goal: Will remain from skin breakdown due to incontinence and brief use. Interventions: Check as required for incontinence. During an interview on 10/30/24 at 7:37 A.M., the resident said he/she is incontinent of bowel and bladder. Most night shifts, staff will check and change him/her twice at the most, sometimes only once, and in the past couple of weeks, there had been some nights no one came to check him/her at all. When he/she is checked once or not at all, he/she lays in a puddle of urine. Most nights, he/she is unable to turn on his/her call light because staff do not leave the call light where he/she can reach it. When the call light is in reach and he/she turns it on, it can take hours for someone to answer it. He/She feels ignored by staff. 8. Review of Resident #24's electronic medical record (EMR), showed: -Diagnoses of high blood pressure and a-fib. -A progress note, dated 9/27/24 at 3:47 A.M., and documented by Licensed Practical Nurse (LPN) N: This nurse was notified that resident called 911 stating he/she was having chest pain. His/Her chest felt like it was filling with water. EMS arrived asking resident why he/she did not turn on his/her call light for this nurse to evaluate him/her. Resident stated he/she just wanted to go to the hospital. Resident transferred to stretcher going to hospital for evaluation. No signs or symptoms noted. Review of the staffing schedule for the night shift of 9/26/24 (the shift started at 11:00 P.M. on 9/26/24 and ended at 7:00 A.M. on 9/27/24), showed one nurse working on the two units on the first floor where Resident #24 resided. Review of the resident's Des [NAME] Department of Public Safety report (EMS/ambulance report) dated 9/27/24, showed: -911 Caller: Resident #24. -Alarm: 3:15 A.M. Dispatched: 3:17 A.M. Arrived: 3:21 A.M. -3:34 A.M.: Had to wake up staff to locate the resident. -3:36 A.M.: Caller (resident) states he/she has been having chest pains for 45 minutes. -3:37 A.M.: Attempted to contact staff two times no answer to locate resident's room number. -3:38 A.M.: EMS has been on the scene for over 10 minutes at the front door. -3:40 A.M.: Staff was contacted a third time and finally picked up. Dispatch advised that DSFD (Des [NAME] Fire Department) was on scene and ambulance was there for over 10 minutes. Staff was asked to check a resident name for a room number. They advised they would have to go downstairs and look for it. -Narrative: Upon arrival, observed Resident #24 laying supine (on the back) in bed. The resident could speak without deficit and appeared to be stable. The resident advised he/she was having substernal (behind the breastbone) chest pain that did not radiate for approximately and hour and a half. Resident advised he/she tried to call staff for approximately one hour however, no one would answer his/her call light. It should be noted, staff was found sleeping in the hallway wrapped in blankets sleeping and other staff members coming in from their vehicles in the parking lot. An ECG was conducted at which time A-fib was observed. The resident was provided with 324 milligram aspirin orally. During transport (to the hospital) no changes in the resident's vitals were observed. -Call closed at 4:12 A.M. During an interview on 9/27/24 at 7:29 A.M., Emergency Medical Technician (EMT) AA said they had been at the facility for 10 minutes and could not find any staff. Dispatch called the facility and did not get an answer. Upon entrance to the facility, several call lights were flashing and there was no staff in sight. While walking around trying to find the resident's room, the paramedics saw a someone curled up on the couch, asleep. Resident #24 said he/she yelled for help for 10 minutes. When they didn't respond, he/she called 911. Two staff eventually appeared, and several staff were seen exiting their cars and returning to the building. The lights were off at the nurse's station and one of the staff had to restart the computer to get the resident's face sheet. During an interview on 10/31/24 at 6:31 A.M., CNA E said he/she worked on the night shift of 9/26/24. He/She worked on the same floor, but not the same unit where the resident resided. During that shift EMS was in the building and said they had been looking for staff because the resident had called them and said he/she was having chest pain. He/She also saw a policeman in the building at the same time EMS was in the building. He/She was not sleeping on duty and did not see other staff sleeping. 9. Review of Resident #25's EMR, showed: -admitted [DATE]. -Diagnoses of syncope (fainting), vertigo (light headed/dizziness), A-fib and cognitive communication deficit; -A progress noted dated 9/26/24 at 8:36 P.M.: Resident complained of feeling like he/she did when he/she had a brain bleed. He/She said he/she wants to go to the hospital for evaluation. Physician and DON notified. -A progress note dated 9/27/24 at 3:37 A.M.: Resident returned from hospital. Family arrived with resident. During an interview on 9/27/24 1:50 P.M., Family Member (FM) MM said he/she arrived at the facility from the hospital on 9/27/24 at 3:30 A.M. The Des [NAME] Police Department (PD) and ambulance were in the building. The paramedic said they had been walking around trying to find staff and the resident who called the police for 20 minutes. There were call lights going off. Another resident was having chest pain, had his/her call light on, and when no one answered it, he/she called 911. FM M walked around with the paramedics for an additional 20 minutes before staff came out of a dark room. During an interview on 10/31/24 at 8:17 A.M., the Director of Nursing (DON) said no one told her the paramedics and police could not locate staff when they responded to Resident #24's emergency call or when Resident #25 returned to the facility. No one told her a staff member was found sleeping by the EMS crew. If they would have called her, she would have come in at that time and began an investigation as to why the staff could not be found and why a staff member was sleeping on duty. 10. Review of Resident #20's EMR, showed: -admitted [DATE]. -Diagnoses included: Heart failure, below the knee amputation (BKA) of right leg and diabetes mellitus. Review of the resident's progress notes, showed: -On 9/11/24, at 7:15 P.M., Fire and Ambulance arrived, making nurse aware 911 had been called for the resident's room. This nurse approached room noting this resident in bathroom on toilet. Two EMTs entered the restroom to assess resident. Resident stated he/she would like to be transported to ED for eval for pain. Resident left facility at this time remaining alert and able to make needs known. During an interview on 9/27/24 at 12:09 P.M., EMT AA said EMS was dispatched to the facility on Labor Day weekend and staff were seen sleeping. The residents were complaining they had not received their medication. The agency staff said there was not a nurse in the building, and they didn't pass meds, because the residents were new admits and they had not received their meds from the pharmacy. Review of the resident's hospital ED records, showed: -Arrival Date/Time: 9/11/24 at 6:20 P.M -Chief Complaint: The resident was unable to get off toilet at Skilled Nursing Facility. There for BKA on right knee. Alert and orientated time three to four (to self, place, time, and situation). -History of Present Illness: The patient was brought in EMS with complaints of being left on the toilet for the past three hours per the patient, resulting in stiffness and pain to his/her buttocks. -Nurse ED note, dated 9/11/24 at 8:17 P.M., Multiple attempts have been made to contact nursing staff at the facility with no response. Patient is amenable to waiting until contact can be made and then returned to facility. Des [NAME] PD has been contacted and is sending a patrol officer to conduct a wellness check on the staff at the facility as the patient, ED Nursing staff and PD have n

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. The facility also failed to provide fresh ice water to three residents (Resident #31, #46 and #45). The census was 118. Review of the facility's Incontinent Care Policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care. Incontinent care will include a skin evaluation of the resident; promoting hygiene and skin prevention with infection/irritation; -Responsibility: Nursing Assistant, Licensed Nurses, Nursing Administration, Infection Control Preventionist and Director of Nursing (DON). Review of the facility's Certified Nurse Aide (CNA) job description, revised 1/2024, showed: -Facilitates all care and service in a friendly customer-driven approach; assures Residents are treated with dignity and respect at all times; -Provides for activities of daily living by assisting with serving meals; feeding Residents as necessary; and ambulating, turning. and positioning Residents; toileting assistance; and providing fresh water and nourishment between meals; -Provides Residents with hygiene supports including nail care, light hair or other grooming, oral hygiene, bathing, and incontinence care; -Follows all company policies and procedures. 1. Review of Resident #33's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/6/24, showed: -Moderate cognitive impairment; -Rejection of care, not exhibited; -Upper extremity impairment on both sides; -Toileting, shower, lower body dressing, put on and take off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer: substantial maximal assistance (helper does more than half the effort); -Always incontinent of bowel and bladder; -Diagnoses included deaf nonspeaking, muscle weakness, dementia, reduced mobility and insomnia (a sleep disorder that makes it hard to fall or stay asleep). Review of the resident's care plan during the survey, showed: -Focus: ADL, self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Requires staff assistance to turn and reposition in bed; -Requires staff assistance to dress; -Transfer one assist; -Focus: The resident has bowel incontinence related to immobility; -Goal: The resident will have less than two episodes of incontinence per day through the review date; -Interventions: -Check resident every two hours and assist with toileting as needed; -Observe pattern of incontinence and initiate toileting schedule if indicated; -Provide loose fitting, easy to remove clothing; -Provide peri care after each incontinent episode; -Focus: Resident is incontinent of bowel and bladder; During an interview and observation on 10/28/24 at 4:23 A.M., the resident lay in bed on his/her right side. Registered Nurse (RN) D said residents do not get changed often on the night shift. RN D pulled the white quilt back and pulled the resident's sweatpants down. Observation showed the resident wore two briefs. The brief that was closest to the resident's body was a pull up brief and the second brief (secured with fastening tape on the wings that attaches to the front of the brief) was located over the pull up. The brief was taped on both sides. The inner pull up was soiled with dried feces and the outer brief was soiled with urine. The white quilt had large yellow spots on it. RN D said the resident had not been changed on the night shift. Before exiting the room, RN D went to wash his/her hands in the resident's bathroom and there was a large amount of dried feces on the left side of the toilet seat. During an interview and observation on 10/28/24 at 5:54 A.M., with CNA E and Assistant Director of Nursing (ADON) M, CNA E said the resident took himself/herself to the bathroom. CNA E and ADON M entered the resident's room, and the resident lay in bed on his/her right side. CNA E removed the white quilt that had yellow spots on it. He/She pulled the resident's sweatpants down which showed the resident wore two briefs. The pull up brief closest to the resident's body had dried and fresh feces and the outer brief was soiled with urine. CNA E said the resident had the outer brief over the pull up, because the resident doesn't keep the pull up on. CNA E said he/she checked the resident around 1:30 A.M. or 2:00 A.M. and did not remember if the resident had both a pull up and brief on at that time. CNA E said he/she only checked the resident when he/she walked down the hall because the resident took himself/herself to the bathroom. CNA E said he/she glanced, peeked at the resident when he/she walked down the hall. CNA E assisted the resident in standing from the bed and the resident's sweatpants were wet down to his/her knees. The resident's shirt was wet up to his/her waist and below his/her elbows. CNA E walked and guided the resident to the bathroom. When CNA E entered the bathroom there was a large amount of dried feces on the right side of the toilet seat and side of the toilet. CNA E left the room and obtained supplies to clean the toilet. ADON M verified the resident was soiled and began looking for clean clothing for the resident in the resident's closet. ADON M had to exit the room to obtain clean clothing for the resident. CNA E returned and cleaned the toilet as the resident sat on the toilet seat. CNA E had the resident then stand and began cleaning the resident. The resident had no open areas or red areas. CNA E did not change the resident during the night shift. During an interview on 10/28/24, at 6:05 A.M., CNA E, said: -The resident often walked around the unit during the night; -He/She checked the resident for incontinence while the resident walked the halls last night; -CNA E checked for incontinence by peeking in the resident's brief. He/She also touched the resident's brief on the outside of his/clothes, on his/her lower buttocks. If the CNA felt the brief was hard it meant the resident was incontinent and needed care. During an interview on 10/31/24 at 7:23 A.M., ADON M said he/she expected staff to make rounds on the resident every two hours to check for incontinence. ADON M said it was inappropriate to see if the resident was soiled by feeling the resident's brief through his/her clothing while the resident walked down the hall. ADON M expected staff to provide privacy and to visually check the resident's brief to see if the resident was soiled. It was inappropriate to place a brief on top of a pull up to prevent a resident from removing the pull up. 2. Review of Resident #34's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Unclear speech; -Rarely/never understood by others; -Rarely/never was able to understand others; -Short and Long term memory problems present; -Severely impaired cognitive skills for daily decision making; -Impairment to upper body on one side; -Impairment to lower body on both sides; -Wheel chair used for mobility; -Always incontinent of bowel and bladder; -Dependent on staff for toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and all transfers. Review of the resident's care plan, undated, showed: -Problem: The resident had the potential for impaired skin integrity and/or development of pressure-related ulcers and/or breakdown related to incontinence and bedfast; -Interventions included: Assist with toileting needs an incontinence care on routine rounds and as needed; Assist as needed with toileting hygiene and with wearing and changing incontinence undergarments; -Problem: The resident was frequently incontinent of bowel and bladder; -Interventions included: Check and change for incontinence. Observation on 10/28/24 at 4:34 A.M., showed: -There was a strong odor of urine emitting from the resident's room into the hall; -The resident lay on his/her bed on a low air loss mattress; -RN D pulled the resident's bed covers down to show the resident wore two briefs; -The resident's outer brief was soaked with urine, with the padding in the brief in clumps; -The resident lay in a pool of urine, with visible brown rings of urine on the sheet extending from the resident's thighs to his/her shoulders. During an interview on 10/28/24, at 4:35 A.M., RN D said: -He/She did not think the resident was changed during the night shift; -He/She verified the resident wore two briefs, both soaked with urine, and was lying in urine extending up to his/her shoulders. During an interview on 10/28/24, at 5:49 A.M., CNA E said: -He/She worked from 11:00 P.M. to 7:00 A.M. that day; -He/She was assigned to care for the resident; -He/She checked on the resident between 2:45 A.M. and 3:00 A.M. and the resident was not wet and did not require incontinence care; -He/She had just provided incontinence care to the resident; -He/She confirmed the resident was wearing a shirt that was wet with urine up to the middle of his/her back and the resident was lying on a wet absorbent pad before CNA E gave the resident incontinence care. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Wheelchair for locomotion; -Required maximal assistance for toileting hygiene, to shower/bathe self, for upper and lower body dressing, personal hygiene and to roll left and right in the bed; -Dependent on staff for chair/bed-to-chair transfers; -Always incontinent of bowel and bladder. Review of the resident's care plan, undated, showed: -Problem: ADL self-care performance deficit related to activity intolerance, cognitive impairment, debility and decreased mobility; -Interventions included: Required staff assistance to turn and reposition in bed; Required skin inspection with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to Nurse; -Problem: Bladder and bowel incontinence and was at risk for urinary tract infections; -Interventions included: Apply incontinence cream after each incontinence episode; The resident wore briefs; Check and change for incontinence; -Problem: Potential for impairment to skin integrity/pressure ulcer development related to bowel/bladder incontinence and impaired mobility; -Interventions included: Apply incontinence cream after each incontinence episode; Pressure reducing mattress while in bed. Review of the resident's progress notes, showed no documentation the PCP or RRP was alerted to a change in the resident's skin or that a new order for treatment was obtained. Review of the resident's weekly skin assessment, dated 10/21/24, showed no new skin issues noted. There was no documentation to show existing skin issues. Observation on 10/28/24 at 4:50 A.M., showed: -A strong odor of urine and feces emitting from the resident's room into the hall; -The odor of urine and feces was strong upon entry into the room; -The resident was lying in his/her bed on a low air loss mattress; -The resident wore two briefs which were soaked with urine; -The resident was lying on an absorbent pad, placed under his/her buttocks, which was visibly soaked with urine; -The resident's sheet was visibly soaked with urine extending from below the resident's buttocks up to the resident's neck, with brown rings outlining the urine soaked areas; -The resident was wearing a hospital gown that was also urine soaked; -The resident had dried feces on his/her buttocks and inside the inner brief; -The resident's mattress was visibly wet with urine; -The resident's bilateral buttocks were reddened; -The resident's inner thighs were reddened. During an interview on 10/28/24, at 4:52 A.M. and at 5:06 A.M., the resident, said: -He/She had not received incontinence care since the evening before around 6:00 P.M.; -The staff did not usually provide incontinence care during the night shift; -Lying in a pool of urine on the wet sheet was annoying to the resident; -He/She did not like wearing two briefs at once as the briefs cut into his/her inner thighs in a sawing motion and caused him/her pain. During an interview on 10/28/24, at 5:06 A.M., RN D said: -The resident's bilateral buttocks were red with suspected moisture associated skin damage (MASD); -The resident also had MASD located on his/her inner thighs. During an interview on 10/28/24, at 5:17 A.M., CNA F said: -He/She began work yesterday around 11:30 P.M.; -He/She rounded on his/her assigned residents every two hours to check if they needed incontinence care; -He/She was not able to get to the resident until 4:50 A.M. and he/she gave the resident incontinence care at that time; -He/She only put two briefs on residents if they asked for them; -It was not right to put two briefs on a resident because it was not possible to see if the inner brief was wet; -It was difficult for CNA F to give care to all his/her residents last night due to the lack of staff; -The resident required the assistance of two people when giving incontinence care and CNA F had to wait until CNA E, who worked the other hall, was able to assist. Review of the resident's weekly skin assessment, dated 10/28/24 at 12:43 P.M., showed no documentation of skin issues at the resident's buttocks or groin. During an interview on 10/29/24 at 6:19 A.M., the resident said he/she was changed at 10:00 P.M. last night and one other time earlier this morning. The resident's room had a very strong urine odor. The resident said he/she was unsure if he/she had on two briefs. The resident said it depended on what staff changed him/her if they put one or two briefs on. The resident said it seemed like they put two briefs on all the time. The resident said he/she was changed and repositioned one time each shift, but needed changed and repositioned more often. The resident said when he/she turned his/her call light on it took an hour to an hour and a half before staff responded to the call light. The resident also said staff did not offer ice water. The resident had a water pitcher on his/her bed side table without a lid with approximately 2 inches of water. The resident said the water in the cup was left over from the ice he/she requested yesterday after dinner. The resident would like ice water to be passed out each shift. During an observation and interview on 10/29/24 at 6:36 A.M., RN D entered the resident's room and asked if he/she could check to see if the resident was wet. The resident agreed. RN D verified the resident had on two briefs and the briefs were soaked with urine. RN D said it was not appropriate for any resident to have on two briefs. If a resident wore two briefs, staff could think the resident was dry by only looking at the outer brief. If residents were left soiled for an extended periods of time it could cause skin integrity issues such as redness and skin breakdown that could lead to open areas. Observation and interview on 10/29/24 at 6:40 A.M., with the resident, showed: -He/She wore two briefs which were both visibly soaked with urine; -He/She did not like to wear two briefs as they were uncomfortable, too tight between his/her legs and cut into his/her groin. During an interview on 10/31/24 at 7:23 A.M., ADON M expected residents to be rounded on every two hours. ADON M expected residents to only have one brief on. The resident's skin integrity was at risk due to the moisture. It could cause skin break down because the briefs did not allow for oxygen to get to the skin. It was imperative to only use one brief on residents. 4. Review of Resident #46's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Toileting, shower, upper and lower body dressing, put on and take off footwear, personal hygiene, and roll left and right: substantial maximal assistance; -Shower transfer, dependent; -Eating and oral hygiene: Partial moderate assistance (helper does less than half the effort); -Frequently incontinent of bladder; -Always incontinent of bowel; -Diagnoses included muscle weakness, dementia, difficulty in walking, and need for assistance with personal care. During an observation and interview on 10/28/24 at 4:51 A.M., RN D entered the resident's room and asked permission to check the resident's brief. The resident agreed. The resident said the last time he/she had been changed was at 5:00 P.M. the previous day. The resident said he/she had not been changed all night. The resident wore two briefs. The inner brief was brown and saturated with urine. The resident's room had a strong urine odor. During an interview on 10/28/24 at 12:01 P.M., the resident said he/she did not like to be soiled for extended periods of time. The resident also said his/her family got ice water for him/her on the days they were at the facility. On days the family was not at the facility, the resident was not offered ice water. During an interview on 10/29/24 at 7:30 A.M. and at 9:24 A.M., the resident, said: -There was a cup with approximately four inches of water on his/her bedside table, within reach; -He/She did not have fresh ice water; -He/She could not remember the last time staff gave him/her fresh ice water; -Staff last checked on the resident around 6:00 A.M. that morning. The resident was not sure when staff would return; -The resident wanted fresh ice water and hoped staff would fill up his/her cup as it sure would be nice. During an interview on 10/31/24 at 6:20 A.M., the resident said he/she had not been changed since 10:00 P.M. the previous day. The resident said he/she was wet and needed changed. The resident's room had a strong odor of urine. During an observation and interview on 10/31/24 at 6:24 A.M., ADON M entered the resident's room and asked permission to check the resident's brief, and the resident agreed. The resident's room had a strong odor of urine. The resident wore one brief that was saturated with urine. The resident was lying on an absorbent pad that was also saturated with urine. The fitted sheet under the absorbent pad was also saturated with urine and had brown rings extending up to the middle of the resident's back. The resident's shirt was also saturated up to the middle of the resident's back. ADON M washed his/her hands and exited the room. ADON M walked up to CNA J who was sitting in the hallway and asked CNA J who had the resident. CNA J responded the resident was on another CNA's assignment. ADON M told CNA J the resident needed a full bed change and CNA J said he/she would assist the resident. During an interview on 10/31/24 at 7:23 A.M., ADON M said it was not appropriate for staff to not complete rounds every two hours on residents. He/She said it was not appropriate for a resident to not be changed from 10:00 P.M. unit 6:30 A.M. the following day. He/She said night shift started at 11:00 P.M. and the resident was not changed for the entire night shift. ADON M said he/she spoke to the night shift charge nurse and CNA J was the CNA responsible for completing rounds and changing the resident but he/she did not have an opportunity to speak with CNA J before he/she left. ADON M said CNA J reported the resident was on another CNA's assignment. ADON M said he/she expected staff to be knowledgeable of and follow the facility's policies. ADON M said he/she expected staff to make rounds on residents every two hours and know what residents they were responsible for each shift. 