Every finding on record at Rancho Rehab and Healthcare Center

Based on record review and interview, the facility failed to ensure 10 of 10 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) were free from misappropriation of resident property when the former Business Office Manager (FBOM) withdrew resident funds to use for his/her personal use. This had the impact to affect all residents for whom the facility managed funds. The facility census was 84.1. Record review of Resident #1's medical record showed the resident is his/her own responsible party. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawals from Resident #1's account: Date Amount Description04/19/23 $400.00 Personal Needs06/05/23 $100.00 Resident Advance06/21/23 $100.00 Resident Advance07/27/23 $100.00 Resident Advance 02/03/25 $50.00 Resident Advance 02/03/25 $50.00 Resident Advance 04/21/25 $300.00 Resident Advance 05/12/25 $50.00 Resident Advance05/27/25 $150.00 Resident Advance06/16/25 $1,000.00 Resident Advance08/04/25 $500.00 Resident Advance08/19/25 $450.00 Resident Advance10/30/25 $500.00 Resident Advance02/03/26 $650.00 Resident Advance03/12/26 $800.00 Resident Advance04/07/26 $1,000.00 Resident Advance04/28/26 $1,500.00 Resident Advance Record review of Resident #1's Personal Spending Log for 02/03/26 showed Resident #1 requested and gave written authorization for only $50.00 to be withdrawn. Record review of Resident #1's Personal Spending Logs showed no written authorization nor documentation provided for all other sampled withdrawals. During an interview on 05/21/26 at 3:02 P.M., Resident #1 said the following:-He/She has a resident trust account;-He/She withdraws $50 once per month; -He/She did withdraw either $300 or $600 only one time last year and no other amount besides $50. 2. Record review of Resident #2's medical record showed the resident is his/her own responsible party. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawals from Resident #2's account: Date Amount Description06/21/23 $40.00 Resident Advance06/21/23 $40.00 Resident Advance08/28/23 $100.00 Resident Advance02/20/24 $50.00 Resident Advance04/01/24 $100.00 Resident Advance 04/08/24 $1,500.00 Resident Advance05/09/24 $100.00 Resident Advance05/30/24 $500.00 Resident Advance06/04/24 $1,000.00 Resident Advance06/12/24 $3,644.20 Personal Needs 06/18/24 $400.00 Resident Advance08/06/24 $2,000.00 Resident Advance09/05/24 $2,000.00 Resident Advance09/24/24 $2,000.00 Resident Advance10/31/24 $200.00 Resident Advance12/04/24 $250.00 Resident Advance04/01/25 $100.00 Resident Advance04/21/25 $100.00 Resident Advance05/12/25 $200.00 Resident Advance06/16/25 $100.00 Resident Advance07/08/25 $100.00 Resident Advance07/28/25 $100.00 Resident Advance08/04/25 $300.00 Resident Advance10/20/25 $100.00 Resident Advance02/03/26 $40.00 Resident Advance Record review of Resident #2's Personal Spending Logs showed no written authorization nor documentation provided for all sampled withdrawals. During an interview on 05/21/26 at 2:55 P.M., Resident #2 said he/she withdraws no more than $20 at a time. 3. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawals from Resident #3's account: Date Amount Description06/21/23 $100.00 Resident Advance09/05/23 $80.00 Personal Needs12/04/23 $100.00 Resident Advance01/08/24 $200.00 Resident Advance02/20/24 $200.00 Resident Advance03/11/24 $500.00 Resident Advance04/16/24 $340.00 Resident Advance05/09/24 $200.00 Resident Advance06/12/24 $1,000.00 Resident Advance06/18/24 $600.00 Resident Advance07/23/24 $250.00 Resident Advance09/24/24 $500.00 Resident Advance03/03/25 $1,000.00 Resident Advance04/10/25 $382.91 Clothing04/21/25 $300.00 Resident Advance05/12/25 $200.00 Resident Advance06/06/25 $200.00 Resident Advance06/16/25 $250.00 Resident Advance07/15/25 $200.00 Resident Advance08/11/25 $400.00 Resident Advance10/30/25 $150.00 Resident Advance02/03/26 $50.00 Resident Advance Record review of Resident #3's Personal Spending Logs showed no written authorization nor documentation provided for all sampled withdrawals. Record review of Resident #3s's facesheet showed a family member is the resident's legal guardian. Record review of an email provided by the resident's guardian, dated 03/07/25 at 10:17:19 