5. Review of Resident #43's annual MDS, dated [DATE], showed: -Adequate hearing; -Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses of anxiety and depression. Review of the resident's care plan, located in the electronic medical record (EMR), showed: -11/9/21, Focus: ADL self-care performance deficit; -Goal, Resident requires assistance with ADL care and mobility; -Interventions: Personal hygiene, one assist. Toilet use, utilize check and change to manage incontinence; -10/23/24, Focus: Frequently incontinent bowel and bladder; -Goal: Will remain free from skin breakdown; -Interventions: Incontinent. Check and change for incontinence. During an interview on 10/30/24 at 7:47 A.M., the resident said he/she was incontinent of bowel and bladder. It was not uncommon for staff to put two incontinent briefs on him/her on the night shift, which he/she did not mind. Most nights staff checked him/her for incontinence one time, which was not enough. Staff told the resident there was not enough help to check him/her more than once. If he/she turned on his/her call light it could take hours for staff to answer it. Or, they would answer it, turn the call light off and leave without taking care of him/her. It made him/her feel bad when he/she was left wet for long periods. 6. Review of Resident #44's annual MDS, dated [DATE], showed: -Adequate hearing; -Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses of anxiety and depression. Review of the resident's care plan, located in the EMR, showed: -8/22/23, Focus: Bladder incontinence related to impaired mobility; -Goal: Will remain from skin breakdown due to incontinence and brief use; -Interventions: Check as required for incontinence. During an interview on 10/30/24 at 7:37 A.M., the resident said he/she was incontinent of bowel and bladder. Most night shifts, staff would check and change him/her twice at the most; sometimes only once. In the past couple of weeks there had been some nights no one came to check him/her at all. Sometimes staff put two incontinent briefs on him/her but he/she would prefer only one. When he/she was checked once or not at all, he/she laid in a puddle of urine. Most nights he/she was unable to turn on his/her call light because staff did not leave the call light where he/she could reach it. When the call light was in reach and he/she turned it on, it could take hours for someone to answer it. He/She felt ignored by staff. 7. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Rejection of care not exhibited; -Frequently incontinent of bowel and bladder; -Diagnosis included need for assistance with personal care, abnormalities of gait and mobility, muscle weakness, and reduced mobility. Review of the resident's care plan during the survey, showed: -Focus: ADL self-care performance deficit; -Goal: Resident requires assistance with ADL care and mobility; -Interventions: -Bed mobility requires staff assistance to turn and reposition in bed; -Toilet use requires staff assistance of one; -Transfer requires staff assistance of one; -Encourage use of call light. During an interview on 10/28/24 at 8:08 A.M., the resident said staff did not come in and offer to change him/her when he/she was soiled. The resident said he/she must get out of bed and change himself/herself and put the soiled briefs in the trash can next to his/her bed. The resident said the trash was just changed and was overflowing with soiled briefs. The staff member who came in and took the trash threw a fit and wanted to know why all the briefs were in the trash can. The resident then became tearful and said he/she was doing the best he/she could. The resident said it would be helpful if the staff assisted him/her to change his/her brief when soiled, but said staff would not assist him/her. The resident said it took up to two hours for staff to answer his/her call light if they came at all. The resident said staff did not pass or offer ice water. The resident said he/she had a small green cooler he/she kept on his/her walker. The resident filled this small cooler up himself/herself. 8. During an observation on 10/31/24 at 6:44 A.M. a resident walked up to the ice chest next to the nurse's station and opened the lid and said there was no ice in the cooler. The cooler was half full of water at that time. The resident made the comment that he/she last received ice before he/she went to bed. 9. During an interview on 10/28/24, at 4:10 A.M., RN D, said: -He/She worked the night shift from 11:00 P.M. until 7:00 A.M. last night; -There were two CNAs for 58 residents and one nurse during his/her shift; -He/She did not feel the residents were getting appropriate care as there was not enough staff to care for them; -Sometimes it took them over an hour to answer call lights and the residents were left wet for all that time because there were so many residents who required two people for direct care; -He/She had not told the Administrator or DON, as he/she understood they were already aware; -He/She had to wake CNA F around 1:00 A.M. to answer call lights. CNA F was sleeping at the nurses' station in a chair with a blanket; -He/She found CNA E asleep in a bed in an un-occupied resident room at 3:30 A.M.; -The CNAs typically started to round on residents at 5:00 A.M. to clean up the residents before day shift came in. During an interview on 10/28/24 at 5:18 A.M., CNA F said rounds should be completed every two hours. While making rounds residents were checked to see if they need to be changed, repositioned, trash was checked to see if it needed to be taken out and see if the residents needed fresh ice and water. CNA F said he/she completed rounds on night shift between 11:30 P.M. and 12:00 P.M., 2:00 A.M. and 5:00 A.M. CNA F said if residents wore two briefs, it helped the urine not go all the way to the resident's back. CNA F said it was not normal to put two briefs on residents. He/She would only put two briefs on a resident if they requested it. CNA F said when a resident had two briefs on it was hard to determine if the resident was wet. During an interview on 10/30/24 at 7:22 A.M., CNA F said night shift was from 11:00 P.M. to 7:00 A.M. and rounds were completed two times before 5:00 A.M. When he/she came in at 11:00 P.M. he/she made rounds with the evening shift CNA. During rounds he/she checked to see if residents needed ice water, tv remote, call light, if the residents needed to be changed or taken to the bathroom and made sure the residents were breathing. If a resident had on two briefs it was not good because the outer brief could look dry and the inner brief could be wet. He/She would be reluctant to change them if the resident looked dry. If residents were not changed it could cause them to get red bottoms or bed sores. CNA F said when there was only one CNA on each side and one nurse it took a long time to answer call lights. CNA F said if four to five call lights were on he/she would quickly go to each person with a call light on to make sure there was not an emergency like slipping off the bed or a fall. CNA F said he/she would then start changing the first resident that had the call light on. It took up to 20 minutes to change one resident because he/she had to go to the room see what he/she needed, then go to the clean utility closet and get supplies, then go back to the resident's room to clean and change the resident. CNA F said it could take up to an hour and forty minutes to answer a call light at times. During an interview on 10/30/24 at 7:00 A.M., CNA K said he/she worked the day shift, 7:00 A.M. until 3:00 P.M. When he/she started to get residents ready after first arriving on duty, it was not uncommon to find several residents wearing two incontinent briefs soaked through with urine. This occurred several times a week. He/She did not think those residents could possibly have been checked and changed every two to three hours. He/She had not told the nurses. During an interview on 10/30/24 at 7:27 A.M., CNA L said he/she worked the day shift. When he/she reported to work he/she started to get residents ready for the day. He/She frequently found residents heavily saturated in urine. Sometimes some residents wore two incontinent briefs, and they were saturated with urine. He/She did not feel those residents could possibly have been checked for incontinence every two hours. During an interview on 10/30/24 at 11:16 A.M., the Administrator and DON said they expected call lights to be answered within 15 to 20 minutes. They said it was not appropriate for residents wait for a call light to be answered over the period of one to two hours. If a resident waited one to two hours for a call light to be answered there was a risk if the resident needed to use the restroom, they could attempt to take themselves and fall. They wanted call lights answered as promptly as possible because the staff did not know what the resident needed. Ice water should be passed every shift at a minimum and more if needed. It was not appropriate to feel a resident's brief through the resident's clothing in the hallway to check and see if the resident was soiled. MO00242946 MO00241933 MO00243961

37681 Based on observation, interview and record review, the facility failed to keep the second floor unit with functioning, alarmed doors for one of three second floor stairwell doors. Observation on 1/9/24 at 10:40 A.M. and 1/10/24 at 8:00 A.M., showed the second floor door to the stairwell, adjacent to room [ROOM NUMBER], alarmed at the nurse's station with the same sound as the call light system. The door was also equipped with a local alarm, but the local alarm did not function when the door was opened. The door's delayed-egress function did not operate, and the door opened immediately when pushed. Observation on 1/9/24 at 11:05 A.M. and 1/10/24 at 8:00 A.M., showed the door at the bottom of the stairwell also alarmed at a nurse's station with the same sound as a call light, and had no functioning local alarm at the door. The door's delayed-egress function did not activate and the door opened immediately when pushed. Not all second floor staff interviewed were aware of the call light code which indicated an exit door was open. Prior to 1/9/24, maintenance staff were not aware the exit door alarm at the second floor stairwell was not functioning properly. Maintenance staff were not aware how the door at the bottom of the stairwell alarmed. The second floor had 12 ambulatory residents. Six of the 12 residents were cognitively impaired. As of 1/9/24, one resident was identified by the facility as a moderate risk for elopement (Resident #83) and one resident at risk for elopement (Resident #14). The census was 107. The Administrator was notified on 1/12/24 at 6:00 P.M., of an immediate jeopardy (IJ) which began on 1/9/24. The IJ was removed on 1/10/24 as confirmed by surveyor on-site verification. Review of the facility's Accident and Incident Documentation and Investigating Policy, revised 4/26/23, showed: -Policy: Accidents and/or incidents involving residents will be investigated and documented on an Incident Report entry in the Electronic Health Record (EHR). An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventative measures to reduce the occurrence of incidents; -Responsibility: Licensed Nursing, Nursing Administration, Director of Nursing (DON) and Administrator. Review of the undated facility instructions for checking the delayed egress operation, showed: -Push door release hard for a fraction of a second. Door should not open and alarm should not sound; -Apply pressure to the door release for the pre-determined nuisance period setting (normally 1-3 seconds); -Door should go into irreversible unlocking sequence; *Door alarm will sound; *Door will automatically open within 15-30 seconds; -Confirm that security panels at Nurse's Station activate when the door is opened and that it properly indicates the location of the door release. 1. Review of Resident #83's Elopement Risk Evaluation, dated 10/5/23, showed the resident at a moderate risk for elopement. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/12/23, showed: -Severe cognitive impairment; -Exhibited no behaviors; -Walks with supervision or touching assistance; -Diagnoses included Alzheimer's disease and arthritis. Review of the resident's undated care plan, in use during the time of survey, showed no information regarding the resident being at risk for elopement. During an interview on 1/17/24 at 12:00 P.M., Certified Nursing Assistant (CNA) C said the resident tended to wander. 2. Review of Resident #14's Elopement Risk Evaluation, dated 12/22/23, showed: -At risk for elopement; -The resident wandered; -The wandering behavior was a pattern and goal-directed with specific destinations in mind. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Exhibited no behaviors; -Walks with supervision or touching assistance; -Diagnoses included anemia (inadequate amount of healthy red blood cells), seizures and bipolar disease (a disorder associated with moods swings ranging from depressive lows to manic highs). Review of the resident's undated care plan, in use during the time of survey, showed no information regarding the resident being at risk for elopement. 3. During an interview on 1/17/24 at 3:59 P.M., the Administrator and DON said on 1/10/24, Residents #83 and #14 were reassessed for the risk of elopement and were determined to be not at risk. 4. Observations on 1/9/24 of the second floor delayed-egress door leading to the stairwell, near room [ROOM NUMBER] between 10:35 A.M. and 3:00 P.M., and 1/10/24 between 8:05 A.M. and 8:30 A.M., showed: -A sign on the door read, Push until alarm sounds. Door can be opened in 15 seconds.; -A keypad on the wall to the left of the door; the keypad was not illuminated; -An alarm box at the top of the door; -On 1/9/23 at 10:35 A.M., the Maintenance Associate pushed the door and it opened without delay. No alarm sounded at the door. The door opened into the stairwell. The stairwell led down to the first floor and another delayed- egress door which opened to a side driveway; -The alarm at the nurse's station could not be heard from the egress door. During an interview on 1/9/23 at 10:40 A.M., the Maintenance Associate said there was obviously something wrong with the keypad because it was not lit up. It was not getting any power to it. The door should not be opening without a delay. He/She had no idea how long it had been like that. No one had reported the door was not working. There should be an alarm going off at the door to alert staff when the door opened. 5. Observations of the first floor egress door, near room [ROOM NUMBER], on 1/9/23 between 11:05 A.M. and 3:00 P.M., and 1/10/24 between 8:00 A.M. and 8:35 A.M., showed: -A key pad on the wall to the right of the door; -An alarm box on the top of the door; -The door opened onto a walkway that led to a driveway on the side of the facility; -At 11:05 A.M., the Maintenance Supervisor pushed the door and it immediately opened without delay and no alarm sounded at the door. He said he thought the door should have a delay on it and should have alarmed, but was not sure. No one had reported it was not working to him. It could be a problem because the second floor stairwell delayed-egress door was not working, and residents could exit out this door; -The alarm from the nurse's station could not be heard from the egress door; -On 1/10/24 at 8:00 A.M., the surveyor pushed the door and it opened without a delay. No alarm sounded at the door. No alarm could be heard from the area of the door and no staff responded to the door. 6. Observation on 1/10/24 between 1:25 P.M. and 1:50 P.M., of the second floor nurse's station, showed a light at the panel with the door 2087 (which was the delayed-egress door to the stairwell adjacent to room [ROOM NUMBER]) lit up. The alarm at the nurse's station was indistinguishable from the other call lights from resident rooms. During this period of time, no staff entered the nurse's station to check the lights. 7. During an interview on 1/10/24 at 8:05 A.M., Certified Medication Technician (CMT) K said he/she worked at the facility for about nine years, and the door at the 200 stairwell had not worked since he/she had been there. It would alarm at the nurse's station but you could not hear it if you were down at the end of a hall or in a resident's room. During an interview on 1/10/24 at 8:10 A.M., CNA Q said he/she worked at the facility for about a month. The door to the 200 hall stairway had not worked since he/she started working at the facility. He/She did not know it alarmed at the nurse's station and would not know to go look for the door alarm there. No one told him/her to watch for residents going out that door. During an interview on 1/10/24 at 10:05 A.M., Nurse C said the exit doors alarm at the nurse's stations, but you have to be close to the station to hear them. They sound just like a call light. There was a list on the wall with the locations of the door alarms on it, which staff could look at to see where the alarms were going off. If a resident got out the second floor door and then out the first floor door, then they were free. Every once in a while, you had a resident who got out of the building. They did not have elopement risk residents on their hall, but they had residents who would wander from the other halls and they had to watch out for those residents and redirect them away from the door. During an interview on 1/10/24 at 10:15 A.M., CMT R said he/she did not know the second and first floor doors were unlocked. He/She did not know the doors alarmed at the nurse's station or that there was a list of door codes posted. They did not always go to the nurse's station to look at the call lights because they would look down the hall and answer them, or they might see a light on and it would take a few minutes to get to that resident. He/She did not think they had any residents at risk for elopement on the second floor. During an interview on 1/10/24 10:21 A.M., CNA S said he/she had been working at the facility since July and was not aware of any residents who were at risk for elopement and did not know the door at the end of the hall was not alarming. During an interview on 1/10/24 at 10:18 A.M., the Director of Rehabilitation, said she had worked at the facility for [AGE] years and she was not aware of any residents who were at risk for elopement and did not know the door was not alarming. During an interview on 1/10/24 at 10:16 AM., the Regional Corporate Executive said he was just made aware the door was not alarming. He said he was not sure how long it had not been working. During an interview on 1/10/24 at 12:25 P.M., the Chief Nursing Officer said the Maintenance Supervisor told them the day before the delayed-egress doors were not working, but she thought he fixed them. During an interview on 1/10/24 at 12:15 P.M., the Administrator said maintenance staff were responsible for checking the egress doors monthly. Maintenance records showed the doors were last inspected on 1/3/24 and they passed. The Maintenance Director quit on 1/8/24. She would have expected staff to have informed maintenance or administration the doors were not working. She did not know the alarms could not be heard from the end of the hall or could not be distinguished from the call lights. Note: At the time of the 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 actions 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 the exit, the deficiency was lowered to the D level. This statement does not denote 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). 44948

Based on observation, interview and record review, the facility failed to uphold a resident's right to a dignified existence when staff left a bag of briefs soiled with bowel movement (BM) on the resident's nightstand, approximately one foot from the head of the resident's bed for an extended amount of time (Resident #89). The resident reported having a fear of retaliation from the facility. In addition, staff left a soiled towel on the floor of the resident's room and failed to remove a trash can smeared with BM from the resident's room. The sample size was 18. The census was 107. Review of the facility's Resident Rights policy, dated 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect and dignity and ensure Resident Rights are being followed. The Resident/Resident Representative will be informed on their rights upon admission; -Procedures: -Employees will receive education and training on resident rights upon hire and annually; -The Administrator/designee will process concerns with resident rights; -Resident Rights: -Exercise rights; -Planning/implementing care; -Respect and dignity; -Self-determination; -Safe environment. Review of Resident #89's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/23, showed: -Cognitively intact; -Exhibited no behaviors; -Dependent on staff for personal hygiene, showers, toileting hygiene and transfers. Helper does all of the effort; -Always incontinent of bowel and bladder; -Diagnoses included cancer, diabetes and quadriplegia (a form of paralysis that affects all four limbs, plus the torso). Review of the resident's undated care plan, in use during the time of the investigation, showed: -Focus: The resident has bowel and bladder incontinence related to impaired mobility; -Goal: The resident will remain free from skin breakdown due to incontinence and brief use; -Interventions: Clean peri-area with each incontinent episode. Resident prefers/request to use two briefs at night due to increased incontinence; -Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to impaired mobility, bilateral hand contractures and requires assistance with mobility; -Goal: The resident will demonstrate appropriate use of adaptive devices to increase ability with ADLs through the review date; -Interventions: Personal hygiene routine. The resident prefers his/her family member to assist with shaving. The resident would like for staff to offer assist with shaving if family is not available. Bed mobility. Requires staff assistance to turn and reposition in bed. Observation on 3/5/24 at 9:35 A.M., showed a strong odor of BM present at the doorway of the resident's room. The resident's call light was pressed. The resident lay in bed on his/her back. He/She emitted a strong smell of urine and BM. A towel soiled with BM was on the floor near the resident's bed. The resident's trash can did not have a trash can liner, and contained wadded up paper. A brown substance was smeared on the inside of the trash can. The resident's bed was in the center of the room. To the left of the resident's bed was a nightstand, approximately one foot away from the head of the resident's bed. On top of the nightstand sat an unsealed bag. Observation of the bag, showed approximately three used briefs, filled with BM, in the open plastic bag. During an interview on 3/5/24 at 9:36 A.M., the resident said he/she pressed his/her call light earlier during the morning, and no one came to check on him/her. He/She had a bowel movement and needed to be changed. Observation and interview on 3/5/24 at 9:37 A.M., showed Certified Nursing Assistant (CNA) Q responded to the resident's call light. The resident said he/she needed to be changed. When shown the bag on the resident's nightstand, close to the resident's head, CNA Q said the bag contained used briefs filled with BM. He/She tied the bag and removed it from the resident's nightstand. When shown the trash can, CNA Q said BM was in the trash can and the trash can needed a liner. He/She was not sure who left the bag of soiled briefs on the nightstand and had not changed the resident's trash can from earlier that day. CNA Q said he/she would get the resident cleaned up. Observation and interview on 3/5/24 at 10:51 A.M., showed the resident lay in bed on his/her back. The bag of briefs soiled with BM had been removed from the resident's room. The soiled towel remained on the floor in the resident's room. The trash can still contained the smeared BM on the inside, with no liner. The resident said the aide cleaned him/her up and said he/she would return to get the resident up and in his/her wheelchair. On 3/4/24, he/she was changed around 2:00 P.M., after lunch. He/She pressed the call light during the evening shift, and no one responded. After a change in shift, around 11:45 P.M., he/she was changed again. The resident said he/she always smelled of urine and BM and was used to it. He/She had not been changed until 9:37 A.M. on 3/5/24, after the surveyor arrived in the resident's room. He/She had a spinal cord injury and could not turn his/her head to see the bag of dirty briefs on the nightstand. The resident said the aide must have left the briefs in the resident's room the night before and could not recall who the aide was. He/She smelled odors of BM and urine, but thought it was him/her because staff rarely cleaned him/her. The resident said he/she was afraid of the situation being addressed because of fear of retaliation. He/She said since the last survey, things had gotten worse and the resident felt it was retaliation because he/she spoke with the surveyors. He/She said staff already did not do anything prior to the first survey, but it had gotten worse. He/She said, I have to survive here. The resident pressed his/her call light for assistance to get out of bed and into his/her wheelchair. The resident had tears in his/her eyes during the interview. Observation on 3/5/24 at 11:01 A.M., showed CNA Q and CNA M arrived and said they would get the resident into his/her chair. The aides transferred the resident using a mechanical lift and sat the resident in the wheelchair. CNA M left as CNA Q placed a blanket over the resident. CNA Q obtained a trash can liner and placed it into the trash can. He/She did not clean the inside of the trash can and the smear of BM remained. CNA Q adjusted the resident's movable nightstand and placed the call light, a cup of water and television remote control within reach, then left the resident's room. Observation on 3/5/24 at 11:22 A.M., showed the Administrator walked past the resident's room. The surveyor showed the BM smeared trash can to the Administrator. She said it was absolutely unacceptable and removed the trash can from the resident's room. The odor remained in the resident's room. During an interview on 3/6/24 at 11:40 A.M., the Administrator said residents should be treated with dignity and respect. It was unacceptable for a bag of dirty briefs to be present in the resident's room. Staff should have removed the briefs after providing care to the resident. The resident's trash can should have been removed and cleaned after the aide discovered the smear of BM in the trash can. The resident should be able to express concerns without fear of retaliation. MO00231882 MO00231534