A.M. from the FBOM to the guardian, showed the attached Resident Trust Statement for the period 01/02/24 through 12/31/24 contained different withdrawal amounts than the Resident Trust Statement above: Date Amount Description01/08/24 $20.00 Resident Advance02/20/24 $20.00 Resident Advance03/11/24 $50.00 Resident Advance04/16/24 $340.00 Resident Advance05/09/24 $20.00 Resident Advance06/12/24 No withdrawal shown06/18/24 $60.00 Resident Advance07/23/24 $25.00 Resident Advance09/24/24 $50.00 Resident Advance During an interview on 05/21/26 at 3:00 P.M., Resident #3 said his/her family member handles the money. During an interview on 05/29/26 at 10:27 A.M., Resident #3's family member/guardian said the following:-He/She is the financial guardian over Resident #3;-The resident does not have the mental capacity to withdraw funds;-He/She did not question the Resident Trust Statement provided by the facility for 2024 since the amounts listed were smaller, but would have questioned larger withdrawals;-He/She drops off soda and any other items that the resident needs. 4. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawals from Resident #4's account: Date Amount Description09/19/23 $954.00 Dental Premium10/24/23 $200.00 Resident Advance12/04/23 $100.00 Resident Advance12/19/23 $100.00 Resident Advance02/16/24 $494.72 Care Cost Payment02/20/24 $100.00 Resident Advance04/23/24 $1,000.00 Resident Advance05/14/24 $338.00 Care Cost Payment07/23/24 $350.00 Resident Advance01/13/25 $750.00 Transfer to Burial07/08/25 $400.00 Resident Advance Record review of Resident #4's Personal Spending Logs showed no written authorization nor documentation provided for all sampled withdrawals. During an interview on 06/08/26 at 2:20 P.M., Resident #4's Family Member said the following:-He/She was over Resident #4's finances;-He/She would go to the facility every now and then to see if Resident #4 had any money in the account to put aside for a burial plan since Resident #4 had no money and no insurance; -He/She bought everything for Resident #4; -Resident #4 did not withdraw anything that he/she is aware of; -He/She never withdrew the Resident Trust Account to leave less than $200 because the Former Business Office Manager (FBOM) said there had to be some money left in the account;-He/She remembers withdrawing two or three checks- one for $750 and one for $400- but the amount was under $2000 because he/she had to add his/her own money for the burial;-The facility Activity Director (AD) told him/her get reimbursed for items he/she bought, like toiletries, etc., and said the resident had over $2,000 in the account, however when the family member spoke with the FBOM, the FBOM said there was nothing there, it was gone. 5. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawals from Resident #5's account: Date Amount Description06/21/23 $200.00 Resident Advance07/17/23 $400.00 Personal Needs07/27/23 $151.90 Clothing08/28/23 $200.00 Resident Advance08/28/23 $100.00 Resident Advance11/01/23 $100.00 Tobacco12/04/23 $100.00 Resident Advance02/20/24 $100.00 Resident Advance03/04/24 $60.00 Resident Advance05/30/24 $100.00 Resident Advance09/05/24 $100.00 Resident Advance03/03/25 $150.00 Resident Advance04/01/25 $150.00 Resident Advance04/21/25 $100.00 Resident Advance04/29/25 $100.00 Resident Advance05/27/25 $150.00 Resident Advance07/28/25 $200.00 Resident Advance08/04/25 $150.00 Resident Advance08/27/25 $150.00 Resident Advance09/09/25 $150.00 Resident Advance10/30/25 $100.00 Resident Advance12/22/25 $300.00 Resident Advance04/28/26 $350.00 Resident Advance Record review of Resident #5's Personal Spending Logs showed no written authorization nor documentation provided for all sampled withdrawals. During an interview on 06/05/26 at 11:24 A.M., Resident #5's Family Member said the following:-Resident #5 would not be able to understand if asked questions as he/she has special needs and can no longer speak;-Resident #5 had an account at the facility and would say, They gave me my $50. This would happen one time per month;-Resident #5 cannot talk or walk, nor move his/her arms. There is no way the resident could have withdrawn $350 on 04/28/26. 6. Record review of Resident #6's medical record showed the resident is his/her own responsible party. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawal from Resident #6's account: Date Amount Description04/29/25 $200.00 Resident Advance Record review of Resident #6's Personal Spending Logs showed no written authorization nor documentation provided for the sampled withdrawal. During an interview on 05/21/26 at 2:55 P.M., Resident #6 said the following:-He/She had to wait until after the 3rd of the month to withdraw funds;-It had been a long time since he/she withdrew money;-He/She was not sure and could not remember if he/she withdrew $200 in 2025. 7. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawals from Resident #7's account: Date Amount Description05/16/23 $288.37 Clothing08/28/23 $250.00 Resident Advance09/08/23 $2,300.46 Personal Needs09/20/23 $2,348.86 Personal Needs11/01/23 $200.00 Resident Advance12/04/23 $250.00 Resident Advance01/03/24 $100.00 Resident Advance02/12/24 $250.00 Resident Advance03/05/24 $1,030.52 Personal Needs03/11/24 $200.00 Resident Advance03/12/24 $1,030.52 Clothing04/10/24 $802.33 Care Cost Payment04/16/24 $250.00 Resident Advance05/23/24 $300.00 Resident Advance06/18/24 $400.00 Resident Advance08/20/24 $450.00 Resident Advance09/18/24 $600.00 Resident Advance11/19/24 $150.00 Resident Advance12/17/24 $300.00 Resident Advance01/16/25 $300.00 Resident Advance02/24/25 $150.00 Resident Advance04/29/25 $150.00 Resident Advance05/27/25 $100.00 Resident Advance06/06/25 $300.00 Clothing 07/15/25 $100.00 Clothing09/19/25 $110.00 Clothing 11/12/25 $63.81 Clothing12/30/25 $50.00 Resident Advance Record review of Resident #7's Personal Spending Logs showed no written authorization nor documentation provided for the sampled withdrawals. During an interview on 05/29/26 at 12:57 P.M., Resident #7's Family Member said the following:-Resident #7 had some money in the resident account but the facility does not take him/her shopping. The money should have accumulated;-He/She purchases clothes for Resident #7 with his/her own money;-Resident #7 is nonverbal, has the mentality of a child and is not aware of money;-About a year or two ago a staff member called from the facility and said Resident #7 needs some clothes and the family member said to only take out $200. The facility staff said that will not be enough and they would need $300-$400. He/She did not know why the facility would need $300-$400 for clothes for the resident; -The family member visited the resident over a year ago and there were no clothes or shoes in the closet. The facility staff told her to look in the little cubby hole in laundry for Resident #7. The clothes in the cubby looked like a bunch of rags. The resident wore a man's t-shirt that was labeled with a different name. 8. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed only two withdrawals for Resident #8 during this time period. Review showed the following unauthorized withdrawals: Date Amount Description03/05/26 $8,868.07 Resident Advance04/22/26 $2,644.00 Resident Advance Record review showed no Personal Spending Logs for the resident. During an interview on 06/04/26 at 10:10 A.M., Resident #8's Financial Power of Attorney (FPOA) said the following:-Resident #8 never withdraws money, nor does the FPOA. -He/she was not aware of the withdrawals made on 03/05/26 and 04/22/26. 9. Record review of the facility maintained Resident Trust Statement for the period of 03/17/26 (the resident admitted to the facility on [DATE]) through 05/21/26, showed only two withdrawals for Resident #9 during this time period. Review showed the following unauthorized withdrawals: Date Amount Description04/14/26 $200.00 Resident Advance04/28/26 $400.00 Resident Advance Record review showed no Personal Spending Logs for the resident. During an interview on 06/02/26 at 1:20 P.M., Resident #9's Financial Power of Attorney (FPOA) said the following: -Resident #9's family buys everything for him/her;-Resident #9 would not have any reason, nor does he/she have the mental capacity to withdraw money;-There is no reason Resident #9 would have withdrawn $200 on 04/14/26 and $400 on 04/28/26, nor did the FPOA withdraw the money. 10. Record review of Resident #10's medical record showed the resident is his/her own responsible party. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following unauthorized sampled withdrawals from Resident #10's account: Date Amount Description07/10/23 $100.00 Resident Advance07/13/23 $2,081.08 Clothing08/10/23 $150.00 Personal Needs12/12/23 $1,000.00 Resident Advance02/28/24 $2,621.42 Personal Needs03/05/24 $2,166.59 Clothing06/12/24 $600.00 Resident Advance08/28/24 $200.00 Resident Advance12/17/24 $400.00 Resident Advance02/24/25 $730.00 Resident Advance03/18/25 $1,000.00 Resident Advance06/06/25 $2,000.00 Resident Advance06/24/25 $500.00 Resident Advance07/08/25 $700.00 Resident Advance07/28/25 $300.00 Resident Advance08/19/25 $500.00 Resident Advance10/14/25 $500.00 Resident Advance11/05/25 $1,000.00 Resident Advance12/15/25 $800.00 Resident Advance02/18/26 $300.00 Resident Advance03/27/26 $200.00 Resident Advance04/14/26 $400.00 Resident Advance Record review of Resident #10's Personal Spending Logs showed no written authorization nor documentation provided for the sampled withdrawals. During an interview on 05/21/26 at 2:49 P.M., Resident #10 said the following:-He/She is supposed to have an account to withdraw funds;-He/She has not withdrawn any funds in a couple of years;-He/She did not withdraw the listed withdrawals;-At the most he/she would withdraw $20. 11. During an interview on 05/21/26 at 1:41 P.M., the Outside Business Office Consultant (OBOC) said the facility contacted him/her to conduct an audit at the facility due to allegations that the FBOM took money from the Resident Trust Account. The OBOC began an internal audit earlier this month from February 2026 through May 2026 and discovered money was missing from the Resident Trust Account. The OBOC said the resident fund files are missing and when he/she asked the FBOM about the files, the FBOM said, You are not going to find them. 12. During an interview on 05/28/26 at 1:57 P.M., the FBOM said the following:-He/She was sent home for an investigation on 05/04/26;-The Administrator said a resident said he/she gave the FBOM $600, but the administrator did not say the name of the resident who reported this;-He/She did take money a few times from the resident trust account for personal use due to some hardships;-He/She did not take $600, but did not say how much he/she took or from whom she took the money; -He/She would add numbers to the amount the resident wanted to withdraw and take out a little more;- The residents would not know extra money was added to the withdrawal;-He/She knew it was against policy to take resident money. 13. During an interview on 05/28/26 at 3:32 P.M., the President/Owner said the following:-He/She did speak with the FBOM regarding money taken and the FBOM admitted to taking money from residents;-He/she did not have a scope regarding how much money was taken or how often;-The FBOM admitted he/she started taking resident money at the end of 2025. 14. During an interview on 05/28/26 at 3:42 P.M., the FBOM said the following:-He/She told the Owner he/she started taking money around the middle of 2025;-He/She did not know how much money he/she took since he/she gave money out of his/her own pocket to the residents when residents were running low on money. 15. During an interview on 05/29/26 at 3:16 P.M., the Regional Director of Operations said the following:-The investigation was reported to the Florissant Police Department and an officer did come to the facility, but the police have not contacted the facility again;-The termination papers from the facility showed the FBOM's date of termination as of 05/05/26 and the last day worked was 04/30/26. 16. During an interview on 06/12/26 at 9:37 A.M., the Regional Business Office Manager (RBOM) said the following:-The FBOM had a higher level of access in the Resident Funds Management Service (RFMS) computer system and was able to cash checks without going through the RBOM approval level;-The FBOM took care of all the financial information for the RFMS account;-The RBOM met with FBOM on 05/05/26 at a fast food restaurant and the FBOM said he/she took money a few times from the residents because of losing everything when his/her significant other left; -The RBOM did not believe the FBOM only took money a few times from residents and expressed this to the FBOM;-The FBOM got in a brand new [NAME] when he/she left the fast food restaurant. Complaints 3026508, 3004337 and 3004955

Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures for resident consumption within a safe range to prevent the potential of skin burns for two residents. Staff provided a cup of hot water to a resident (Resident #2) who requested it to give to another resident (Resident #1) who wanted to make instant coffee in his/her room. Resident #2 took the cup of hot water to Resident #1's room, placed it on the over the bed table then left the room. When Resident #1 reached for the cup of water, he/she spilled the water on him/herself which resulted in a second-degree burn (involving the first two layers of skin and may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) ranging from his/her right flank to his/her right mid-thigh. Resident #1 had a diagnoses of left sided hemiplegia (total or partial paralysis on one side of the body), polyneuropathy (damage or disease affecting peripheral nerves), stroke, and diabetes and took medications that decreased reaction and sensation to pain. The sample was 5 and the census was 89. Review of the U.S. Consumer Product Safety Commission's Safety Alert showed most adults will suffer third-degree burns (damages the first here layers of skin and fatty tissue) if exposed to 150-degree Fahrenheit (F) water for two seconds. Burns will also occur with a 6-second exposure to 140-degree F water or with a 30-second exposure to 130-degree F water. Review of MedlinePlus.gov, last reviewed on 5/28/24, showed:-Major burns include: Second degree burns more than 2 to 3 inches (5.08 to 7.62 centimeters (cm) wide;-Major burns need urgent medical care. This can help prevent scarring, disability, and deformity;-Adults over the age of 60 have a higher chance of complications and death from severe burns because their skin tends to be thinner than in other age groups. Review of the facility's Food Temperature policy, dated 5/2016, showed:-Purpose: To provide the dietary department with guidelines for food preparation and service temperatures;-Acceptable serving temperatures: Coffee > (greater than) 135 degrees F;-If temperatures do not meet the required serving temperatures, reheat or chill the product to the proper temperature;-No maximum temperature listed. Review of the facility's Incident Investigation policy, dated 10/24/22, showed:-Purpose: To ensure that the facility tracks incidents that take place at the facility in an effort to increase the quality of care provided to residents;-Policy: An incident includes but is not limited to the following: Burns. Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/12/25, showed:-Cognitively intact;-Used a wheelchair;-Upper and lower extremity range of motion - impairment on both sides;-Diagnoses of left side hemiplegia, polyneuropathy, stroke and diabetes. Review of the resident's medical record showed an age of [AGE] years old at the time of the burn. Review of the resident's care plan in use at the time of on-site investigation, showed:-Focus: Resident has acute/chronic pain, revised 10/20/24;-Goal: Pain will be minimized with the use of scheduled and/or as needed (PRN) pain meds;-Interventions included: Administer analgesia (treatment to reduce pain) as per order;-No documentation of the burn incident on 9/8/25. Review of the resident's physician order sheet showed an order dated 2/21/25, for Gabapentin (medication used to treat nerve pain, the action of the medication inhibits the release of certain neurotransmitters which are involved in transmitting and amplifying pain signals. By reducing the activity of these pain-signaling nerve cells, gabapentin decreases or slows the brain's reaction to pain stimuli, resulting in a reduction of pain sensation) 600 milligrams (MG), Give 1 tablet by mouth three times a day for neuropathy. Scheduled administration times: AM, Noon, and PM. Review of the resident's September 2025 Medication Administration Record, showed:-On 9/7/25, Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day for neuropathy, administered as ordered at AM, Noon, and PM;-9/8/25 A.M., Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day for neuropathy, administered