Based on observation, interview and record review, the facility failed to uphold a resident's right to a dignified existence when staff left a bag of briefs soiled with bowel movement (BM) on the resident's nightstand, approximately one foot from the head of the resident's bed for an extended amount of time (Resident #89). The resident reported having a fear of retaliation from the facility. In addition, staff left a soiled towel on the floor of the resident's room and failed to remove a trash can smeared with BM from the resident's room. The sample size was 18. The census was 107. Review of the facility's Resident Rights policy, dated 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect and dignity and ensure Resident Rights are being followed. The Resident/Resident Representative will be informed on their rights upon admission; -Procedures: -Employees will receive education and training on resident rights upon hire and annually; -The Administrator/designee will process concerns with resident rights; -Resident Rights: -Exercise rights; -Planning/implementing care; -Respect and dignity; -Self-determination; -Safe environment. Review of Resident #89's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/23, showed: -Cognitively intact; -Exhibited no behaviors; -Dependent on staff for personal hygiene, showers, toileting hygiene and transfers. Helper does all of the effort; -Always incontinent of bowel and bladder; -Diagnoses included cancer, diabetes and quadriplegia (a form of paralysis that affects all four limbs, plus the torso). Review of the resident's undated care plan, in use during the time of the investigation, showed: -Focus: The resident has bowel and bladder incontinence related to impaired mobility; -Goal: The resident will remain free from skin breakdown due to incontinence and brief use; -Interventions: Clean peri-area with each incontinent episode. Resident prefers/request to use two briefs at night due to increased incontinence; -Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to impaired mobility, bilateral hand contractures and requires assistance with mobility; -Goal: The resident will demonstrate appropriate use of adaptive devices to increase ability with ADLs through the review date; -Interventions: Personal hygiene routine. The resident prefers his/her family member to assist with shaving. The resident would like for staff to offer assist with shaving if family is not available. Bed mobility. Requires staff assistance to turn and reposition in bed. Observation on 3/5/24 at 9:35 A.M., showed a strong odor of BM present at the doorway of the resident's room. The resident's call light was pressed. The resident lay in bed on his/her back. He/She emitted a strong smell of urine and BM. A towel soiled with BM was on the floor near the resident's bed. The resident's trash can did not have a trash can liner, and contained wadded up paper. A brown substance was smeared on the inside of the trash can. The resident's bed was in the center of the room. To the left of the resident's bed was a nightstand, approximately one foot away from the head of the resident's bed. On top of the nightstand sat an unsealed bag. Observation of the bag, showed approximately three used briefs, filled with BM, in the open plastic bag. During an interview on 3/5/24 at 9:36 A.M., the resident said he/she pressed his/her call light earlier during the morning, and no one came to check on him/her. He/She had a bowel movement and needed to be changed. Observation and interview on 3/5/24 at 9:37 A.M., showed Certified Nursing Assistant (CNA) Q responded to the resident's call light. The resident said he/she needed to be changed. When shown the bag on the resident's nightstand, close to the resident's head, CNA Q said the bag contained used briefs filled with BM. He/She tied the bag and removed it from the resident's nightstand. When shown the trash can, CNA Q said BM was in the trash can and the trash can needed a liner. He/She was not sure who left the bag of soiled briefs on the nightstand and had not changed the resident's trash can from earlier that day. CNA Q said he/she would get the resident cleaned up. Observation and interview on 3/5/24 at 10:51 A.M., showed the resident lay in bed on his/her back. The bag of briefs soiled with BM had been removed from the resident's room. The soiled towel remained on the floor in the resident's room. The trash can still contained the smeared BM on the inside, with no liner. The resident said the aide cleaned him/her up and said he/she would return to get the resident up and in his/her wheelchair. On 3/4/24, he/she was changed around 2:00 P.M., after lunch. He/She pressed the call light during the evening shift, and no one responded. After a change in shift, around 11:45 P.M., he/she was changed again. The resident said he/she always smelled of urine and BM and was used to it. He/She had not been changed until 9:37 A.M. on 3/5/24, after the surveyor arrived in the resident's room. He/She had a spinal cord injury and could not turn his/her head to see the bag of dirty briefs on the nightstand. The resident said the aide must have left the briefs in the resident's room the night before and could not recall who the aide was. He/She smelled odors of BM and urine, but thought it was him/her because staff rarely cleaned him/her. The resident said he/she was afraid of the situation being addressed because of fear of retaliation. He/She said since the last survey, things had gotten worse and the resident felt it was retaliation because he/she spoke with the surveyors. He/She said staff already did not do anything prior to the first survey, but it had gotten worse. He/She said, I have to survive here. The resident pressed his/her call light for assistance to get out of bed and into his/her wheelchair. The resident had tears in his/her eyes during the interview. Observation on 3/5/24 at 11:01 A.M., showed CNA Q and CNA M arrived and said they would get the resident into his/her chair. The aides transferred the resident using a mechanical lift and sat the resident in the wheelchair. CNA M left as CNA Q placed a blanket over the resident. CNA Q obtained a trash can liner and placed it into the trash can. He/She did not clean the inside of the trash can and the smear of BM remained. CNA Q adjusted the resident's movable nightstand and placed the call light, a cup of water and television remote control within reach, then left the resident's room. Observation on 3/5/24 at 11:22 A.M., showed the Administrator walked past the resident's room. The surveyor showed the BM smeared trash can to the Administrator. She said it was absolutely unacceptable and removed the trash can from the resident's room. The odor remained in the resident's room. During an interview on 3/6/24 at 11:40 A.M., the Administrator said residents should be treated with dignity and respect. It was unacceptable for a bag of dirty briefs to be present in the resident's room. Staff should have removed the briefs after providing care to the resident. The resident's trash can should have been removed and cleaned after the aide discovered the smear of BM in the trash can. The resident should be able to express concerns without fear of retaliation. MO00231882 MO00231534

See Event ID # MK6L13. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 11/16/22. Based on observation, interview and record review, the facility failed to ensure pain management by not following physician orders or assessing pain for two residents (Resident #20 and Resident # 29) who required such services. The sample was 3. The census was 98. Review of the facility's Physician Order policy, dated 9/28/22, showed the following: -Purpose: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, State and Federal guidelines; -Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy, if available. Review of the facility's Pain Management Policy, last review date 11/15/22, showed: -Policy: The facility will use a systematic approach to pain management; recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmacological/non-pharmacological interventions to assist in pain management. The facility will provide employees education on pain management & opioid overdose; -Responsibility: nursing personnel, nursing administration, and Director of Nursing (DON); -Procedure: Recognition: -1. Evaluate/Prevent: -Recognize when resident is experiencing pain and identify circumstances when pain can be anticipated; -Evaluate resident for pain on admission and routine evaluations; -Manage/Prevent pain, consistent with the comprehensive evaluation and plan of care; -Current professional standards of practice, and resident's goals/preferences; -2. Observe for nonverbal indicators: -Change in gait (e.g., limping), skin color/perspiration, vital signs (V/S) (e.g., increased pulse, respirations, blood pressure); -Loss of function or decline in activities of daily living (ADL) (e.g., rubbing a specific location of the body, or guarding a limb); -Fidgeting, increased restlessness; -Facial Expressions (e.g., grimacing, frowning, clenching of the jaw); -Behavioral Changes (e.g., pacing, irritability, depressed mood, decreased participation in activities); -Weight Loss, Loss of Appetite, Difficulty Eating; -Difficulty Sleeping or Decline in Activity Level; -Negative Vocalization (e.g., groaning, crying, whimpering, screaming); -Skin Conditions; -3. Verbal Descriptors: -Heaviness/Pressure; -Stabbing; -Throbbing; -Hurting/Aching; -Gnawing; -Cramping; -Burning; -Numbness, tingling, shooting, radiating; -Spasms; -Soreness, tenderness, discomfort, pins, needles; -Tearing/Ripping; -Pain evaluation: -1. Nursing will complete a Pain Evaluation Tool, appropriate for the Resident's Cognitive Status, to assist with Evaluation of a Resident's Pain; -2. Evaluation of Pain by the Licensed Nurse or Medical Provider; -History of pain and treatment; -Non-Pharmacological, Pharmacological, & Alternative Medicine (CAM) Treatment; Response/Effective to treatment; -Ask the resident to rate the intensity of his/her pain using a numerical scale, verbal or visual descriptor that is appropriate and preferred by the resident; -Reviewing the resident's current medical conditions (e.g., pressure injuries, diabetes with neuropathic pain (pain caused by damage to the nerves), immobility, infections, amputation, oral health conditions, cerebrovascular accident (CVA, stoke), venous and arterial ulcers ulcer (caused by decreased blood circulation), and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue)); -Identifying Key Characteristics of Pain: -Duration; -Frequency; -Location; -Timing; -Pattern (e.g., constant, or intermittent); -Radiation; -Obtaining Descriptors of Pain (e.g., stabbing, aching, pressure, spasms); -Identifying activities, Resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate Pain; -Impact of Pain on ADL (e.g., sleeping, social activities, physical activity and mobility, emotions, intimacy, appetite, and mood, etc.); -Current prescribed pain medications, dosage, frequency, treatments, and modalities; -Pain management and treatment: -1. Based on the evaluation, nursing in collaboration with the physician/prescriber, other health care professionals, the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent/manage a resident's pain beginning at admission; -2. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing medical conditions that may be associated with pain management goal; -3. The interdisciplinary team, the resident and/or the resident's representative will collaborate and discuss realistic, and measurable goals for treatment; -4. Factors influencing treatment: -Cause, location, and severity of pain; -Resident's medical condition; -Resident's current medications; -Resident's desired level of relief & tolerance (e.g., partial Pain reduction with fewer adverse consequences); -Potential risk/benefits and adverse consequences of medications; -Available treatment options; -Resident's elected hospice benefit; -5. Non-Pharmacological Interventions: -Environmental comfort measures (e.g., adjusting room temperature, comfortable seating/lines, assistive devices); -Loosening constrictive bandage, clothing, or device; -Applying Splinting (e.g., pillow or folded blanket); -Physical Modalities (e.g., cold compress, warm shower/bath, massage, turning/repositioning); -Exercises to assist with Stiffness, contractures, and restorative nursing programs to maintain Joint mobility. Cognitive/behavioral interventions (e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the Resident coping techniques and education about Pain); -6. Pharmacological interventions will follow a systematic approach for selecting medications/doses to manage pain. The practitioner and interdisciplinary team (IDT) is responsible for developing a pain management regimen that is specific to each resident who has pain/potential for pain; -General principles for analgesics (a medication to relieve pain); -Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic for pain therapy; -Consider evidence-based practice tools to assist in the evaluation of the resident's pain; -Consider administering medication routinely instead of as needed (PRN) or combining longer acting medications with PRN medications for breakthrough pain; -Utilize the most effective and least invasive route for analgesic administration (e.g., oral, rectal, topical, injection, infusion pump and/or transdermal); -Use lower doses of medication initially and titrate slowly upward until comfort is achieved; -Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects; -Review medical conditions which may require several analgesics and/or adjuvant medications; -Documentation will clarify the rationale for a Treatment Regimen and acknowledge associated risks; -Opioids (medication for pain) will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences; -Nursing will notify practitioner if the resident's pain is not controlled by the current treatment regimen; -Referral to a pain management clinic for other interventions that need to be administered under the close supervision of pain management specialists will be considered for residents with advanced, complex, or poorly controlled pain; -7. Monitoring, Re-evaluation, and care plan revision; -Nursing will reassess resident's pain management for effectiveness and/or adverse consequences (e.g., constipation, sedation, anorexia, change in mental status, delirium, respiratory depression, pruritus, nausea, vomiting, addiction and falling or drowsiness) at established intervals; -If Re-Evaluation findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated; -If pain has resolved or there is no longer an indication for pain medication, the IDT will work to discontinue or taper analgesics (as needed to prevent withdrawal symptoms). 1. Review of Resident #20's medical record showed the following: -admitted on [DATE]; -A baseline care plan, dated 12/30/22 was started at 7:47 P.M. Pain was not listed as a focus. -Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/12/23, showed: -Cognitively intact; -Required extensive assistance of two staff for bed mobility and transfers; -On a scheduled pain regimen in the last 5 days, receives PRN medications for pain, and has occasional pain; -Diagnoses included coronary artery disease (CAD, damage or disease in the heart's major blood vessels), hip fracture, hypertension (high blood pressure), arthritis, anxiety and depression. Review of the resident's physician orders for December 2022, showed the following: -An order dated 12/30/22, for a wound consult for ulcer at genitals and pressure areas on the sacrum (large triangular bone at base of spine) buttocks and posterior (lower) genital area; -An order, dated 12/30/22, for oxycodone-acetaminophen (opioid used to treat severe pain) 10-325 milligrams (mg), give one tablet by mouth one time a day for pain; -An order, dated 12/30/22, for OxyContin (an opioid, used to treat severe pain) tablet extended release 20 mg, give one tablet twice a day for pain; -An order, dated 12/30/22, for pain assessment every shift, document pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain. Review of the resident's MAR, dated 12/1/22 through 12/31/22, showed the following: -Oxycodone-acetaminophen tablet 10-325 mg, give one tablet by mouth one time a day for pain was documented as not administered on 12/31/22 at 8:00 A.M.; -OxyContin tablet extended release 20 mg, give one tablet twice a day for pain was documented as not administered on 12/30/22 at 8:00 P.M. and not administered on 12/31/22 at 8:00 A.M. and 8:00 P.M.; -Pain assessment every shift, document pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain, showed: --Staff did not document a pain assessment on 12/30/22 during the night shift, --Staff did not document pain on 12/31/22 during the evening shift, --Documented a pain level of 6 on 12/31/22 during the night shift. Review of the resident's medical record, showed there was no documentation found regarding notifying the Primary Care Physician (PCP) and family of the resident's missed medication administrations. Review of the facility's on-site formulary (medication dispensary system) medication list, showed the following medication was stocked in the system: -Oxycodone-acetaminophen tablets were available in 10-325 mg tablets. Review of the resident's physician orders, showed an order, dated 1/3/23, for an x-ray to lumbar spine (lower back) diagnosis of severe back pain. Further review of the resident's medical record showed the staff reported the x-ray results to the PCP on 1/4/23. There were no new orders. During an interview on 1/11/23 at 8:35 A.M., the resident said he/she was often in pain and he/she did not always get his/her medications. He/she made the staff aware, but nothing happened. Observation on 1/11/23 at 8:43 A.M., showed Nurse F administering treatments to the resident's genital area, buttocks, and left femur. Nurse F turned the resident to his/her right side and the resident moaned loudly and said his/her back hurt because he/she had a bad back. The resident continued groaning and was sweating while the nurse administered treatments. The nurse did not offer any pain relief medications or offer to stop his/her task and come back at a later time. The nurse did not ask the resident to describe and rate his/her pain. During an interview on 1/12/23 at 10:23 A.M., Nurse C said if a resident is complaining of pain and is a new admission, Nurse C would check the resident's orders to see if the resident had an existing order for a pain medication. If the resident had an existing order, he/she would pull the medication form the on-site formulary and administer the pain medication. If the resident did not have an order for pain medication, Nurse C would contact the physician to get an order. This would be documented in the resident's progress notes. 2. Review of Resident #29's medical record, showed the following: -admitted [DATE] at 5:58 P.M.; -discharge date [DATE] at 12:00 P.M.; -A baseline care plan, dated 1/3/23, showed, E. Pain: 1. Presence of pain, yes or no, blank, with yes not checked and no not checked; -Diagnoses listed osteoarthritis of left knee, osteoarthritis of right knee, and low back pain. Review of the resident's physician orders, dated 1/11/23, showed the following: -An order, dated 1/3/23 at 11:00 P.M., for pain assessment every shift, document pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain; -An order dated 1/3/23 at 6:30 P.M., for Meloxicam (reduces pain, swelling, and stiffness of the joints) tablet 15 milligrams (mg), give 1 tablet by mouth PRN for knee pain once daily if Tylenol has not improved pain; -An order dated 1/3/23, for Tylenol 500 mg, give 2 tablets three times per day for pain; -An order dated 1/3/23 at 6:15 P.M., for Hydrocodone-Acetaminophen (Norco, opioid used to relieve moderate to severe pain) tablet 5-325 mg, give one tablet by mouth every 12 hours PRN for pain. Review of the resident's electronic medication administration record (eMAR), dated 1/1/23 through 1/31/23, showed the following: -Pain assessment every shift, times not noted when pain was assessed on each shift, Day shift 7:00 A.M. through 3:00 P.M., Evening shift 3:00 P.M. through 11:00 P.M., Night shift 11:00 P.M. through 7:00 A.M.: -1/3/23 Night shift pain level 8, no PRN medication administered; -1/5/23 Night shift pain level at 5, no PRN pain medication administered; -1/6/23 Evening shift pain level at 5, no PRN pain medication administered; -1/7/23 Day shift pain level at 4, no PRN pain medication administered; -1/7/23 Night shift pain level at 5, no PRN pain medication administered; -1/8/23 Day shift pain level at 4, no PRN pain medication administered; -1/8/23 Evening shift pain level at 7, no PRN pain medication administered; -1/8/23 Night shift pain level not assessed (blank). -The routine Tylenol was given 1/3/23 at 10:00 P.M. through 1/8 at 10:00 PM. Review of the resident's progress notes, dated 1/3/23 through 1/9/23, showed; -1/3/23 no nurse progress note on night shift related to pain rated at 8 or PRN pain medication offered or other interventions provided; -1/5/23 no nurse progress note on night shift related to pain rated at 5 or PRN pain medication offered or other interventions provided; -1/6/23 no nurse progress note on evening shift related to pain rated at 5 or PRN pain medication offered or other interventions provided; -1/7/23 no nurse progress note on day shift related to pain rated at 4 or PRN pain medication offered or other interventions provided; -1/7/23 no nurse progress note on night shift related to pain rated at 5 or PRN pain medication offered or other interventions provided; -1/8/23 no nurse progress note on day shift related to pain rated at 4 or PRN pain medication offered or other interventions provided; -1/8/23 no nurse progress note on evening shift related to pain rated at 7 or PRN pain medication offered or other interventions provided; -1/8/23 no nurse progress note on night shift related to why pain was not assessed. -There was no documentation found notifying the PCP of pain. During an interview on 1/12/23 at 10:23 A.M., Nurse C said if a resident has scheduled Tylenol three times a day and was still rating pain from a 4 to an 8. Nurse C would assess the resident's pain and administer the PRN pain medication and come back and reassess the resident's pain. Nurse C would call the physician and inform the physician the resident is still complaining of pain and inform the physician what has already been done for the resident and ask if the physician wants to try something different because the current medication is not effective. Nurse C expected the certified nursing assistant (CNA) to report to the nurse of a resident complaining of pain. This would be documented in the resident's progress notes. During an interview on 1/12/23 at 12:50 P.M., the Regional Nurse Consultant (RNC) said if a resident had Tylenol scheduled three times a day and PRN pain medications and the resident had complaints of pain that ranged from 4 through 8, she expected staff to offer a PRN pain medication. She expected the nurse to enter a progress note if other interventions were completed for the resident if no PRN pain medication was administered. During an interview on 1/13/23 at 11:36 A.M., the resident's Primary Care Physician (PCP) #2 said if a resident has complaints of pain, the expectation is the PRN pain medication be administered. 3. During an interview on 1/12/23 at 7:20 A.M., Nurse E said the following: -Nursing staff works eight hour shifts; -Day shift works from 7:00 A.M. through 3:00 P.M.; -Evening shift works from 3:00 P.M. through 11:00 P.M.; -Night shift works from 11:00 P.M. through 7:00 A.M. During an interview on 1/12/23 at 11:18 A.M., CNA J said if a resident reported pain, he/she would ask the resident where the pain was and how it happened and then report the pain to the nurse. During an interview on 1/12/23 at 11:25 A.M., CNA D said if a resident reported pain, he/she would report it to the certified medication technician (CMT) and if there was not a CMT, he/she would report it to the nurse. During an interview on 1/12/23 at 11:34 A.M., CMT A said if a resident reported pain, he/she would ask the level of pain and where the pain was located. CMT A would then check the resident's eMAR to see if the resident had any PRN pain medication. If the resident was complaining of pain that is higher than normally reported, he/she would report it to the nurse. If CMT A was unsure if the pain was a new pain, he/she would report it to the nurse so the nurse could assess the resident's pain. If a PRN pain medication was administered and not effective, he/she would report it to the nurse. The nurse can assess the resident and call the physician to report the assessment. During an interview on 1/12/23 at 12:50 P.M., the RNC said if a resident was complaining of pain, she expected staff to inform the nurse. The nurse should look in Point Click Care (PCC, electronic charting system) to see what the resident has ordered for pain. If the resident has chronic pain, the nurse should administer the PRN pain medication. If there is a change from the resident's baseline, the nurse should contact the physician and get an order. This would be documented in the resident's progress notes. She expected the nurse to enter a progress note if other interventions were completed for the resident if no PRN pain medication was administered. During an interview on 1/19/23 at 12:25 P.M., the facility's Medical Director, said the following: -She expected staff to follow all physician orders as prescribed; -She expected staff to pull medications from the facility formulary if they were available; -She expected staff to notify her after one day of missed medications so she could determine if a change in plan of care was needed; -She expected staff to write a progress note in the residents' medical record showing they notified her of the missing medication, pharmacy estimated arrival of the medication and any new orders. MO00211979