as ordered at AM, Noon, and PM. Review of the resident's progress notes, showed:-On 9/7/25 at 11:45 A.M., Weekly Skin Observations: Late Entry: Skin color is normal. No skin issues to report;-On 9/8/25 at 1:01 P.M., Weekly Skin Observations: skin color is normal. Skin temperature is dry, warm. Skin turgor (the ability of the skin to return to its normal shape after being pulled or pinched) is normal as skin returns promptly. Skin issues present. Refer to assessment for more information;-On 9/9/25 at 11:14 A.M., Nursing Note: nurse went into resident's room to check on him/her after receiving burn from spilled coffee. Resident stated that he/she was doing fine, and his/her treatment was still intact. Resident also stated that he/she was not in any pain and burned area was not affecting him/her or causing discomfort. Review of the resident's Weekly Skin Observation, completed on 9/8/25 at 1:01 P.M., showed burn to right flank side due to spilled coffee. No measurements or description documented. Review of the facility's Incident by Incident Type report, dated 8/1/25 to 9/8/25, showed the record privileged and confidential - not part of the medical record. No documentation of Resident #1's burn injury on 9/8/25. During an interview on 9/9/25 at 11:15 A.M., Resident #1 said he/she got a 3rd degree burn on his/her right side because he/she spilled hot coffee on him/herself. He/She did not know the water was hot enough to burn him/her, but his/her skin just fell off. He/She said Resident #2 got hot water from Dietary [NAME] A in the kitchen. Wound Nurse D came to see about the burn on his/her side the same day. He/She thought that was about 7:30 A.M. or so. He/She was not in pain. He/She took Gabapentin, so he/she did not feel any pain. The coffee did not spill directly onto him/her. It spilled on the sheet and went into the side of his/her brief. He/She could use his/her right hand, however, the last three fingers on the left hand are contracted (a permanent shortening or tightening of muscles, tendons, or other tissues that restricts movement). He/She used both hands to hold the cup to drink his/her coffee. Observation of the resident at this time, showed a dried brown ring underneath the resident. He/She said it was spilled coffee. The visible part of the dried brown ring spread out from the armpit level, down underneath the white blanket. The resident's right arm was bent in a triangle shape, and part of the dried brown ring was visible. A dressing was in place over the right flank. Review of the resident's physician order sheet, showed:-An order dated 9/10/25, for Xeroform oil emulsion gauze (not adherent dressing). Apply to right flank topically one time a day every Monday, Wednesday, and Friday for wound healing. Cleanse would with hypochlorous acid (used to clean and prevent infection), pat dry. Apply xeroform to wound bed and cover with dressing;-No treatment order obtained prior to 9/10/25. During an interview on 9/10/25 at 9:42 A.M., Certified Nursing Assistant (CNA) B said Nurse Assistant (NA) C helped him/her with Resident #1 after spilling the coffee. The resident told them he/she had spilled coffee on him/herself earlier that day. There was a brown coffee stain on the sheet underneath him/her. When CNA B and NA C rolled the resident onto his/her side they saw the burn. CNA B said his/her white meat showed on the resident's side and skin had rolled off. He/She asked the resident if the resident knew he/she was burned. CNA B did not know how the resident was not in pain because he/she (CNA B) would have been screaming. During an interview on 9/10/25 at 9:40 A.M., NA C said he/she helped CNA B change the resident. When the resident was rolled to his/her side he/she saw the burn. The burn was big. The resident said he/she spilled coffee on himself/herself earlier. They called the Wound Nurse (Wound Nurse D) to see the burn. The resident usually drank coffee throughout the day. During an interview on 9/9/25 at 11:15 A.M., Wound Nurse D said there must have been a blister that popped before he/she assessed the resident. Wound Nurse D talked to the Dietary Manager (DM) that day about giving Resident #1 hot water and informed them of the burn. He/She was told by the DM