Refer to Event ID MK6L12 Based on interview and record review, the facility failed to ensure a resident's complaints of pain and change in condition were assessed and interventions implemented. Resident #6 reported pain and staff noticed a change in condition, however no interventions were implemented until the resident was placed on hospice and pain medication ordered. An x-ray ordered by hospice revealed an acute femoral neck fracture (a type of hip fracture of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint). The sample was 14. The census was 96. Review of the Pain Management Guidelines policy, revision date ,d+[DATE], showed: -Purpose: To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: -Recognize when a resident is experiencing pain; -Identify circumstances when pain can be anticipated; -Evaluates existing pain and cause; -Practice Guidelines: -Those who cannot report pain may present with non-specific signs such as grimacing, increased confusion, restlessness, etc. To distinguish between pain and other signs or symptoms of distress (delirium, depression, etc.) it is imperative to assess resident to confirm signs and symptoms are indeed related to pain; -If any resident reports inadequate pain control, resident will have an assessment performed; -Following the pain evaluation, notify the physician of the findings; - The IDT will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT Team conference; Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Diagnoses included hypertension (HTN, high blood pressure), diabetes mellitus (DM), Alzheimer's disease and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination); -Severe cognitive impairment; -Behavior Symptoms: verbal/vocal symptoms like screaming, behavior not exhibited; -Pain Management: -Been on a scheduled pain medication regimen, yes; -Received PRN pain medication, yes; -Received non-medical intervention for pain, yes; -Pain presence, no. Review of the resident's electronic medication administration record (eMAR,) dated [DATE] through [DATE], showed the following medications for pain: -An order date of [DATE] at 8:45 P.M., acetaminophen (Tylenol) tablet 325 mg give 2 tablets by mouth every 8 hours PRN for temperature/pain. Do not exceed 300 mg per day from all sources, with no documentation of PRN Tylenol given in the month of [DATE]; -An order start date of [DATE] at 8:00 A.M., acetaminophen tablet 325 mg give 2 tablets by mouth two times a day for pain not to exceed 3 gm per day at 8:00 A.M. and 4:00 P.M., administered twice daily in the month of September with 1 opportunity missed on [DATE] at 4:00 P.M.; -No other pain medications were prescribed in the month of [DATE]. Review of the resident's record, showed no pain tool assessments completed in the month of [DATE]. Review of the resident's nurse's notes, showed: -No progress note documentation related to pain from [DATE] through [DATE]. Review of vital signs summary, showed pain documented at a 0 (,d+[DATE], 1 indicating mild pain and 10 is worst pain possible), daily from [DATE] to [DATE]. During an interview on [DATE] at 7:27 A.M., Nurse E said that he/she is the regular nurse for the [NAME] unit and worked with the resident. Nurse E said the resident used to be very mobile and would be a frequent resident in the hallway and dining room between his/her room and the nurse's station throughout the night. Nurse E said after returning from vacation on [DATE], the resident was like a different person. The resident was not getting up at night. The resident was now yelling out help but unable to say what he/she needed help with. You could hear the resident yelling help at the nurse's station. Nurse E said during report, it was passed on the resident was yelling out for help but the resident was unable to say what he/she needed help with. Nurse E did not report the decline because he/she said everyone had noticed the resident was declining in health. Nurse E said the resident was diagnosed with degenerative brain disease and he/she thought the resident yelling out for help was related to the brain degeneration. Nurse E did not link the resident asking for help to pain because the resident used to tell him/her what he/she needed. Nurse E said he/she would not usually chart if a resident is calling out for help, it would just be passed on in report to the next nurse. During an interview on [DATE] at 8:55 A.M., Certified Nurse Aide (CNA) G said he/she noticed the resident not eating as much and not wanting to get out of bed. The resident would often complain of pain to his/her left leg by saying, my leg hurts, my leg hurts. CNA G said the resident started complaining of pain the beginning of [DATE]. CNA G said it was reported to the charge nurse anytime the resident complained and the nurse would say we know he/she fell a while ago and that is why his/her leg hurts. CNA G said every time he/she worked with the resident, he/she complained of pain. CNA G said if he/she noticed the resident was not up, he/she would go and check on the resident and the resident would be complaining of pain to his/her left leg. CNA G said the resident didn't want to get up and didn't want to move and the nurses asked the CNAs to get the resident up every other day. The resident would yell for help and CNA G would go in and get the resident up. The resident used to do well with transfers and stand and after he/she started complaining of left leg pain, he/she didn't want to stand on it and it took two people to transfer the resident. During the transfers, the resident would groan. When the resident started not wanting to get out of bed, this was a change for the resident. During an interview on [DATE] at 1:57 P.M., Nurse I said the resident had a change in condition that started approximately two weeks before the resident expired on [DATE]. The resident used to be a one person assist and propel him/herself in the wheelchair and feed him/herself without assistance. The changes the resident showed were being sleepy, needing assistance with meals, yelling out for help out of nowhere. Nurse I said he/she would go in to see if the resident needed changed. The resident had no medication changes to make the resident sleepy. He/she called the POA and explained how the resident was acting and asked if the POA wanted the resident to stay a full code or change the resident's code status to a DNR and the POA changed the resident's code status to a DNR. The POA and family came in and the social worker talked to the family about hospice. The POA and family kept saying the resident was hurting and that the resident was rubbing his/her left leg. When Nurse I went in to assess the resident, he/she did not observe pain. The POA and family kept saying the resident was having some type of pain. During an interview on [DATE] at 9:52 A.M., Family Member (FM) K said he/she received a phone call on [DATE] around 8:30 A.M., from CMT F stating the resident had a decline in the last day or two and Family Member K needed to come into the facility. After arriving at the facility, the resident wasn't able to move, was bed ridden and was coughing and choking on food. FM K said other family came with him/her to see the resident on [DATE] and the resident was grabbing the family, screaming my leg, my leg. Staff did not do an assessment. CMT F said he/she was giving the resident Tylenol as needed. The family was concerned because nobody reported the changes the resident had and this had been going on for several weeks. The facility did not notify the family or the doctor when this started happening. A nurse told the family that lots of residents yell and scream and then walked out of the room. Review of physical therapy notes, dated [DATE], showed: -Patient up in wheelchair upon arrival. Bilateral lower extremities active range of motion preformed to right lower extremity in seated position for improved strength to maximize independence with transfers. Patient complained of left thigh pain when attempting to extend left knee. Patient rubbing area stating it hurts. Nursing consulted and brought in to assess patient's complaint of pain. -Pain present, assessment indicated; -Behaviors exhibited: patient rubbing left thigh nursing notified; -Does pain limit patient's functional activities, yes; -Pain limits the following functional activities, left lower extremity range of motion; -What relieves pain, remaining still; -What exacerbates pain, range of motion; -Response to session intervention; -Patient progress: progress and response to treatment, patient did not meet goals due to discharge from therapy services and transition to hospice care. During an interview on [DATE] at 11:05 A.M., Physical Therapist R said he/she went to do an evaluation on [DATE] and the resident was sitting up in the wheelchair next to the bed. Physical Therapist R said when he/she tried to do leg exercises with the resident's left leg the resident began rubbing his/her left thigh area and Physical Therapist R asked the resident if he/she was in pain and the resident said it hurts. Physical Therapist R stopped the exercise and went and got the nurse, he/she does not recall who the nurse was. The nurse came in and looked at him/her and said ok I will keep an eye on him/her and left. Physical Therapist R stopped the session due to pain. Physical Therapist R is unsure if there was any other follow up completed after that. Review of the resident's nurse's notes, dated [DATE] at 10:09 P.M., showed resident has been admitted to hospice for diagnosis of Senile Degeneration of the Brain. New orders have been entered, follow up with medication MAR. Resident tolerated medications well on this shift without any difficulty in swallowing, resident only consumed about 50 percent of dinner, with assistance with ADLs, vitals are with in normal limit, resident denies being in any pain at this time, resident call light is within reach. Review of the resident's eMAR dated [DATE] through [DATE], showed the following medications for pain: -An order date of [DATE] at 8:45 P.M., acetaminophen tablet 325 mg give 2 tablets by mouth every 8 hours PRN for temperature/pain. Do not exceed 300 mg per day from all sources, with no documentation of PRN Tylenol given in the month of [DATE]; -An order start date of [DATE] at 8:00 A.M., acetaminophen tablet 325 mg give 2 tablets by mouth two times a day for pain not to exceed 3 gm per day at 8:00 A.M. and 4:00 P.M., -[DATE] through [DATE] administered twice daily at 8:00 A.M. and 4:00 P.M.; During an interview on [DATE] at 2:00 P.M., the Interim Director of Nursing (DON) said if a staff member reports to a nurse that a resident is having pain, the expectation is the nurse will assess the resident and contact the family, physician, nurse on call and DON and document the assessment and notifications in a progress note. The Interim DON expected pain documentation to be accurate and equal to what the resident is reporting. Review of hospice records, showed: -Visit date [DATE] at 2:15 P.M.; -Visit type Hospice RN start of care: -Resident getting scheduled Tylenol twice daily that is not managing pain. New order for tramadol 50 mg every 6 hours PRN for pain. First does give as soon as possible. Licensed Practical Nurse (LPN) I states understanding to notify hospice if medication is ineffective; -Eligibility criteria- Resident has been a resident at the facility since 2017 in long term care where he/she has been able to make his/her needs known, fed self, and was interactive with fell ow residents and staff. In the last month resident has taken a significant decline now calling out day and night with complaints of left hip and knee pain which is unmanaged. Resident has 3 pound weight loss since last month, unable to stand anymore, needs assistance x 2 with staff to assist with transfers. Family can see dramatic decline; -Pain assessment: -Location of pain: extremity's lower; -How does the patient describe the pain: aching; -Indicate duration of pain: continuous; -Frequency of pain: all of the time; -Indicate effects of pain on quality of life: appetite, functional status, mobility, sleep/rest disturbance; -Comments regarding patient's cognitive function: Resident did not know birthdate, place, or time of year. Resident able to follow direction and able to indicate pain location and remembered that the hospice nurse was going to get him/her something for pain (half an hour later). Minimum interaction only responded to pain questions and need for relief; During an interview on [DATE] at 8:35 A.M., Hospice Nurse C said he/she saw the resident on [DATE]. It was reported the resident had an acute decline in the last month or two. The last ,d+[DATE] weeks, the resident was unable to stand or bear weight, prior the resident was able to stand. A facility nurse told Hospice Nurse C the resident had no falls in the last 3 months. Hospice Nurse C said the resident was in tears because he/she was hurting so badly during the admission. It was reported to Hospice Nurse C the resident had been complaining of pain and yelling out and complaining of left leg and knee pain for the last ,d+[DATE] weeks. The resident told Hospice Nurse C, I hurt here, and pointed to left upper thigh and knee. The facility nurse told Hospice Nurse C Oh, the resident always does that. Family was unsure if the resident had a fall. Hospice Nurse C asked the family if the facility had done an x-ray and the family said they were unsure if an x-ray had been completed. In his/her Hospice template (a report that is passed to members on the hospice team for the resident), a note was placed for the team that Hospice Nurse C had concerns the facility staff was not taking the resident's pain seriously and to please monitor pain during visits and to let facility staff know if any uncontrolled pain is noticed, mostly left hip/knee pain. Hospice Nurse C obtained a new order for tramadol for pain. Review of hospice records, showed: -Visit date [DATE] at 11:29 A.M.; -Visit type Hospice RN rapid subsequent visit; -Pain assessment: -Describe behavior: Negative vocalization, repeated trouble calling out; -Location of pain: extremities lower; -Indicate duration of pain: continuous; -Frequency of pain: all of the time; -Indicates what makes pain worse: activity, movement, exercise; -Narrative: Admission follow up visit. Resident in common room visiting with family upon arrival. Tramadol was administered 20 minutes prior to arrival for left knee pain. Family stated that an order for an x-ray would be placed for left knee/hip x-rays, no order given to facility and unable to see chart. Resident falling asleep during visit, confused and minimally verbal, only yells help every few minutes. Resident did shake head yes after asking if pain medication was helping. Hospice nurse will send scripts to pharmacy and speak with physician about obtaining x-rays. Educated on nonverbal signs of pain and discomfort. During an interview on [DATE] at 9:35 A.M., Hospice Nurse L said the resident was admitted to hospice on [DATE] and he/she saw the resident on [DATE] for a follow up visit. The family was requesting an x-ray because the resident was reporting pain to the left leg and knee. Hospice Nurse L said that at the end of each visit the hospice staff send out a report to the case manager. Hospice Nurse L sent a report to the case manager requesting follow up regarding the request for x-ray since the resident was on hospice, asking the case manager to check with the attending physician. The family's main concern was pain. The family did voice when the resident was started on tramadol the resident wasn't calling out as often and said that before the tramadol was started the resident was calling out constantly. Hospice Nurse L said he/she did not hear anything for a little while but then saw a color report (reports that are sent out to staff that are on the residents caseload) about the resident from another hospice nurse that said the resident had to have been in severe pain for quite a while and has an acute fracture with no evidence of previous falls. Review of vital signs summary for pain, showed: -Pain documented at 2 on [DATE] at 12:15 P.M., with PRN tramadol 50 mg administered at 12:15 P.M.; -Pain documented at 1 on [DATE] at 12:43 P.M.; -Pain documented at 1 on [DATE] at 4:43 P.M., with PRN tramadol 50 mg administered at 4:43 P.M. Review of vital signs summary for pain, showed: -Pain documented as 0 on [DATE], [DATE] and [DATE]. Review of pain assessments completed for the month of [DATE], showed: -[DATE] at 1:22 P.M., pain assessment completed with score of 0; -[DATE] at 6:29 P.M., pain assessment completed with score of 0. Review of hospice records, showed: -Visit date [DATE] at 2:20 P.M.; -Visit type RN hospice subsequent with supervisor visit; -Narrative: On arrival resident resting in bed with relaxed facial expression, scoring zero on pain. Careful exam of left leg from iliac crest (iliac crest is the curved area at the top of the ilium bone, the largest of three bones that make up the pelvis) to ankle preformed because family stated resident had been grasping at left leg and complaining loudly of severe pain over the weekend and yesterday. Hospice nurse did not find any deformity, point tenderness, heat resistance to passive range of motion. Patient was able to support his/her left legs weight and lower it to the bed on his/her own without grimacing. Situation discussed with physician and obtained orders for left hip and knee x-rays to reduce residents family's anxiety; Review of the resident's nurse's notes, dated [DATE] at 4:31 P.M., showed the resident has complaints of pain to left knee and hip, hospice in facility, new order for 2 view x-ray to left knee pelvis and hip, family and physician aware. Review of the x-ray results dated [DATE], showed: -Clinical Information: Increased pain to both areas, difficulty bearing weight; -Unknown etiology (unknown cause); -Findings: There is moderate arthritic changes of the hip with circumferential collar osteophytes (When hip cartilage thins, the hip bones may produce osteophytes (a smooth bony growth or deposit) to compensate.) and joint space narrowing. Acute fracture involving the femoral neck. Bony mineralization (the process of deposition of minerals on the bone for the development of bone) is within normal limits for age. No evidence of osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Remainder the pelvis is intact; -Impression: Acute femoral neck fracture (a type of hip fracture of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint). Review of the resident's nurse's notes, showed: -[DATE] at 10:11 P.M., x-ray results reported to physician findings left knee no fracture but fracture to left hip noted; -[DATE] at 10:39 P.M., resident has no bruising or bones protruding from skin, no pain noted upon touch doing assessment. During an interview on [DATE] at 11:44 A.M., Hospice Nurse Q said the first time he/she went to see the resident, he/she read the notes from the hospice admission which said the resident had a decline in the last several weeks and stopped eating. Resident scoring ,d+[DATE] on the pain score, complaining of left knee pain and reaching down towards the knee. The resident was clear the pain was from his/her knee. Resident's leg was not rotated, there was no heat or swelling at the knee. Hospice Nurse Q lifted and flexed the resident's left leg with no point tenderness. The family told Hospice Nurse Q the resident was miserable over the weekend so Hospice Nurse Q called the physician and obtained an order for an x-ray to the left knee, hip and pelvis. After the x-ray was completed, hospice received a call that the resident has a left femoral neck fracture. Hospice Nurse Q said the resident could have been experiencing referred pain from the left hip to the knee. The resident was admitted to hospice due to a decline but the decline could have been caused from the hip fracture. While speaking to the family, they were very frustrated because staff reported the resident had not fallen since September. The family felt like something had been missed with the resident because the pain had been there for several weeks. Family was also concerned nothing was done by the facility with the resident's complaints of pain. Review of vital signs summary for pain, showed: -Pain documented as 3 on [DATE] at 1:17 A.M., with PRN morphine sulfate concentrate solution 0.25 ml administered at 1:18 A.M.; -Pain documented as 1 on [DATE] at 5:24 A.M., with no PRN pain medication administered; -Pain documented as 7 on [DATE] at 9:23 P.M., with PRN morphine sulfate concentrate solution 0.25 mg administered at 9:23 P.M. Review of the resident's nurse's notes, showed: -[DATE] at 6:01 A.M., Last evening nurse reported to this writer positive fracture results to left hip x-ray. This nurse had no prior reason to suspect a health concern related to fracture due the fact the writer had no knowledge of any incidence that could have caused a fracture. The Hospice nurse called and asked the condition of the resident. This writer assessed the patient's pain level at 11:10 P.M. and administered a dose of Morphine per PRN orders. The resident admitted presence of pain. Later the resident was noted hallucinating and a PRN dose of Lorazepam (medication used to relieve anxiety) was administered. Both medications showed positive results and the resident slept. The resident was observed alert after some time but there was no signs or symptoms of pain to necessitate further dose of morphine. Monitoring still continues; -[DATE] at 9:03 P.M., resident remains in bed, ate 10% of dinner with no complaints. Supplement offered. Denied any pain. This nurse asked resident was he/she in pain. Resident declined. -[DATE] at 9:21 P.M., resident yelling out help uncontrollable. This nurse asked resident was he/she in pain. Resident shook his/her head yes. This nurse administered PRN morphine 0.25 ml, resident currently in room sleeping peacefully. Review of hospice records, showed: -Visit date [DATE] at 11:13 A.M.; -Visit type Hospice PRN visit; -Narrative: Resident is alert and identifies that he/she is having left knee pain which is referred pain from the left femoral head fracture. Resident had received Morphine Sulfate extended release tablet 15 mg at 5:00 A.M. and was given an additional 5 mg of Morphine during visit to reduce discomfort during assessment. Reviewed plan of care with Nurse I that resident should receive routine Morphine Sulfate extended release every 12 hours and additional liquid morphine as needed every 3 hours for breakthrough pain. During an interview on [DATE] at 9:52 A.M., Family Member (FM) K said the family placed the resident on hospice and was started on hospice on [DATE]. Family said the hospice nurse could see the resident was in pain. The resident was in pain and yelling out daily until the 12 hour liquid morphine was started by hospice. The hospice nurse started the resident on tramadol on [DATE] and when this did not relieve the pain, the hospice nurse started the resident on morphine tablets. When this did not relieve the pain, the hospice nurse changed the pain medication to 12 hour liquid morphine. During an interview on [DATE] at 11:44 A.M., Hospice Nurse Q said the tramadol that was prescribed was not touching the resident's pain so different orders were obtained for Morphine in tablet form and when that was not effective, the Morphine was changed to liquid Morphine which was effective for the resident's pain. MO00208740