that the water was something like 200 degrees F. On 9/10/25 at 2:00 P.M., Wound Nurse D described the area as pink and a partial thickness open area. The area was located on the right side from the rib cage down to the waist/hip area, (flank). The area measured 39 centimeters (cm) x 12 cm x 0.1 cm depth. The wound nurse said he/she did not classify the burn; the Wound Nurse Practitioner (NP) would classify it after she saw it on Monday. Observation of Resident #1 and interview on 9/11/25 at 12:00 P.M., showed the resident lay in bed. Staff removed the dressing on his/her right side. There was a large irregular shape area on the right side, where the top layer of skin was missing. The Wound NP assessed the resident and described the area as a second-degree burn; she said the skin had blistered and peeled back. The size of the wound was 30 cm X 10 cm X 0.1 cm. The NP told the staff to monitor the area daily and changed the treatment of xeroform to daily. Observation on 9/9/25 at 12:18 P.M., showed Dietary Aide E tested the water temperature from the new coffee system. The water obtained from the back spicket. The cup filled half full. The coffee pot stationed in the resident dining room, on a table nearest the entrance to the kitchen. Dietary Aide E walked the cup out to the dining room area and took the temperature of the coffee. The temperature measured 189 degrees F. Observation and interview on 9/9/25 at 2:20 P.M., the Dietary Manager tested the water temperature from the new coffee system. The temperature measured 179 degrees F. The DM said the water was too hot for staff to give to any residents to walk through the hall with or to make coffee in their room. Resident #2 got the hot water from Dietary [NAME] A. Resident #1 had instant coffee and gotten hot water before, from the old coffee system. The old coffee system water did not get very hot. The new system was only a week and a half to two weeks old. No one thought the water would get that hot. They did not take water temperatures from the coffee system and did not have a system in place to do that. During an interview on 9/10/25 at 9:57 A.M., Resident #2 said he/she got the hot water from the kitchen. Dietary [NAME] A gave the hot water to him/her. He/She was not in Resident #1's room when the coffee spilled, but Resident #1 told him/her the coffee spilled onto him/her. Resident #2 wondered if the burn Resident #1 got was bad. Resident #2 said he/she got hot water from the kitchen every day. During an interview on 9/10/25 at 10:29 A.M., the Director of Nursing (DON) said she found out about the burn on the morning of 9/8/25. Wound Nurse D told her about Resident #1's burn. She was told the coffee fell over and the resident was burned on his/her right flank area. She did not know what degree it was because the blister had already popped. The NP was at the facility during the morning meeting and was made aware at that time. The DON said hot coffee temperature, from her understanding, was nothing over 140 F. The coffee machine was new. Staff had to let the coffee cool. She heard after the fact that the water was 200 degrees F. Staff should have checked the temperature of the hot water before sending it out to Resident #2. The water was too hot to give to the resident. During an interview on 9/10/25 at 11:00 A.M., Dietary [NAME] A said on 9/8/25, Resident #2 asked for hot water. The resident had a cup with a lid. He/She put hot water in that cup. Dietary [NAME] A said he/she let the cup sit for about 15 minutes to cool off. He/She did not take the temperature of the hot water before he/she gave it to the resident. He/She gave the cup back to the resident and told the resident to be careful. The water was hot. Dietary [NAME] A said it was too hot. He/She did not know the resident was getting the water for someone else. He/She found out about the burn right before lunch that day, about two or three hours later. Other residents came for hot water, but Resident #2 came every day. The coffee system was about two weeks old. The machine filled up on its own, staff did not need to add water to it. Hot coffee should be between 140 to 150 degrees F. The machine temperature showed 180-190 degrees F when the coffee was ready to brew. He/She