46104 Based on interview and record review, the facility failed to ensure a resident's complaints of pain and change in condition were assessed and interventions implemented. Resident #6 reported pain and staff noticed a change in condition, however no interventions were implemented until the resident was placed on hospice and pain medication ordered. An x-ray ordered by hospice revealed an acute femoral neck fracture (a type of hip fracture of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint). The sample was 14. The census was 96. Review of the Pain Management Guidelines policy, revision date ,d+[DATE], showed: -Purpose: To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: -Recognize when a resident is experiencing pain; -Identify circumstances when pain can be anticipated; -Evaluates existing pain and cause; -Practice Guidelines: -Those who cannot report pain may present with non-specific signs such as grimacing, increased confusion, restlessness, etc. To distinguish between pain and other signs or symptoms of distress (delirium, depression, etc.) it is imperative to assess resident to confirm signs and symptoms are indeed related to pain; -If any resident reports inadequate pain control, resident will have an assessment performed; -Following the pain evaluation, notify the physician of the findings; - The IDT will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT Team conference; Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Diagnoses included hypertension (HTN, high blood pressure), diabetes mellitus (DM), Alzheimer's disease and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination); -Severe cognitive impairment; -Behavior Symptoms: verbal/vocal symptoms like screaming, behavior not exhibited; -Pain Management: -Been on a scheduled pain medication regimen, yes; -Received PRN pain medication, yes; -Received non-medical intervention for pain, yes; -Pain presence, no. Review of the resident's electronic medication administration record (eMAR,) dated [DATE] through [DATE], showed the following medications for pain: -An order date of [DATE] at 8:45 P.M., acetaminophen (Tylenol) tablet 325 mg give 2 tablets by mouth every 8 hours PRN for temperature/pain. Do not exceed 300 mg per day from all sources, with no documentation of PRN Tylenol given in the month of [DATE]; -An order start date of [DATE] at 8:00 A.M., acetaminophen tablet 325 mg give 2 tablets by mouth two times a day for pain not to exceed 3 gm per day at 8:00 A.M. and 4:00 P.M., administered twice daily in the month of September with 1 opportunity missed on [DATE] at 4:00 P.M.; -No other pain medications were prescribed in the month of [DATE]. Review of the resident's record, showed no pain tool assessments completed in the month of [DATE]. Review of the resident's nurse's notes, showed: -No progress note documentation related to pain from [DATE] through [DATE]. Review of vital signs summary, showed pain documented at a 0 (,d+[DATE], 1 indicating mild pain and 10 is worst pain possible), daily from [DATE] to [DATE]. During an interview on [DATE] at 7:27 A.M., Nurse E said that he/she is the regular nurse for the Lafayette unit and worked with the resident. Nurse E said the resident used to be very mobile and would be a frequent resident in the hallway and dining room between his/her room and the nurse's station throughout the night. Nurse E said after returning from vacation on [DATE], the resident was like a different person. The resident was not getting up at night. The resident was now yelling out help but unable to say what he/she needed help with. You could hear the resident yelling help at the nurse's station. Nurse E said during report, it was passed on the resident was yelling out for help but the resident was unable to say what he/she needed help with. Nurse E did not report the decline because he/she said everyone had noticed the resident was declining in health. Nurse E said the resident was diagnosed with degenerative brain disease and he/she thought the resident yelling out for help was related to the brain degeneration. Nurse E did not link the resident asking for help to pain because the resident used to tell him/her what he/she needed. Nurse E said he/she would not usually chart if a resident is calling out for help, it would just be passed on in report to the next nurse. During an interview on [DATE] at 8:55 A.M., Certified Nurse Aide (CNA) G said he/she noticed the resident not eating as much and not wanting to get out of bed. The resident would often complain of pain to his/her left leg by saying, my leg hurts, my leg hurts. CNA G said the resident started complaining of pain the beginning of [DATE]. CNA G said it was reported to the charge nurse anytime the resident complained and the nurse would say we know he/she fell a while ago and that is why his/her leg hurts. CNA G said every time he/she worked with the resident, he/she complained of pain. CNA G said if he/she noticed the resident was not up, he/she would go and check on the resident and the resident would be complaining of pain to his/her left leg. CNA G said the resident didn't want to get up and didn't want to move and the nurses asked the CNAs to get the resident up every other day. The resident would yell for help and CNA G would go in and get the resident up. The resident used to do well with transfers and stand and after he/she started complaining of left leg pain, he/she didn't want to stand on it and it took two people to transfer the resident. During the transfers, the resident would groan. When the resident started not wanting to get out of bed, this was a change for the resident. During an interview on [DATE] at 1:57 P.M., Nurse I said the resident had a change in condition that started approximately two weeks before the resident expired on [DATE]. The resident used to be a one person assist and propel him/herself in the wheelchair and feed him/herself without assistance. The changes the resident showed were being sleepy, needing assistance with meals, yelling out for help out of nowhere. Nurse I said he/she would go in to see if the resident needed changed. The resident had no medication changes to make the resident sleepy. He/she called the POA and explained how the resident was acting and asked if the POA wanted the resident to stay a full code or change the resident's code status to a DNR and the POA changed the resident's code status to a DNR. The POA and family came in and the social worker talked to the family about hospice. The POA and family kept saying the resident was hurting and that the resident was rubbing his/her left leg. When Nurse I went in to assess the resident, he/she did not observe pain. The POA and family kept saying the resident was having some type of pain. During an interview on [DATE] at 9:52 A.M., Family Member (FM) K said he/she received a phone call on [DATE] around 8:30 A.M., from CMT F stating the resident had a decline in the last day or two and Family Member K needed to come into the facility. After arriving at the facility, the resident wasn't able to move, was bed ridden and was coughing and choking on food. FM K said other family came with him/her to see the resident on [DATE] and the resident was grabbing the family, screaming my leg, my leg. Staff did not do an assessment. CMT F said he/she was giving the resident Tylenol as needed. The family was concerned because nobody reported the changes the resident had and this had been going on for several weeks. The facility did not notify the family or the doctor when this started happening. A nurse told the family that lots of residents yell and scream and then walked out of the room. Review of physical therapy notes, dated [DATE], showed: -Patient up in wheelchair upon arrival. Bilateral lower extremities active range of motion preformed to right lower extremity in seated position for improved strength to maximize independence with transfers. Patient complained of left thigh pain when attempting to extend left knee. Patient rubbing area stating it hurts. Nursing consulted and brought in to assess patient's complaint of pain. -Pain present, assessment indicated; -Behaviors exhibited: patient rubbing left thigh nursing notified; -Does pain limit patient's functional activities, yes; -Pain limits the following functional activities, left lower extremity range of motion; -What relieves pain, remaining still; -What exacerbates pain, range of motion; -Response to session intervention; -Patient progress: progress and response to treatment, patient did not meet goals due to discharge from therapy services and transition to hospice care. During an interview on [DATE] at 11:05 A.M., Physical Therapist R said he/she went to do an evaluation on [DATE] and the resident was sitting up in the wheelchair next to the bed. Physical Therapist R said when he/she tried to do leg exercises with the resident's left leg the resident began rubbing his/her left thigh area and Physical Therapist R asked the resident if he/she was in pain and the resident said it hurts. Physical Therapist R stopped the exercise and went and got the nurse, he/she does not recall who the nurse was. The nurse came in and looked at him/her and said ok I will keep an eye on him/her and left. Physical Therapist R stopped the session due to pain. Physical Therapist R is unsure if there was any other follow up completed after that. Review of the resident's nurse's notes, dated [DATE] at 10:09 P.M., showed resident has been admitted to hospice for diagnosis of Senile Degeneration of the Brain. New orders have been entered, follow up with medication MAR. Resident tolerated medications well on this shift without any difficulty in swallowing, resident only consumed about 50 percent of dinner, with assistance with ADLs, vitals are with in normal limit, resident denies being in any pain at this time, resident call light is within reach. Review of the resident's eMAR dated [DATE] through [DATE], showed the following medications for pain: -An order date of [DATE] at 8:45 P.M., acetaminophen tablet 325 mg give 2 tablets by mouth every 8 hours PRN for temperature/pain. Do not exceed 300 mg per day from all sources, with no documentation of PRN Tylenol given in the month of [DATE]; -An order start date of [DATE] at 8:00 A.M., acetaminophen tablet 325 mg give 2 tablets by mouth two times a day for pain not to exceed 3 gm per day at 8:00 A.M. and 4:00 P.M., -[DATE] through [DATE] administered twice daily at 8:00 A.M. and 4:00 P.M.; During an interview on [DATE] at 2:00 P.M., the Interim Director of Nursing (DON) said if a staff member reports to a nurse that a resident is having pain, the expectation is the nurse will assess the resident and contact the family, physician, nurse on call and DON and document the assessment and notifications in a progress note. The Interim DON expected pain documentation to be accurate and equal to what the resident is reporting. Review of hospice records, showed: -Visit date [DATE] at 2:15 P.M.; -Visit type Hospice RN start of care: -Resident getting scheduled Tylenol twice daily that is not managing pain. New order for tramadol 50 mg every 6 hours PRN for pain. First does give as soon as possible. Licensed Practical Nurse (LPN) I states understanding to notify hospice if medication is ineffective; -Eligibility criteria- Resident has been a resident at the facility since 2017 in long term care where he/she has been able to make his/her needs known, fed self, and was interactive with fell ow residents and staff. In the last month resident has taken a significant decline now calling out day and night with complaints of left hip and knee pain which is unmanaged. Resident has 3 pound weight loss since last month, unable to stand anymore, needs assistance x 2 with staff to assist with transfers. Family can see dramatic decline; -Pain assessment: -Location of pain: extremity's lower; -How does the patient describe the pain: aching; -Indicate duration of pain: continuous; -Frequency of pain: all of the time; -Indicate effects of pain on quality of life: appetite, functional status, mobility, sleep/rest disturbance; -Comments regarding patient's cognitive function: Resident did not know birthdate, place, or time of year. Resident able to follow direction and able to indicate pain location and remembered that the hospice nurse was going to get him/her something for pain (half an hour later). Minimum interaction only responded to pain questions and need for relief; During an interview on [DATE] at 8:35 A.M., Hospice Nurse C said he/she saw the resident on [DATE]. It was reported the resident had an acute decline in the last month or two. The last ,d+[DATE] weeks, the resident was unable to stand or bear weight, prior the resident was able to stand. A facility nurse told Hospice Nurse C the resident had no falls in the last 3 months. Hospice Nurse C said the resident was in tears because he/she was hurting so badly during the admission. It was reported to Hospice Nurse C the resident had been complaining of pain and yelling out and complaining of left leg and knee pain for the last ,d+[DATE] weeks. The resident told Hospice Nurse C, I hurt here, and pointed to left upper thigh and knee. The facility nurse told Hospice Nurse C Oh, the resident always does that. Family was unsure if the resident had a fall. Hospice Nurse C asked the family if the facility had done an x-ray and the family said they were unsure if an x-ray had been completed. In his/her Hospice template (a report that is passed to members on the hospice team for the resident), a note was placed for the team that Hospice Nurse C had concerns the facility staff was not taking the resident's pain seriously and to please monitor pain during visits and to let facility staff know if any uncontrolled pain is noticed, mostly left hip/knee pain. Hospice Nurse C obtained a new order for tramadol for pain. Review of hospice records, showed: -Visit date [DATE] at 11:29 A.M.; -Visit type Hospice RN rapid subsequent visit; -Pain assessment: -Describe behavior: Negative vocalization, repeated trouble calling out; -Location of pain: extremities lower; -Indicate duration of pain: continuous; -Frequency of pain: all of the time; -Indicates what makes pain worse: activity, movement, exercise; -Narrative: Admission follow up visit. Resident in common room visiting with family upon arrival. Tramadol was administered 20 minutes prior to arrival for left knee pain. Family stated that an order for an x-ray would be placed for left knee/hip x-rays, no order given to facility and unable to see chart. Resident falling asleep during visit, confused and minimally verbal, only yells help every few minutes. Resident did shake head yes after asking if pain medication was helping. Hospice nurse will send scripts to pharmacy and speak with physician about obtaining x-rays. Educated on nonverbal signs of pain and discomfort. During an interview on [DATE] at 9:35 A.M., Hospice Nurse L said the resident was admitted to hospice on [DATE] and he/she saw the resident on [DATE] for a follow up visit. The family was requesting an x-ray because the resident was reporting pain to the left leg and knee. Hospice Nurse L said that at the end of each visit the hospice staff send out a report to the case manager. Hospice Nurse L sent a report to the case manager requesting follow up regarding the request for x-ray since the resident was on hospice, asking the case manager to check with the attending physician. The family's main concern was pain. The family did voice when the resident was started on tramadol the resident wasn't calling out as often and said that before the tramadol was started the resident was calling out constantly. Hospice Nurse L said he/she did not hear anything for a little while but then saw a color report (reports that are sent out to staff that are on the residents caseload) about the resident from another hospice nurse that said the resident had to have been in severe pain for quite a while and has an acute fracture with no evidence of previous falls. Review of vital signs summary for pain, showed: -Pain documented at 2 on [DATE] at 12:15 P.M., with PRN tramadol 50 mg administered at 12:15 P.M.; -Pain documented at 1 on [DATE] at 12:43 P.M.; -Pain documented at 1 on [DATE] at 4:43 P.M., with PRN tramadol 50 mg administered at 4:43 P.M. Review of vital signs summary for pain, showed: -Pain documented as 0 on [DATE], [DATE] and [DATE]. Review of pain assessments completed for the month of [DATE], showed: -[DATE] at 1:22 P.M., pain assessment completed with score of 0; -[DATE] at 6:29 P.M., pain assessment completed with score of 0. Review of hospice records, showed: -Visit date [DATE] at 2:20 P.M.; -Visit type RN hospice subsequent with supervisor visit; -Narrative: On arrival resident resting in bed with relaxed facial expression, scoring zero on pain. Careful exam of left leg from iliac crest (iliac crest is the curved area at the top of the ilium bone, the largest of three bones that make up the pelvis) to ankle preformed because family stated resident had been grasping at left leg and complaining loudly of severe pain over the weekend and yesterday. Hospice nurse did not find any deformity, point tenderness, heat resistance to passive range of motion. Patient was able to support his/her left legs weight and lower it to the bed on his/her own without grimacing. Situation discussed with physician and obtained orders for left hip and knee x-rays to reduce residents family's anxiety; Review of the resident's nurse's notes, dated [DATE] at 4:31 P.M., showed the resident has complaints of pain to left knee and hip, hospice in facility, new order for 2 view x-ray to left knee pelvis and hip, family and physician aware. Review of the x-ray results dated [DATE], showed: -Clinical Information: Increased pain to both areas, difficulty bearing weight; -Unknown etiology (unknown cause); -Findings: There is moderate arthritic changes of the hip with circumferential collar osteophytes (When hip cartilage thins, the hip bones may produce osteophytes (a smooth bony growth or deposit) to compensate.) and joint space narrowing. Acute fracture involving the femoral neck. Bony mineralization (the process of deposition of minerals on the bone for the development of bone) is within normal limits for age. No evidence of osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Remainder the pelvis is intact; -Impression: Acute femoral neck fracture (a type of hip fracture of the thigh bone (femur)-just below the ball of the ball-and-socket hip joint). Review of the resident's nurse's notes, showed: -[DATE] at 10:11 P.M., x-ray results reported to physician findings left knee no fracture but fracture to left hip noted; -[DATE] at 10:39 P.M., resident has no bruising or bones protruding from skin, no pain noted upon touch doing assessment. During an interview on [DATE] at 11:44 A.M., Hospice Nurse Q said the first time he/she went to see the resident, he/she read the notes from the hospice admission which said the resident had a decline in the last several weeks and stopped eating. Resident scoring ,d+[DATE] on the pain score, complaining of left knee pain and reaching down towards the knee. The resident was clear the pain was from his/her knee. Resident's leg was not rotated, there was no heat or swelling at the knee. Hospice Nurse Q lifted and flexed the resident's left leg with no point tenderness. The family told Hospice Nurse Q the resident was miserable over the weekend so Hospice Nurse Q called the physician and obtained an order for an x-ray to the left knee, hip and pelvis. After the x-ray was completed, hospice received a call that the resident has a left femoral neck fracture. Hospice Nurse Q said the resident could have been experiencing referred pain from the left hip to the knee. The resident was admitted to hospice due to a decline but the decline could have been caused from the hip fracture. While speaking to the family, they were very frustrated because staff reported the resident had not fallen since September. The family felt like something had been missed with the resident because the pain had been there for several weeks. Family was also concerned nothing was done by the facility with the resident's complaints of pain. Review of vital signs summary for pain, showed: -Pain documented as 3 on [DATE] at 1:17 A.M., with PRN morphine sulfate concentrate solution 0.25 ml administered at 1:18 A.M.; -Pain documented as 1 on [DATE] at 5:24 A.M., with no PRN pain medication administered; -Pain documented as 7 on [DATE] at 9:23 P.M., with PRN morphine sulfate concentrate solution 0.25 mg administered at 9:23 P.M. Review of the resident's nurse's notes, showed: -[DATE] at 6:01 A.M., Last evening nurse reported to this writer positive fracture results to left hip x-ray. This nurse had no prior reason to suspect a health concern related to fracture due the fact the writer had no knowledge of any incidence that could have caused a fracture. The Hospice nurse called and asked the condition of the resident. This writer assessed the patient's pain level at 11:10 P.M. and administered a dose of Morphine per PRN orders. The resident admitted presence of pain. Later the resident was noted hallucinating and a PRN dose of Lorazepam (medication used to relieve anxiety) was administered. Both medications showed positive results and the resident slept. The resident was observed alert after some time but there was no signs or symptoms of pain to necessitate further dose of morphine. Monitoring still continues; -[DATE] at 9:03 P.M., resident remains in bed, ate 10% of dinner with no complaints. Supplement offered. Denied any pain. This nurse asked resident was he/she in pain. Resident declined. -[DATE] at 9:21 P.M., resident yelling out help uncontrollable. This nurse asked resident was he/she in pain. Resident shook his/her head yes. This nurse administered PRN morphine 0.25 ml, resident currently in room sleeping peacefully. Review of hospice records, showed: -Visit date [DATE] at 11:13 A.M.; -Visit type Hospice PRN visit; -Narrative: Resident is alert and identifies that he/she is having left knee pain which is referred pain from the left femoral head fracture. Resident had received Morphine Sulfate extended release tablet 15 mg at 5:00 A.M. and was given an additional 5 mg of Morphine during visit to reduce discomfort during assessment. Reviewed plan of care with Nurse I that resident should receive routine Morphine Sulfate extended release every 12 hours and additional liquid morphine as needed every 3 hours for breakthrough pain. During an interview on [DATE] at 9:52 A.M., Family Member (FM) K said the family placed the resident on hospice and was started on hospice on [DATE]. Family said the hospice nurse could see the resident was in pain. The resident was in pain and yelling out daily until the 12 hour liquid morphine was started by hospice. The hospice nurse started the resident on tramadol on [DATE] and when this did not relieve the pain, the hospice nurse started the resident on morphine tablets. When this did not relieve the pain, the hospice nurse changed the pain medication to 12 hour liquid morphine. During an interview on [DATE] at 11:44 A.M., Hospice Nurse Q said the tramadol that was prescribed was not touching the resident's pain so different orders were obtained for Morphine in tablet form and when that was not effective, the Morphine was changed to liquid Morphine which was effective for the resident's pain. MO00208740

Based on interviews and record review, the facility failed to provide care and services consistent with professional standards of practice, to promote the prevention of pressure ulcer/injury, development and promote the healing of pressure ulcers to include prevention of infection when one of three sampled residents developed a pressure ulcer that led to infection and hospitalization . The facility also failed to follow their policy to notify the resident's family and physician with any change of condition. (Resident #1) The census was 93. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/24/20, showed the following: -admitted to facility on 8/19/20; -Incontinent of bowel and bladder; -No behaviors; -Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment) score of 4 out of 15 (severe cognitive impairment); -Required one-person physical assist with all activities of daily living (ADLs); -Used a wheelchair and walker for ambulation; -Weight 133 pounds (lbs); -At risk for pressure ulcers; -No unhealed pressure ulcers; -Has a surgical wound; -[DIAGNOSES REDACTED]. Review of the resident's undated care plan, in use at time of the survey, showed the following: -Focus: Bowel/bladder incontinence and at risk for signs and symptoms of urinary tract infection and/or skin breakdown related to incontinence. Dementia, unable to communicate or unaware of toileting needs and/or to follow directions to participate in toileting program; -Goal: The resident will be kept clean, dry, and comfortable daily with use of urinary/bowel incontinence products; -Interventions/task: Check the resident before and after meals and P.M., for incontinent episodes. Communicate any changes in urine odor, color, bleeding, pain with urination to physician/nurse immediately. Place call light or other communication device within reach at all times. Provide incontinence perineal (peri) care after each incontinent episode, use barrier cream; -Focus: At risk for abnormal bleeding, hemorrhage and/or increased/easy bruising related to anticoagulant medication use; -Goal: Will be free from signs and symptoms of abnormal bleeding; -Interventions/tasks: Administer medication as currently prescribed by physician. Monitor the resident and report to nurse and physician any bleeding gums, nose bleeds, unusual bruising, black stools, pink urine; -Focus: At risk of skin breakdown as evidenced by incontinence, thin, fragile skin; -Goal: The resident will have intact skin, free of redness, blisters, discoloration through review date; -Interventions/task: Apply skin barrier cream as needed. Complete skin observation tool weekly and as needed. Review risk factors noted on pressure injury risk as needed. Provide perineal care after each episode. Report changes in skin integrity to nurse. Review of the resident's nursing note, dated 8/19/20 at 4:00 P.M., showed he/she was brought into his/her room. Per report he/she had left hip hemiarthroplasty (a surgical procedure where half of the hip is replaced). He/she denied any pain when asked, had an extra-large bowel movement after arrived, was cleaned and dried. Call light has been in reach. Medications verified with physician and faxed to pharmacy already. Review of the resident's skin assessment, dated 8/19/20 and completed by a facility nurse, showed multiple bruises on all extremities, 25 staples on his/her left hip, related to left femur neck fracture (where left leg meets hip) and left hip hemiarthroplasty. Further review of the resident's nursing notes, showed the following: -8/21/20 at 11:45 A.M., he/she is alert and oriented with forgetfulness. Incontinent of bowel and bladder, pain to left hip, as needed [MEDICATION NAME] (pain medication) given, getting effective. Skilled for left femur neck fracture, small amount drainage noticed, no redness noticed however, mild warmness to touch, dressing changed per order for today. Resident is more lethargic, not willing to eat, fluid encouraged, reported to Nurse Practitioner (NP), new orders given: lab work stat, (lab performed by lab staff already). Supplement shake to give twice daily, weight for admission; -8/21/20 at 2:22 P.M., Resident was seen by physician today with new order to schedule [MEDICATION NAME] every 6 hours. Orders noted and faxed to pharmacy; -8/22/20 at 1:25 P.M., The resident remains on skilled services for left femur neck fracture. Has remained in bed this shift. Notable bruising to bilateral lower and upper extremities. Dressing to left hip changed as ordered. Appetite poor. Encouragement needed by staff. No [MEDICAL CONDITION] to left leg noted. Call light in reach. Further review of the resident's nursing notes, dated 8/24/20 through 9/1/20, showed no changes to surgical wound on left hip, no other skin abnormalities noted. Review of the resident's skin assessment, dated 8/26/20, and completed by a facility nurse, showed no new unreported skin abnormalities at this time. Further review of the resident's nursing note, dated 9/2/20 at 2:20 P.M., showed the resident came back from orthopedic appointment, new orders for weight bearing as tolerated (WBAT) to left leg, continue on posterior hip precautions abduction pillow when in bed. Incision open to air (OTA). Review of the resident's shower sheets, completed by certified nurse aides (CNAs) and signed off by a nurse, showed the following: -Directions: Perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to the charge nurse immediately. Forward any problems to the Director of Nursing (DON) for review. Use this form to show the location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number; -9/3/20 bed bath given, no skin findings reported. During an interview on 9/28/20 at 2:43 P.M., CNA E said he/she gives residents showers. Some residents will get showered four times a week. When a shower is given he/she looks over the resident's skin and a shower sheet is filled out. Any skin findings are reported to the nurse. Review of the resident's skin assessment, dated 9/5/20 and completed by a facility nurse, showed no new unreported skin abnormalities at this time. Further review of the resident's nursing notes, showed the following: -9/7/20 at 6:29 A.M., The resident in bed at start of shift. He/she is incontinent of bowel and bladder. Peri-care check, assist with one staff, pressure area noted on left butt cheek. Staff repositioned resident on the right side to relieve pressure from left Side. Resident incision to left hip, well approximated and open to air (OTA), no redness, warm to touch, no [MEDICAL CONDITION], feet elevated in bunny boots while in bed. Resident refused routine [MEDICATION NAME]. Resident continues to receive skilled care for fractured left hip related to fall. Call light in reach. Further review of the resident's medical records, showed: -9/7/20 shower sheet: shower/bathing refused, no skin findings reported. -An inner office notification was sent to the facility wound nurse on 9/7/20, the resident has a red, non-open, blanchable wound on left buttock; -No documentation that the physician or family was notified of pressure area noted on 9/7/20. During an interview on 9/30/20 at 10:00 A.M., the Director of Nurses (DON) said skin assessments are assigned weekly and as needed for each resident, to be completed by the nurse. CNA's also look over the resident's skin during showers and should report all findings to the nurse and record on the resident's shower sheet. If a new area of concern is found, the nurse should immediately contact the physician for a treatment order, write a note in the resident's chart with a detailed description of the skin and notify the wound nurse who will assess the wound on his/her rounds. She expects nursing staff to contact the physician and the resident's family with any new skin findings or change in condition. After reviewing the resident's nurse notes, she said on 9/7/19, she would expect a detail description of the skin findings to have been charted, the physician and family to be notified. She used this as a teachable moment with this nurse. Review of the resident's NP's consult note, dated 9/8/20, showed the following: -The resident sustained [REDACTED]. -According to facility nursing staff, the resident has been lethargic, sleeping a lot during the day, drinking well but has a low appetite. The resident was evaluated by therapy, and has poor endurance; -Staff noted new pressure ulcer to coccyx this morning, seen by wound nurse, both eschar (thick adherent black necrotic of wound) and deep tissue injury noted; -Very sleepy this morning. Nurse states the resident had [MEDICATION NAME] early and sleepy after pain medication. The resident's family member reports he/she seemed sleepy on phone call over the weekend; -Staff reports poor by mouth intake 5-10% of meal. Taking shakes but only twice a day. The resident states not hungry; -Review speech note. Resident is oriented to person only; -New pressure ulcer and deep tissue injury to sacrum and left buttock, unstageable. (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (refers to the yellow/white material in the wound bed made up of dead cells) or eschar are by definition unstageable). Immobility and poor nutrition contributing. Wound specialist to see resident in morning. The wound will need debridement and Santyl (ointment used to remove damaged tissue from chronic skin ulcers); -Weight loss and [MEDICATION NAME] (low [MEDICATION NAME] blood level, decreased production in the liver, increased loss in the gastrointestinal tract or kidneys) The resident's family member reports recent weight loss at home. Weight 118 lbs in July and physician added supplements. Weight then back up to 129 lbs. Weight 134 lbs at hospital with discharge. He/she has had poor intake since admit, taking shakes twice a day but little of meals; -Resident also has [DIAGNOSES REDACTED]. -Orders: add low air loss mattress, add turn schedule, and add prosource (a protein supplement) daily and increase shakes to three times a day, change pain medication, staff to help with feeding. Review of the resident's initial wound evaluation summary consultation, dated 9/9/20, and completed by the wound physician, showed the following: -At request of referring physician a thorough wound care assessment and evaluation was completed; -Coccyx wound; -Wound etiology: pressure; -Wound stage: unstageable necrosis (the death of the cells); -Wound size: 6.1 centimeters (cm) x 3.5 cm with depth not measurable; -Eschar tissue: 30%; -Thick adherent devitalized necrotic (death of cells or tissue): 60 % -Slough: 10%; -Drainage: light serous (pale yellow and transparent and of a benign nature); -Surgical excisional debridement procedure (surgical removal or cutting away of devitalized tissue, necrosis, and slough, down to viable tissue using a blade/scalpel to promote healing) completed at bed side; -Treatment order provided, treatment completed today; -Goal is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue. Further review of the resident's care plan, undated and in use at time of the abbreviated survey, showed the following: -Focus: Impaired skin integrity area to coccyx; -Goal: Will exhibit signs of progressive healing without signs and symptoms of infection; -Interventions/task: Administer supplements as ordered. The resident is followed by wound physician. Wound measured weekly. Perform treatment to wound per current treatment order. Assess wound for signs and symptoms of infection with each dressing change/treatment. Report positive findings of redness warmth, swelling increased drainage, increased pain. Report progress/wound healing to physician, with any changes or lack or response to treatment. Apply automating pressure air mattress to bed. Assure inflation control is correct. Apply pressure reducing cushion to wheelchair. Monitor for verbal and nonverbal symptoms of pain. Administer [MEDICATION NAME] as ordered by physician and update physician regarding effectiveness. Further review of the resident's skin assessments, completed by nursing staff, showed the following: -9/10/20, Unstageable pressure to sacrum, followed by wound physician, air mattress in place, supplements, wheelchair cushion. Treatment in place. Skin tear to right lateral leg. Multiple bruises to both upper and lower extremities; -9/16/20, Continue with wound care to coccyx followed by wound nurse and physician. Review of the resident's wound evaluation, consult dated 9/16/20, showed the following: -Pressure wound on coccyx; -Wound etiology: pressure; -Wound stage: unstageable necrosis -Wound size: 8.5 cm x 2.4 cm with depth not measurable; -Eschar tissue: 20%; -Thick adherent devitalized necrotic: 60%; -Slough: 20%; -Drainage: light serous; -This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm (a slimy buildup of bacteria); -Wound progress: improved; -Surgical excisional debridement procedure completed at bedside. Further review of the resident's nursing notes, showed the following: -9/19/20 at 12:51 P.M., The resident is pleasantly confused. He/she is skilled for fracture to left hip and falls. He/she is alert to self, one person assist with transfers and ADLs, no labs noted this shift, no complaints of pain nor discomfort noted. No drainage to leg wound, coccyx wound has green drainage noted with odor, treat, cleaned and new dressing applied per order; -9/20/20 at 1:41 P.M., The resident is skilled for fracture to left hip and falls. He/she is alert to self and place, one person assists with ADLs and transfers. Lungs sound clear. He/she ate 50% for breakfast and 75% for lunch. Wound dressing intact, odor noted to wound bed, greenish yellow slough noted. No complaint from resident of pain or discomfort noted this shift. Further review of the resident's nursing notes, showed no documentation the physician or the family were notified of new odor or green drainage to wound on 9/19/20 or 9/20/20. During an interview on 9/28/20 at 2:49 P.M., Nurse D said he/she is a floor nurse in charge of a hall. Resident skin assessments are completed by supervisors only. He/she does do wound treatments. If he/she was notified by a CNA that a resident had a new skin issue, he/she would look at it, assess the wound, call the wound nurse, notify the resident's family and call the physician for orders. He/she would know if a wound was infected if it was red, swollen or had drainage. A wound would be considered worse if it became necrotic. He/she does not do skin assessments. During an interview on 10/2/20 at 10:20 A.M., Nurse B said if a wound has an odor or green drainage it means something is wrong or it is infected. The wound nurse, the physician and the family should be notified with any changes or irregular findings. He/she noted an odor and green drainage to the resident's wound on 9/19 and 9/20. Nurse B cannot say why he/she did not contact the physician or family on 9/19 or 9/20. Review of the resident's wound evaluation consult, dated 9/21/20, showed the following: -Pressure wound on coccyx; -Wound etiology: pressure; -Wound stage: unstageable Necrosis -Wound size: 7.9 cm x 2.4 cm x 0.5 cm; -Eschar tissue: 20%; -Thick adherent devitalized necrotic: 60%; -Slough: 20%; -Drainage: moderate serous; -This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm; -Wound progress: no change; -Surgical excisional debridement procedure completed at bed side; -[DIAGNOSES REDACTED]. Review of the resident's physician orders, showed the following: -9/21/20, [MEDICATION NAME] (Antibiotic) tablet 100 MG Give one tablet by mouth two times a day for [MEDICAL CONDITION] (infection of the skin) for 10 Days; -9/22/20, Lab work in A.M. basic metabolic panel (BMP, a blood test that gives doctors information about the body's fluid balance, levels of electrolytes, and how well the kidneys are working) and complete blood count (CBC, a blood test used to evaluate your overall health) with [DIAGNOSES REDACTED]. Further review of the resident's nursing notes, showed the following: -9/23/20 at 1:44 A.M., Resident remains on skilled services related to left hip, denied pain or discomfort at this time, alert to person and place, assist of one with ADLs and transfers, respirations even non-labored, bowel sounds active, cleaned and dried as needed, dressing intact, new order for CBC, BMP for 9/23/20 and weight in A.M., voiced no concerns resting in bed with call light within reach. -9/23/20 at 6:40 A.M., Remains on antibiotic for coccyx wound, tolerating well without adverse reactions, weight 102 lbs. -9/25/2020 at 7:56 P.M., labs were drawn at 8:00 A.M., this morning BMP results were in at 11:13 A.M., Nurse was still waiting on CBC. Lab called this nurse at 7:45 P.M., for critical lab, this nurse logged into lab computer and observed that CBC was not successfully run do to being hemolyzed (clotting of blood) called lab and lab employee informed this nurse they will have tech to come and redraw the labs. This nurse will inform oncoming nurse and awaiting tech to redraw the labs. Physician is aware. During an interview on 10/2/20 at 10:28 A.M., NP A said he/she expected orders to be followed as written. The resident was on antibiotics for a skin infection and was dehydrated the week prior. On 9/22/20, he/she wrote an order for [REDACTED]. During an interview on 10/2/20 at 10:20 A.M., Nurse B said when an order is given for lab work, the order needs to be provided to the lab by entering it in the computer system, filling out a paper rec or calling the lab. During an interview on 10/2/20 at 1:00 P.M., Nurse F said he/she worked on 9/22/20 at 7:00 P.M, through 9/23/20 at 7:00 A.M. That evening, NP A, informed him/her that he/she wrote an order for [REDACTED]. He/she also passed on the information to the next shift nurse in report. The lab tech used to come in the early morning, around 5:00 A.M., but now the lab comes after he/she leaves. Review of the resident's lab results, collected on 9/25/20 at 8:07 A.M., and collected again at 10:29 P.M., showed white blood cell count: Critically High at 38.2 (WBC, fight bacteria, viruses, and other organisms your body identifies as a danger. A higher than normal amount of WBCs in a blood could mean an infection. Lab normal reference range 4.8-10.8). Further review of the resident's nursing notes, showed the following: -9/25/20 at 11:48 A.M., Resident is skilled for fractured left hip, and falls. On antibiotics related to [MEDICAL CONDITION]. No complaints of pain noted at this time. Water encouraged. Requires assist of one with ADLs and transfers. Alert to self. He/she is up in wheelchair unable to propel self in wheelchair. He/she is pleasantly confused, ate 25% of breakfast, supplement shake given and drank all. Labs drawn, awaiting result; -9/26/20 at 5:15 A.M., Received critical lab results contact physician and spoke with NP, gave lab results. Vitals are in normal limits, no fever no complaints of pain. NP will call physician to see the plan of action, after talking to physician office went to check on the resident. Vital signs within normal limits, change wound dressing due to dressing soaked. Nothing further at this time. -9/26/20 at 8:02 A.M., NP called new order given to send the resident to hospital; -9/26/20 at 8:15 A.M., The resident was transported to hospital by ambulance. Review of the resident's emergancy room hospital records, showed the following: -9/26/20, The resident arrived via emergency medical services, to emergancy room, from facility due to abnormal labs/WBC of 38. He/she also presents with a skin tear on his/her right arm and a decubitus ulcer on his/her right back; -Physician initial assessment showed a large right-sided decubitus ulcer (pressure ulcer), induration and redness extending into the gluteal (pertaining to the buttock muscles) area on the right. Foul smell to wound; -Radiologist impression of computed tomography scan, (CT, medical imaging technique that uses computer-processed x-ray measurements to see inside the body), showed a right decubitus ulcer with right gluteal abscess (a painful, swollen lump that's filled with pus) measuring 11cm x 3cm x 8cm; -Lab work: WBC elevated at 37.5, [MEDICATION NAME] low at 2.9 (indicator of nutritional status normal range is 3.5 - 5.2), hemoglobin low at 8.9 (indicators of [MEDICAL CONDITION], normal range is 11.8 -14.8), platelets high at 368 (indicates infection, normal range is 140 -350), sodium high at 153 ([MEDICAL CONDITION], involves dehydration, normal range is 136-145); -Urine test result showed urine to be brown, cloudy with leukocyte +1(normal result is negative), and bacteria +1 (normal result is negative), (results indicate a likely urinary tract infection); -Started intravenous fluids, broad-spectrum antibiotics; -Requested general surgery consulted for evaluation of abscess and operative intervention; -Admited to hospital on [DATE], with [DIAGNOSES REDACTED]. During an interview on 10/2/20 at 10:10 A.M., NP C said he/she expected to be notified if a resident's wound developed an odor, drainage or any change of condition. During an interview on 10/2/20 at 11:20 A.M., the resident's wound physician said he absolutely expected to be notified if a wound develops an odor or drainage. This is very important information and he/she would act on it right away. During an interview on 10/1/20 at 1:52 P.M. and on 10/2/20 at 10:10 A.M., the DON said the resident's labs should have been drawn on 9/23/20. When a nurse received an order for [REDACTED]. The lab tech comes to the facility every day. They are to check each unit for orders on paper recs. The physician should have also been notified on 9/19/20 and 9/20/20 when the nurses noted new drainage and an odor to the resident's wound. During an interview on 9/30/20 at 10:13 A.M., the administrator said he expected all staff to follow the facility policies and procedures. Physician orders [REDACTED]. Review of the facility's skin management guidelines revised 7/2017, and in use at time of survey showed the following: -Upon admission, all residents are assessed for skin integrity by completing an assessment and documenting in the electronic health records (EHR); - Nurse aides will complete body audits. The body audits post shower will be turned into the licensed nurse to review for changes in skin condition; -Appropriate preventive measures will be implemented on all residents identified at risk and the interventions documented on the Care Plan. - Residents admitted with skin impairments will have: appropriate interventions implemented to promote healing, a physician's orders [REDACTED]. Review of the facility's notification of a change in a resident's condition policy reviewed 11/01/2018, and in use at time of the survey, showed the following: -The attending physician/physician extender (NP, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations; -All licensed nursing personnel are responsible; -Guideline for notification of physician/resident representative (not all inclusive): significant change of unstable vital; -Signs emesis/diarrhea; -Onset of pressure sores; -Any accident or incident (per federal and state regulations); -Symptoms of any infectious process; -Abnormal lab findings; -5% Weight gain or loss in 30 days; -Repeated refusals to take prescribed medication (for two days); -Change in level of consciousness; -Abnormal complaints of pain; -Ineffective relief of pain from current regimen; -Unusual behavior; -Missing resident; -Glucometer reading below 70 or above 200 unless specific parameters given by physician for reporting. MO 981

Based on observation, interview and record review, the facility failed to follow their policy to provide potential treatments that could promote healing of existing pressure ulcers. The facility also failed to communicate the wound company's Nurse Practitioner's recommendations, to one resident's physician, to hold a blood thinner so the resident's Stage IV pressure ulcer could be debrided and later failed to follow the Nurse Practitioner's recommendation to obtain a wound culture of that pressure ulcer. The resident eventually was admitted to the hospital with [REDACTED]. In addition, the facility failed to ensure another resident with a pressure ulcer on the heel wore protective boots while in bed as ordered. Of the 21 residents sampled, four had known pressure ulcers and problems were identified with two. (Residents #194 and #66). The census was 101. Review of the facility Skin Management Guidelines Overview, dated 2/2016 and revised on 7/2017, showed: Overview: -Residents who are at risk or with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes; -A pressure injury is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure injuries are usually over bony prominence's and are staged to classify the degree of tissue damage observed. Review of the facility Skin Management Guidelines Practice guidelines, dated 2/2016 and revised on 7/2017, showed: -Purpose: -To identify at risk residents for potential breakdown or ulcerations; -To prevent breakdown of tissue or ulcerations; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations -Risk Factors: -Impaired mobility; -Co-morbid conditions, such as, end stage [MEDICAL CONDITIONS] disease or diabetes mellitus; -Impaired diffuse or localized blood flow, for example, generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency; -Resident right of choice in some aspect of care and treatment; -Cognitive impairment; -Exposure of skin to urinary or fecal incontinence; -A healed ulcer: The history of a healed pressure ulcer and its stage (if known) is important, since areas of healed pressure ulcers are more likely to have recurrent breakdown. 1. Review of Resident #194's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/18, showed: -Adequate hearing and vision; -Speech clarity: Clear speech - distinct intelligible words; -Understood/understands; -Intact cognition; -Total dependence of two (+) persons required for bed mobility and transfers; -Walking in room/corridor did not occur; -Extensive assistance of one person required for dressing; -Physical help of one person required for bathing; -Functional limitation in range of motion: Impairment of both upper extremities and one lower extremity; -Supra-pubic catheter (a tube surgically inserted into the bladder through the abdominal wall to drain urine); -Always incontinent of bowel; -[DIAGNOSES REDACTED]. -Risk of pressure ulcers: Yes; -Unhealed pressure ulcers: Yes; -Number of Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). (MONTH) also present as an intact or open/ruptured blister): One; -Number of Stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) may be present on some parts of the wound bed. Often includes undermining and tunneling): One; -Number of unstageable pressure ulcers - (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission). Four; -Were pressure ulcers present on the prior MDS assessment: Yes; -[MEDICAL CONDITION]: Yes; -Moisture associated skin damage: Yes; -Applications of dressings to feet (with or without topical medications): Yes. Review of the resident's care plan, dated 12/18, showed: -Perform treatment to wounds per current treatment order; -Assess wounds for signs and symptoms of infection with each dressing change/treatment; -Report positive findings of redness, warmth, swelling, increased drainage, increased pain; -Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications. -Report wound healing to physician with any changes to lack of response to treatment per facility guidelines. Observation on 12/27/18 at 9:15 A.M., showed the resident lay in bed as Nurse Practitioner (NP) F (a wound specialist from a wound care company that sees the resident on a weekly basis) and Nurse G (a facility nurse that makes rounds with NP F) changed the resident's pressure ulcer dressings, including the one on the left gluteal fold (the area located between the lower buttock and the upper posterior thigh). NP F discussed with the resident the need for the pressure ulcer on the left gluteal fold to be debrided during his/her next scheduled visit on 1/3/19. The resident agreed to the procedure. NP F asked Nurse G to contact the resident's physician and ask if the resident's Eliquis (blood thinner) could be held 48 hours before 1/3/19, so he/she could debride the pressure ulcer without danger of excessive bleeding. Review of NP F's Progress Note Details, dated 12/27/18, showed: Chief Complaint: The resident is being seen for pressure ulcers that include the left gluteal fold; -Left gluteal fold: The wound is currently classified as a Stage IV with etiology of pressure ulcer and moisture associated skin damage; -The wound measures 8 centimeters (cm) (length) by 6.4 cm (width) by 8.5 cm (depth). There is muscle and fat layer exposed. There is a large amount of serosanguineous (blood and the liquid part of blood (serum)) drainage; -There is a large (67-100%) amount of necrotic (dead) tissue within the wound bed including adherent slough and necrosis of muscle; -Wound improving; -General notes: -Stop Eliquis (blood thinner) 48 hours before debridement on 1/3/19, pending the primary care physician's approval. Review of NP F's Wound NP to MD Recommendation (a hand written form left at the facility the same day of the visit), dated 12/27/18, showed NP F had written: Left gluteal fold (ischium), stop Eliquis 48 hours before debridement 1/3/19. Review of the resident's progress note, dated 12/27/18 at 8:13 P.M., and completed by Nurse I, showed Physician H (on call for the resident's physician) came to the facility and viewed a lab and x-ray result. Physician H decided to let the resident's physician take care of it when he/she returned on 1/9/19. No new orders were given at that time. Resident was seen by NP F today (12/27/18). Nurse I did not document if Physician H had been informed that NP F wanted to debride the pressure ulcer on the resident's left gluteal fold on 1/3/19, and if the Eliquis could be held 48 hours prior to the debridement. Review of NP F's Progress Note Details, dated 1/3/19, showed: -Left gluteal fold: The wound is currently classified as a Stage IV with etiology of pressure ulcer and moisture associated skin damage; -The wound measures 7.1 cm by 6.6 cm by 6.8 cm. There is muscle and fat layer exposed. There is a large amount of serosanguineous drainage; -There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough and necrosis of muscle; -General notes: Wound bed measured smaller. Wound bed is 100% necrotic. Wound bed is worse. Resident would benefit from surgical debridement of left gluteal fold; -Wound culture routine - left gluteal fold at next dressing change; -Wound worsening; -There was no documentation to indicate the left gluteal had been debrided. Review of the NP to MD Recommendation form completed by NP F and dated 1/3/19, showed the NP had written: Left ischium - wound culture next dressing change. Review of the resident's progress note, dated 1/3/19 at 2:53 P.M., and completed by Nurse I, showed the resident was seen by NP F and (this nurse) has been informed that his/her wounds are worse with a foul smell, excessive drainage and infection. Culture done today. Physician H who is covering for the resident's physician through 1/9/19, has been informed. Review of NP F's Progress Note Details, dated 1/9/19, showed: -Nursing reports wounds are worse and is malodorous (foul, putrid, noxious); -Culture not obtained; -Left gluteal fold: The wound measures 10 cm by 7.8 cm by 6.5 cm; -There is muscle and fat layer exposed; -There is a large amount of serosanguineous drainage noted; -Foul odor was noted after cleansing; -There is no granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough and necrosis of muscle; -General note: Wound is deteriorating. Copious (abundant, extensive) amounts of serosanguineous drainage with small amount of green drainage. Suspect pseudomonas (a bacteria that can cause infection); -Admission to hospital for surgical debridement and intravenous antibiotics. Would benefit from a long term acute care (LTAC) admission after hospital admission for continued wound care. Review of the resident's progress notes, dated 1/9/19, showed: -1:00 P.M., wound rounds were completed with NP F. Upon assessment, wounds have deteriorated and have developed a strong odor. Resident informed of wound conditions and options and has decided that going to the hospital for further management/assessment is in his/her best interest; -1:38 P.M., the resident had asked to go to the emergency room due to the wounds on his/her upper and lower extremities being infected. Physician notified. Review of the resident's hospital records, admission date of [DATE], showed: -History of present illness: Presents with a chief complaint of wound check; -Resident states a visiting wound nurse (NP F) comes to the nursing facility once a week to check on the wounds on his/her left foot, right ankle and bilateral ischial areas (the area between the lower buttock and the upper thigh, when sitting the weight is frequently placed on this area). NP F came to his/her facility today and recommended he/she go to the hospital, stating the wounds are infected; -On his/her left ischial area is a large deep wound the size of a fist which is draining purulent (consisting of, containing, or discharging pus) foul smelling fluid. There is some surrounding [DIAGNOSES REDACTED] (red skin); -Medical decision making and plan of care: On initial evaluation, the left ischial wound is infected with foul smelling discharge. Will obtain a culture and start antibiotics. Update resident to results and plan for admission. Resident is agreeable to plan; -Clinical impression: Infected pressure ulcer (primary); -Further review of the hospital record showed: -Chief complaint: Wound infection; -Presenting from the nursing home with multiple pressure ulcers with concern for infection. There was especially concern for infection of the very large left buttock (ischial) wound. The left ischial area in particular was noted to be draining foul-smelling, purulent fluid with surrounding [DIAGNOSES REDACTED]; -He/she was started on [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) in the emergency department; -Left buttock with large 7 cm by 6 cm open wound with muscle exposed and purulent, foul-smelling drainage; -Assessment and plan:[MEDICAL CONDITION] (a potentially life-threatening illness caused by the body's response to an infection). Exam concerning for multiple pressure ulcers involving bilateral hip/buttocks and feet. Left buttock (which extends down to the muscle) and right hip wounds especially appear to have active drainage and surrounding [MEDICAL CONDITION] (a bacterial skin infection). Continue [MEDICATION NAME] and [MEDICATION NAME]. Follow up wound and blood cultures. Consult with general surgeon for wound care. During an interview on 1/29/19 at 9:47 A.M., Nurse G said he/she makes rounds weekly with NP F. The NP leaves her recommendations on the Wound NP to MD Recommendation form before he/she leaves. A copy is given to the nurses to process. He/she did not know if Nurse I contacted the resident's physician to hold the Eliquis. NP F did not debride the resident's pressure ulcer on the left gluteal fold on 1/3/19, but he/she did not recall why. He/she was not aware the wound culture had not been obtained with the next dressing change as recommended by NP F. During an interview on 1/29/19 at 10:00 A.M., Nurse I reviewed the progress note he/she wrote on 12/27/18 at 8:13 P.M., and said he/she had asked Physician H about stopping the Eliquis for the debridement, but Physician H did not want to stop the medication. He/she should have documented that in the progress note but did not. He/she reviewed the progress note he/she wrote on 1/3/19 at 2:53 P.M., and said NP F was in the hall and he/she thought NP F said he/she (NP F) had obtained the wound culture. He/she receives a copy of NP F's recommendations the day NP F is at the facility. He/she is supposed to review the recommendations and contact the physicians to see if they want to follow the recommendations. He/she did not review NP F's recommendation dated 1/3/19, because he/she thought NP F had already obtained the wound culture. He/she reviewed NP F's recommendation form dated 1/3/19, during the interview and said the recommendation showed the wound culture should be obtained with the next dressing change. He/she misunderstood and should have made arrangements for the wound culture to be obtained. During a telephone interview on 1/31/19 at 8:30 A.M., NP F said he/she recalled seeing the resident on 12/27/18, 1/3/19 and 1/9/19. Nurse G was present each time. On 12/27/18, the pressure ulcer on the left gluteal fold was improving, but needed a bedside debridement. He/she asked Nurse G to contact the primary care physician about holding the Eliquis so he/she could debride it on 1/3/19. He/she did not want bleeding to start and not be able to stop it. On 1/3/19, it was his/her understanding the primary care physician was not notified, but he/she was not sure. Nurse G could not find any information about the Eliquis being held, so he/she could not complete the bedside debridement. The pressure ulcer had an odor and a little bit of a green color that day, making him/her think there may have been a pseudomonas infection, which is why he/she wanted the culture. Normally he/she will get the culture himself/herself at the time of the treatment, but the facility did not have the supplies necessary. He/she told Nurse G to have the culture done with the next dressing change which would have been no later than the next day. After a culture is obtained, the preliminary results are usually available within 24 hours and a sensitivity report is available in about five days. The preliminary report shows what kind of organism is growing in the wound and the sensitivity report shows what antibiotic is susceptible to the organism. Sometimes he/she will order a broad spectrum antibiotic based on preliminary report but not always. On 1/9/19, the pressure ulcer did not appear too much worse than on 1/3/19, but the odor was much stronger and more foul. He/she could smell it when he/she entered the resident's room. He/she told the resident he/she really needed to be hospitalized for [REDACTED]. NP F could not say with 100% certainty, that if the debridement and wound culture had occurred as ordered, that the resident still would not have ended up in the hospital. During a telephone interview on 1/31/19 at 10:40 A.M., Physician H said he/she did not recall Nurse I asking him/her about holding the Eliquis on 12/27/18, or telling him/her why the NP wanted it held. Normally, if he/she is on-call for another physician and is not familiar with the resident, he/she will review the resident's medical record to determine why the resident is receiving it so he/she can decide if it can be held. If the wound NP is not available to speak to, he/she would request to see the pressure ulcer. He/she did not recall reviewing the resident's medical record, speaking to NP F or observing the resident's left gluteal pressure ulcer. During an interview on 1/29/19 at 11:08 A.M., the facility Medical Director said if the wound NP asked staff to contact the resident's physician about stopping the Eliquis, it should have been done. The nurse responsible for processing NP F's recommendations to obtain a wound culture should have processed the recommendation. During an interview on 1/29/19 at 12:35 P.M., the administrator said the Wound NP to MD Recommendation form was developed in response to the F686 citation the facility recently received regarding Resident #194. The form was to be given to the nurses the day the wound NP was in the building so the nurse's could contact the physician promptly. She would have expected better communication between the staff and the wound NP so they would not have missed the wound culture. 2. Review of Resident #66's MDS, dated [DATE], showed: -admission date of [DATE]; -Does not reject care; -Extensive assistance of one person required for bed mobility; -Total dependence of one person required for dressing; -Total dependence of two staff required for transfers; -No [MEDICAL CONDITION] or other open [MEDICAL CONDITION] on feet; -[DIAGNOSES REDACTED]. Review of the resident's progress notes, showed: -1/11/19 at 11:51 A.M.: Writer notes that resident has a blister on left heel, 3 cm by 3 cm. Writer is putting a call out to physician to report blister; -1/11/19 at 12:26 P.M.: New orders for skin prep (a sticky substance that dries leaving a protective film) on left heel daily, blue bunny boots (to reduce foot and heel pressure) on at hour of sleep. Observation on 1/24/19 at 7:08 A.M., showed the resident lay in bed. Certified Nurse Aide (CNA) J and CNA K prepared to provide incontinence care. The CNAs removed the resident's blankets to provide care. The resident had a large purple area on his/her left heel but no bunny boots. During an interview on 1/24/19 at 11:35 A.M., Nurse I said the CNAs know what type of care to provide by looking at the electronic kardex (kept on a device similar to a smart phone). During an interview on 1/24/19 at 11:39 A.M., CNA K reviewed the resident's electronic kardex, but could not find information as to what type of care the resident needed. Observation on 1/25/19 at 6:34 A.M., showed the resident lay in bed without bunny boots. During an interview on 1/25/19 at 8:17 A.M., Nurse L said the resident should wear bunny boots while in bed. The nurse found the resident's bunny boots on top of the resident's chest of drawers in his/her room. He/she did not know why the resident did not have them on that morning while in bed. During an interview on 1/25/19 at 8:28 A.M., CNA D looked through the resident's electronic kardex to see if he/she could find information about bunny boots. After several minutes of searching, the CNA did find the order for the resident to wear bunny boots while in bed. During an interview on 1/25/19 at 9:04 A.M., the administrator said if there is an order to wear the bunny boots she expects staff to know and follow the order. MO 579

Based on interview and record review, the facility failed to ensure staff performed Cardiopulmonary Resuscitation (CPR, life sustaining measure in the event that that heart stops beating) for a resident with a full code order. The resident was found unresponsive by a nurse who thought the resident had been admitted to hospice and had his/her code status changed to do not resuscitate (DNR, no attempts at resuscitation will be made), but failed to check the resident's chart to verify the order. The resident had not been admitted to receive hospice services. Staff did not call a code, start CPR or call 911. The resident expired. (Resident #47) There were 54 residents with full code orders. The census was 85. Review of the facility Policy and Procedure: Cardio-Pulmonary Resuscitation policy, dated [DATE] and revised on [DATE], showed the following: -Policy: Upon determination that a resident is in cardiopulmonary or respiratory arrest, CPR will be initiated by a CPR certified staff member and 911 called for advanced cardiac life support unless one of the exceptions applies - When the resident or surrogate has indicated that resuscitation is not desired and the attending physician has issued a written do not resuscitate (DNR) order that is maintained in the facility's clinical record; or When there is the presence of obviously clinical signs of irreversible death (defined as rigor mortis (the limbs of the deceased stiffens) or dependent lividity (the pooling of blood in the body after the heart has stopped beating, the blood becomes subject to gravity and pools in the lower portions of the body); or There is no physiologic benefit can be expected because the [MEDICAL CONDITION] functions have deteriorated despite maximal therapy for such conditions such as progressive septic shock (when infection is severe enough to effect the organs) or cardiogenic shock (an inadequate circulation of blood due to primary failure of the ventricles of the heart); or When attempts to perform CPR would place the rescuer at risk of personal injury; -Each resident's code status will be maintained in the clinical record; -Procedure: Assess scene for hazards; determine unresponsiveness of the resident while checking for a pulse and adequate breathing; if no response, call out for assistance, instruct other staff responding to scene to obtain emergency supplies and notify 911 or emergency personnel, if no pulse is felt, begin chest compressions - give 30 compressions - open the airway and give 2 rescue breaths; continue the compressions and breaths until resident shows signs of life or help arrives and takes over (emergency personnel) or physician gives order to cease; -Supplies the facility will have readily available may include: bag valve mask, barrier mask, suctioning equipment and backboard; -Note: While CPR or other emergency procedures is being performed, additional staff members should contact the resident's physician and family. Review of Resident #47's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admission date of [DATE]; -Usually understood/usually understands; -Moderate cognitive impairment; -Limited assistance of one person required for bed mobility, transfers, walking in room/corridor and dressing; -[DIAGNOSES REDACTED]. -No pain symptoms; -Did not receive hospice care. Review of the resident's nurse practitioner's progress note, dated [DATE], showed the resident reported he/she did not have an appetite and had an upcoming appointment with oncology (a branch of medicine that deals with the prevention, [DIAGNOSES REDACTED]. Review of the resident's physician's order sheet (POS), dated [DATE] through [DATE], showed an order for [REDACTED]. Review of the resident's nurse's note, showed on [DATE] at 3:28 P.M., the resident arrived to the facility via a stretcher, transported by two emergency medical technicians. Resident sleepy but arousable, bowel sounds hypoactive (an inhibition of activity) in all quads (the abdomen is divided into four quadrants for assessment purposes), lung sounds diminished, pedal [MEDICAL CONDITION] (swelling) to bilateral lower extremities. Skin dry and cool to touch, oral mucous (inside of the mouth) pink and moist, eyes watery. Resident's physician was there and verified medications. Review of the resident's handwritten POS, dated [DATE], showed the resident was a full code. Review of the resident's nurse's notes, showed the following: -[DATE] at 6:54 A.M.: Returned from hospital in more dependent state. Unable to move independently, unable to follow simple commands and unable to voice desire to leave facility. Increased frequency checks not needed. He/she is an increased fall risk. Add floor mats next to bed; -[DATE] at 8:04 P.M.: Alert and oriented to self, responds to verbal commands. Assisted to feed resident. Difficulty swallowing the food and ate less than 25% of pureed (pudding consistency) diet. Fall and aspiration precaution followed. Follow-up appointment in the morning; -[DATE] at 7:15 A.M.: Not following instructions this morning. Morning medication held due to resident's condition. Vital signs (temperature, pulse, respirations and blood pressure) stable. Resident has a doctor's appointment today. Will continue to monitor; -[DATE] at 7:20 A.M.: This nurse (Nurse A) went into room and noticed resident had secretions in his/her mouth. Resident unable to clear his/her throat of secretions or swallow them. Resident not verbally responsive, but opens eyes. Resident suctioned. Call placed to physician to inform of the above. Order received to suction and hospice consultation was made. Oncologist appointment for today was canceled related to current decline in condition. Review of the resident's POS, dated [DATE] through [DATE], showed an order, dated [DATE], for hospice to evaluate and treat. There was no change documented related to the resident's full code status. Review of the resident's nurse's notes, showed the following: -[DATE] at 7:45 A.M.: Resident's representative was called and report given of the above change in condition; -[DATE] at 8:00 A.M.: Hospice was informed and face sheet and orders faxed; -[DATE] at 9:38 A.M.: Hospice Nurse D was here and completed the intake assessment; -[DATE] at 9:59 A.M.: This nurse (Nurse A) was in to see resident. Noted resident in bed without obvious respirations. Vital signs attempted with no vital signs noted; -[DATE] at 10:08 A.M.: Call placed to resident's physician and notified her of resident's absent vital signs. Physician pronounced death with a [DIAGNOSES REDACTED]. -[DATE] at 10:15 A.M.: Call placed to resident's representative and he/she was informed of resident's passing. Representative stated he/she would call back with arrangements. During an interview on [DATE] at 12:00 P.M., the administrator said the resident had passed away that morning. The resident was in the process of becoming a hospice patient and had been evaluated by Hospice Nurse D shortly before he/she passed away. At the time of his/her passing, the resident was not officially on hospice and was still technically a full code. Nurse A, found the resident without respirations or a pulse, but did not call a code, initiate CPR or call 911, because he/she thought the resident had been made hospice and had a DNR order. During an interview on [DATE] at 1:14 P.M., Nurse A said that morning, during report at 7:00 A.M., the night nurse said the resident was unable to swallow his/her medicine at 6:00 A.M. At around 7:20 A.M., when Nurse A first saw the resident, the resident was sleepy. He/she would open his/her eyes, but would not communicate and had a lot of secretions in his/her mouth. He/she suctioned the resident then called the resident's physician to report the change in condition. The physician gave an order for [REDACTED].M., and Nurse A thought the evaluation had been completed. During their conversation, Hospice Nurse D was on the phone and he/she assumed Hospice Nurse D was speaking to the resident's representative. Hospice Nurse D left the facility at around 9:50 A.M., without talking to Nurse A again, or confirming if the evaluation had been completed, if the resident had been admitted to hospice or the resident's code status changed from a full code to a DNR. The resident passed away at around 10:00 A.M., not long after Hospice Nurse D had left the facility. Nurse A was the one who found the resident in bed passed away. Per the facility policy, the resident's code status should be checked in the chart and if the resident was a full code, CPR should be immediately initiated, a code should be called on the intercom and 911 should be called. He/she did not check the resident's chart for the code status or initiate the facility policy, because he/she thought the resident was a hospice patient. He/she called the resident's representative who lived out of town, and informed the representative of the resident's passing. He/she did not inform the representative CPR had not been initiated. Review of a written statement received by the facility from Hospice Nurse D, dated [DATE], showed on the morning of [DATE], he/she tried to use the copy machine at one nurse's station and it was not working, so he/she walked over to another nurse's station to use that copy machine. In the hallway, Nurse A asked if he/she knew of a consult for the resident. He/she told Nurse A no. Nurse A said he/she had faxed it to the hospice office. Nurse A was informed that the office would let him/her know of the referral after they contacted the resident's representative. Nurse A said the resident was not doing well and needed hospice as soon as possible. Hospice Nurse D called the hospice office and spoke to Intake Coordinator E and asked him/her to call the resident's representative as soon as possible as the resident was not doing well at all. Intake Coordinator E said he/she would call the representative immediately. During a telephone interview on [DATE] at 8:10 A.M., Hospice Nurse D said he/she was at the facility on the morning of [DATE], visiting another resident. He/she went to the nurse's station to use the copy machine when Nurse A asked if he/she was there to evaluate the resident. He/she had no idea who the resident was and had no orders to evaluate the resident. Nurse A said he/she had just faxed the paperwork to the hospice office. He/she told Nurse A unless the contracts had been signed with the resident's representative, he/she could not evaluate the resident. He/she finished his/her work with the other resident and left the facility. He/she had not received orders to evaluate the resident before he/she left the facility, and did not tell Nurse A the resident had been evaluated, accepted into hospice or had his/her code status changed from full code to DNR. Review of a written statement received by the facility from Hospice Intake Coordinator E, dated [DATE], showed he/she received an order for [REDACTED]. While checking the resident's insurance and entering the resident's information into the system, he/she received a call from Hospice Nurse D who reported the resident needed to be signed on as soon as possible as the resident had taken a quick decline. He/she then placed a call to the resident's representative and had an approximately 30 minute conversation about what hospice was. He/she explained that with hospice there would be no further hospital stays, no aggressive treatment in order to let nature take its course. He/she discussed pain control and informed the resident's representative that if a resident was not currently on pain medication and was still able to swallow without difficulty, [MEDICATION NAME] would likely not be the first choice. The resident's representative stated ok, and asked to be e-mailed the hospice brochure and admission paperwork to sign. He/she explained that the resident would be admitted to hospice at the time the signed paperwork was received back from him/her. As the paperwork was being prepared to be e-mailed, he/she received a phone call from Hospice Nurse D the resident had passed away. During a telephone interview on [DATE] at 8:50 A.M., the resident's representative said he/she was the resident's designated medical power of attorney. On [DATE], he/she and the facility had attempted to communicate by phone, but both he/she and the facility had missed some calls with each other. He/she reviewed his/her phone log and said at 8:39 A.M., he/she spoke to Nurse A for the first time. He/she was told the resident was weak, not swallowing liquids and his/her oncologist appointment had been canceled. Nurse A asked his/her permission to obtain a hospice evaluation after speaking to him/her about comfort measures for the resident. He/she expressed concerns about giving the resident too much [MEDICATION NAME] and gave permission for the hospice evaluation. Nurse A did not explain an admission to hospice would mean waiving the resident's full code status for a DNR status. At 9:41 A.M., Hospice Intake Coordinator E phoned him/her and said the resident was not eating. He/she told Hospice Intake Coordinator E that he/she did not want the resident on [MEDICATION NAME] unless he/she seemed to be in pain. He/she gave permission for the hospice evaluation at that time. Hospice Coordinator E did not say anything to him/her about changing the resident's code status to a DNR. Had either Nurse A or Hospice Coordinator E mentioned the resident would be a DNR, he/she would not have given permission for the evaluation or admission to hospice. He/she did not sign a contract with the hospice company. When Nurse A phoned him/her about the resident's passing, the nurse did not inform him/her that CPR had not been initiated. He/she would have expected CPR to be initiated for the resident. During interviews on [DATE] at 10:57 A.M. and 1:15 P.M., Nurse A said when he/she called the resident's representative on [DATE], he/she told him/her about canceling the oncologist appointment because of the resident's poor condition. He/she informed him/her about comfort measures, but did not tell him/her the resident's code status would change from a full code to a DNR. Later when he/she entered the room, he/she did not realize the resident had passed because he/she looked as if he/she was sleeping. When he/she felt the resident's neck and arm it felt cool to the touch, but his/her lips and nail beds were pink. The resident wasn't on oxygen and was in the room by him/herself. Nurse A did not initiate the facility CPR policy, because he/she assumed the resident was a hospice patient. During an interview on [DATE] at 12:06 P.M., Nurse O said if a resident was found without respirations or a pulse, he/she would check the code status in the chart to see if the resident was a DNR or a full code. If the resident was a full code, he/she would initiate CPR immediately, yell for someone to get the crash cart and automated external defibrillator (AED, a portable electronic device that automatically [DIAGNOSES REDACTED]. If a resident was in the process of a hospice evaluation and was a full code prior to the evaluation, then he/she would consider the resident to be a full code until a new order was in the resident's chart. During an interview on [DATE] at 12:55 P.M., Nurse G said he/she would check a resident's chart for their code status. If they were a full code CPR should be initiated. If there were no orders from hospice the resident would be a full code, until they had family consent or hospice orders for DNR. During an interview on [DATE] at 1:45 P.M., Nurse H said when a resident expired staff were to check the chart for the code status. If the resident was on hospice, but the code status had not been changed, staff were to initiate CPR and call 911. During an interview on [DATE] at 12:11 P.M., the DON said Nurse A should have explained to the resident's representative what hospice was and how the code status would change. Nurse A should have checked the resident's chart first after finding the resident without a pulse or respirations and if the resident still had a full code order, initiated CPR, called a code and called 911. The facility has three AEDs that could be used used during a code. Nurse A had a current CPR certification and training for the AED. During an interview on [DATE] at 9:30 A.M. and [DATE] at 12:11 P.M., the administrator said she was not aware Hospice Nurse D had not completed the resident's evaluation or the resident's representative had not been made aware that the resident's code status would change from a full code to a DNR once admitted to hospice. She would have expected Nurse A to inform the representative of the code status change prior to requesting permission for the hospice evaluation and certainly would have thought Hospice Intake Coordinator E would have explained everything in detail. She reviewed the written statement from Hospice Intake Coordinator E and said although he/she had identified several aspects of hospice care to the resident's representative, he/she did not specifically tell the resident's representative the resident would be a DNR if admitted to hospice. During an interview on [DATE] at 1:10 P.M., the resident's physician said she was also the facility Medical Director. She spoke to the resident's representative a week or two ago regarding the resident's deterioration. She did not mention hospice services at that time though. Yesterday, [DATE], Nurse A contacted her and she requested the representative be contacted for a hospice evaluation. If the resident was still a full code at the time he/she was found passed away, staff should have followed the facility policy and initiated CPR. She did not think it would have changed the outcome. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to address and lower the violation at the time. During the onsite visit, the facility began auditing resident records to ensure congruent code status, auditing CPR status for nursing staff and began educating staff on reading and identifying the code status of a resident and where the code status was located. All hospice companies were being informed that a resident's current code status would remain effective until a new code status had been received and placed in the resident's chart. A final revisit will be required 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 be taken to address the Class I violation. MO 510

Based on observation, interview and record review, the facility failed to ensure one resident with a history of opioid dependency received appropriate monitoring and counseling. After the resident's initial admission, he/she was readmitted to the hospital on two separate occasions with an altered mental status and respiratory distress related to opioid dependency and the facility did not provide the appropriate oversight to prevent reoccurrence. (Resident #134) The census was 85. 1. Review of Resident #134's hospital discharge summary, located in the resident's medical record at the facility, showed the following: -admitted to the hospital on [DATE]; -Presents with general weakness. Having diarrhea for one week. Has chronic back pain; -Personal history: Opioid dependence with opioid-induced disorder (Opioids are a class of drugs that include synthetic opioids such as [MEDICATION NAME] and [MEDICATION NAME] (Medically opioids are primarily used for moderate to severe pain relief. Side effects may include itchiness, sedation, nausea, respiratory depression, constipation and euphoria. Tolerance and dependence will develop with continuous use, requiring increasing doses and leading to a withdrawal syndrome upon abrupt discontinuation); -Overview: 4/10/16, the patient was on [MEDICATION NAME] 30 milligrams (mg) every 4 hours (h). His/her respiration status and wakefulness suffered so he/she is currently on [MEDICATION NAME] 30 mg every 4 h as necessary (PRN); -[DIAGNOSES REDACTED]. -Discharge medications include [MEDICATION NAME] 20 mg every 4 h PRN; -Discharge planned for 2/12/18. Review of the resident's admission progress note, dated 2/12/18 at 11:02 P.M., showed he/she was admitted with a [DIAGNOSES REDACTED]. Review of the resident's interim care plan, dated 2/12/18, showed no problem, goal or interventions related to the resident's [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] 20 mg every 4 h PRN for pain; -[MEDICATION NAME] 10/325 mg (pain reliever, [MEDICATION NAME] combined with [MEDICATION NAME] (Tylenol)) every 6 h PRN for pain; -[MEDICATION NAME] 325 mg every 6 h PRN. Review of the resident's progress notes, showed the following: -2/13/18 at 3:06 A.M.: Responded to resident's call light at 1:30 A.M., resident is requesting pain medication every hour. He/she said the hospital nurses were giving him/her pain medication every hour. This writer explained that [MEDICATION NAME] 10/325 mg is every 6 h and [MEDICATION NAME] 20 mg is every 4 h. This writer assured patient that PRN medication will be administered as per physician orders. He/she is in agreement; -2/14/18 at 2:31 A.M.: Requesting pain medication for general discomfort. Given at this time; -2/14/18 at 11:07 A.M.: Physician in to see resident who complained of increased abdominal pain that is new onset since hospitalization . On antibiotic therapy (ABT) for [MEDICAL CONDITION]. Physician gave orders to send resident to hospital for abdominal pain evaluation and treatment; -2/14/18 at 10:37 P.M.: admitted with [MEDICAL CONDITION] and abdominal pain; -No social service documentation or assessment from 2/12/18 through 2/14/18. Review of the resident's individual [MEDICATION NAME] narcotic record (a form that nurses use to keep tract of how many narcotics are given and how many are left), showed he/she had requested and received 7 [MEDICATION NAME] 20 mg tablets from 2/13/18 through 2/14/18. Review of the resident's nurse's note, dated 2/16/18 at 6:58 P.M., showed the resident readmitted to the facility with [DIAGNOSES REDACTED]. Normal bowel sounds. Medications verified and faxed to pharmacy. Review of the resident's interim care plan, dated 2/16/18, showed no problem, goal or interventions related to the resident's [DIAGNOSES REDACTED]. Review of the resident's POS, dated 2/12/18 through 2/28/18, showed on 2/16/18, the orders for [MEDICATION NAME] and [MEDICATION NAME] remained the same. Review of the resident's progress notes, showed the following: -2/17/18 at 2:25 P.M.: Continues on ABT for [MEDICAL CONDITION] with no adverse reactions noted. Complains of abdominal pain and PRN [MEDICATION NAME] (administered for intestinal problems) and [MEDICATION NAME] given; -2/17/18 8:17 P.M.: Complains of nausea at 3:15 P.M. and PRN [MEDICATION NAME] (medication to treat nausea) given. Complained of pain at 6:30 P.M. and PRN [MEDICATION NAME] given; -2/18/18 at 7:55 P.M.: Complained of chronic back pain and abdominal pain. PRN [MEDICATION NAME] and [MEDICATION NAME] given; -2/19/18 at 4:13 A.M.: Awake all night. Up and about in his/her room. In bed for 30 minutes then back up ambulating in the room. Resident encouraged to sit and elevate feet and keep oxygen on. Oxygen (O2) saturation (SAT) of 88% (normal range is 95 -100%) and 91% with oxygen on. PRN [MEDICATION NAME] given for pain; -2/19/18 at 10:15 A.M.: Therapist came to this nurse to inform that resident's O2 SAT was 82%. Upon entering room to assess, resident change noted in level of consciousness. Resident unable to communicate completely. One word responses, some words not clear. Respirations labored/short. This nurse checked O2 SAT 84%, on 2 liters (L) of O2 and bumped up to 3 L. This nurse went to get a physician, (not the resident's physician) who was in the facility at the time. Vital signs (temperature, pulse, respirations and blood pressure) obtained. O2 SAT 85% on 3 L. Resident started to have uncontrollable jerking movements in bilateral legs. Physician gave order to send resident to hospital per 911. Physician and another nurse inspected resident's room as resident's clinical condition was stable prior to this event. Upon inspection of the room, a blue see through plastic container with pills was found in resident's drawer with blue round pills inside. Pills identified as [MEDICATION NAME] 30 mg tablets. Resident was given a PRN [MEDICATION NAME] 20 mg when requested for pain at 7:45 A.M. Call placed to hospital where resident was taken. Spoke with intake nurse and informed that [MEDICATION NAME] 30 mg tablets were discovered and it was suspected resident may have self administered an unknown amount prior to change in clinical condition; -No social service documentation or assessment. Review of the resident's individual [MEDICATION NAME] narcotic record, showed he/she had requested and received 8 [MEDICATION NAME] 20 mg tablets from 2/16/18 through 2/19/18. Review of the resident's hospital discharge summary, dated 3/2/18, showed the following: -Resident had been admitted on [DATE], with acute (sudden) respiratory distress/failure requiring non-invasive ventilation with bi-level positive airway pressure ([MEDICAL CONDITION], a non-evasive form of oxygen therapy); -[DIAGNOSES REDACTED]. Continue to wean off [MEDICATION NAME] - on much lower doses - over the next 2 - 4 weeks per his/her pain specialist; -[MEDICATION NAME] 5 mg every 6 h PRN for pain. Review of the resident's progress notes, dated 3/2/18 at 7:50 P.M., showed the resident returned to the facility with a [DIAGNOSES REDACTED]. Resident is alert and oriented to person, place and time and able to make all needs known to staff. Review of the resident's POS, dated 3/2/18 through 3/31/18, showed an order for [REDACTED]. Review of the resident's interim care plan, dated 3/2/18, showed no problem, goal or interventions related to the resident's [DIAGNOSES REDACTED]. Review of the resident's progress notes, showed the following: -3/4/18 at 4:36 A.M.: Up and down all night from the bed to the recliner, requested PRN for pain to back and stiff neck. [MEDICATION NAME] and [MEDICATION NAME] given this shift; -3/4/18 at 11:27 P.M.: Had dinner in his/her room this shift. Complained of nausea, pain to neck and back. PRN [MEDICATION NAME] as requested for nausea and [MEDICATION NAME] for pain administered; -3/6/18 at 3:53 A.M.: Awake at intervals throughout the night, complained of back pain. Medicated with [MEDICATION NAME] with some relief. Up to bathroom with walker. Able to make needs known; -3/8/18 at 2:14 P.M.: Continues on skilled services. Compliant with therapy orders and able to make needs known. Able to ambulate using walker. Gait slow and steady. Went on leave of absence with family for lunch. No signs or symptoms of distress. Did complain of pain and requested PRN. [MEDICATION NAME] given. O2 on 2 L per nasal cannula to keep SATs above 92%. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/18 (due to multiple discharges to the hospital and readmissions this was the first MDS completed), showed the following: -Adequate hearing and vision; -Clear speech - distinct intelligible words; -Understood/understands; -Extensive assistance of one person required for bed mobility, transfers, walking in room, dressing and personal hygiene; -Has the resident been on a scheduled pain management program: Yes; -Received PRN pain medications: [REDACTED] -Pain presence: Yes; -Pain frequency: Frequently; -Has pain made it hard to sleep at night: No; -Have you limited your day to day activities due to pain: No; -Pain intensity (on a scale of 1 -10): 6; -Should the staff assessment for pain be conducted: No; -Indicate how many days the resident received opioids in the last 7 days: 7. Further review of the resident's progress notes, showed the following: -3/10/18 at 10:42 A.M.: Remains on skilled services related to weakness. Up ambulating in hallway and in room with walker. Uses wheelchair to go to and from dining room. Alert and oriented to person, place and time. Skin warm to dry. Respirations even unlabored. Complained of some discomfort and given PRN [MEDICATION NAME]; -3/11/18 at 9:48 P.M.: Awake and alert later in the shift trying to get up to bathroom and found sitting on the edge of the bed. Assisted into wheelchair with assist of two staff and assisted to bathroom. Complained of back pain given PRN [MEDICATION NAME] and ice pack; -3/12/18 at 2:54 P.M.: Resident had change in mental status. Nurse Practitioner gave an order to send to the emergency room for evaluation and treatment; -No social service documentation or assessments. Review of the resident's individual [MEDICATION NAME] narcotic record, showed he/she had requested and received 22 [MEDICATION NAME] 5 mg tablets from 3/2/18 through 3/12/18. Review of the resident's hospital record, dated 3/12/18 at 11:18 A.M., showed resident presented to the emergency department with altered mental status. Has had increasing lethargy that began about 4 - 5 hours ago. [MEDICAL CONDITION] (deficiency in oxygen) and difficulty breathing. O2 SATs were 85%, emergency medical technicians placed resident on 15 L of O2 and O2 SAT increased to 95%. Has a history of pocketing his/her opiate pain medications and taking all at once. He/she is oriented to person and place, but drowsy and lethargic. Given IV (intravenous) [MEDICATION NAME] (counteracts the life-threatening effects of opioid overdose). Became more arousable to the IV [MEDICATION NAME]. Think his/her symptoms are due to opiate use. Because of initial somnolence (drowsiness), placed on [MEDICAL CONDITION] (noninvasive ventilation machine). Review of the resident's care plan, dated 3/22/18, showed the following: -Has pain or potential for pain related to chronic back pain, opioid dependence; -Will verbalize adequate relief of pain or ability to cope with pain as specified by pain level goal: Target date of 3/19/18; -Administer [MEDICATION NAME] (pain medications) as per orders. Give prior to treatments or care as indicated; -Anticipate resident's need for pain relief and respond as soon as possible to any complaints of pain; -Ask resident which position is comfortable, encourage frequent positioning; -Explore non-pharmological pain alleviating interventions such as heat, ice, repositioning, massage, elevation, relaxation, food; -Family educated to not bring in medications from home; -Observe resident during care for signs of pain; -Update physician on effectiveness of [MEDICATION NAME] and pain medication. During an interview on 3/26/18 at 8:33 A.M., the Social Service Director (SSD) said she had been at the facility for about four years. She had resigned briefly, for about two weeks, then returned last week. She is the only person in social services currently, but a new full time social service worker will start on 4/3/18. She was there when the resident was first admitted and remembered discussing the resident's opioid dependency in a morning meeting attended by all department heads. She could not recall anything specific she or anyone else had done to address the resident's opioid dependency. She was still working at the facility on 2/19/18 when the resident was sent to the hospital and she was there when the resident returned on 3/2/18. A nurse told her about finding the [MEDICATION NAME] the next day. She had not discussed anything with the resident since his/her admission. The facility had never asked her to discuss anything with the resident. She did not know of any changes the facility had made in response to the resident's opioid dependency. There was a counseling service that came to the facility, but she had never made a referral. As far as she was aware no one had spoken to the resident about his/her opioid dependency. She should have been involved in the resident's care, but she was probably too busy with other duties. She was not aware the resident's hospital admission on 3/12/18, was for opioid use again. She never completed an initial social service assessment on the resident and had not documented anything about the resident. She had heard the resident was not returning to the facility. During an interview on 3/26/18 at 10:20 A.M., Nurse P said he/she was present when the resident was sent out for an [MEDICATION NAME] overdose on 2/19/18. The resident was alright an hour before he/she was sent out. He/she was aware of the resident's opioid [DIAGNOSES REDACTED]. After returning he/she had heard the facility had spoken to the family member about what had happened. No other adjustments or changes had been made to the resident's plan of care that he/she was aware of. They do try to watch to ensure residents swallowed their medications, but that was just routine for all residents. No routine room sweeps were done after the resident returned. After the last discharge on 3/12/18, they did a room sweep again and found nothing. No one had spoken to the resident about his/her opioid dependency that he/she was aware of. No one had spoken to the resident about counseling services or drug program. When he/she returned on 3/2/18, the hospital had reduced the [MEDICATION NAME] to 5 mg every 6 h PRN, where as before he/she had been on 20 mg every 6 h PRN. The resident would want the [MEDICATION NAME] every time it was available. Nurse P never had the resident open his/her mouth to see if he/she had swallowed the tablets. He/she would ask the resident if the pills had went down. He/she did not think the resident pocketed the [MEDICATION NAME] to save them and take all at once. The nurse felt the resident did have a drug problem. During an interview on 3/26/18 at 10:34 A.M., Nurse O said he/she was aware the resident had a history of [REDACTED]. The resident would ask for the [MEDICATION NAME] every time it was available, like clock work. On 2/19/18, the resident had a quick change in status. They found [MEDICATION NAME] 30 mg tablets in his/her drawer. As far as he/she knew, there had been no changes to the resident's plan of care since the resident returned from the hospital on [DATE]. Another nurse did go through the resident's room again prior to his/her readmission, but nothing since then. After readmission, the resident cooperated better than the prior admission and was not asking for the [MEDICATION NAME] like before. Nurse O assumed the family brought in the [MEDICATION NAME] the first time the resident had been sent to the hospital. He/she had not been given any special instructions after either readmission. That Saturday or Sunday before the resident went to the hospital on [DATE], the nurse did look through the resident's room and found nothing. He/she had not heard of the facility obtaining drug or alcohol counseling. The counseling service that came to the facility offered counseling for things like depression. He/she had no idea, how the resident was able to have more [MEDICATION NAME] this last time, unless the family brought it. The resident never told him/her that he/she had a drug addiction problem. During an interview on 3/26/18 at 12:11 P.M., with the Director of Nurses (DON) and the administrator, the DON said she did not know when the resident's care plan, dated 3/22/18, was originally completed. She could not tell what date any of the interventions had been added. The computer program did not allow them to determine the original date of the interventions. She was not sure if she had been made aware of the resident's opioid dependency [DIAGNOSES REDACTED]. She was aware of what had happened on 2/19/18. On that date, after the resident was sent to the hospital, they destroyed the [MEDICATION NAME] 30 mg tablets and checked the room again. The resident's room was checked again prior to his/her readmission on 3/2/18. She did not know where the [MEDICATION NAME] 30 mg they found came from. They did interview the resident, but he/she would not say where they came from. As far as she was aware no one had offered the resident counseling services and the only inservices she had done, was to ask staff to make sure the resident was swallowing the [MEDICATION NAME]. She had not documented that education though. No one was doing routine room checks. No one had spoken to the resident about what behavior was acceptable. The administrator said social services should have been involved with the resident's care. Neither the administrator nor the DON knew if anyone had spoken to the resident about what behavior was acceptable and what was not. MO 109