did not know the policy and said hot coffee should be served at 135 F or less. Dietary [NAME] A said he/she was in-serviced regarding hot water when he/she returned to work on 9/10/25. He/She was off on 9/9/25. During an interview on 9/17/25 at 4:32 P.M., Resident #2 said he/she went to the kitchen to get hot water for Resident #1. He/She asked Dietary [NAME] A for hot water. He/She waited in the dining room, while Dietary [NAME] A went in the kitchen to get the hot water. Resident #2 said he/she did not wait very long for the hot water. Dietary [NAME] A added a lid on the cup. Then, Resident #2 took the water to Resident #1. During an interview on 9/10/25 at 5:29 P.M. and 6:17 P.M., Licensed Practical Nurse (LPN) G said he/she was not aware if Resident #2 brought Resident #1 coffee or hot water. He/She knew the two were friends. Resident #1 asked him/her on 9/8/25, to change his/her cover because he/she had made a mess. The nurse said the resident had a brown spot on his/her cover and on his/her sheet. The nurse did not know what the discolored spot was, he/she thought it may have been juice or soda. The nurse changed the cover but did not change the sheet. The nurse did not do a skin assessment, the resident was alert and oriented times four (person, place, time, and situation) and if he/she needed something he/she would have told the nurse. The resident did not complain of pain and did not report he/she spilled anything. During an interview on 9/11/25 at 9:40 A.M., Registered Nurse (RN) J said he/she completed a Situation-Background-Assessment-Recommendation (SBAR). He/She did not remember who got the treatment order but a treatment order was obtained. He/She was called by a CNA but could not remember who. He/She was in the middle of doing blood sugar checks. He/She did not take measurements of the burn, but knows they were taken. He/She notified the wound nurse. He/She did not remember if the resident's bed was wet but then said standing back and recalling the events, maybe the resident's bed was wet. After the initial assessment, there should be an order for dressing changes and incident follow-up. The burn was a change in the resident's condition. Incident follow-up was needed because of the incident. Incident follow-up was 72-hour documentation, once a shift. Incident follow-up notes are documented in the progress notes. Review of the resident's SBAR Communication Form and progress note, dated 9/8/25 at 8:27 A.M., showed:-Patient burned by coffee;-Patient spilled coffee on him/herself;-Treatment nurse made aware and new orders obtained;-Nursing Note: Patient spilled coffee. Patient sustained a burn to the right flank. Patient denied pain and/or discomfort. Patent states that he/she spilled coffee and did not notice anything. Patient assessed for burn and pain. Head to toe skin assessment completed. Pain assessment completed 0/10 (indicated no pain). Vital signs obtained and withing normal limits. New orders obtained after calling the medical doctor (MD). During an interview on 9/10/25 at 4:10 P.M., the DON said if a resident had been burned, she would expect staff to immediately assess the resident, complete vital signs, clean the wound, and contact the MD or wound NP to get treatment orders. The resident comes first. The wound nurse completed the resident's assessment, and the wound nurse contacted the Wound NP. The wound was documented under assessment. The DON looked at the wound documentation from 9/8/25 and confirmed no measurements were documented and said she knew the wound nurse completed the measurements and maybe the measurements were documented somewhere else. The resident was not seen in the emergency room (ER) because he/she was not in pain, there was no infection, no drainage and his/her vital signs were stable. This happened on Monday morning before breakfast. The resident got his/her hot water from another resident. To her understanding, staff poured the hot water and let it sit for 15 minutes. The staff member did not know the hot water was for another resident. She found out the resident spilled the water when the resident told staff. Staff told the wound nurse, and the wound nurse went to see the resident. Staff were made aware after it happened, immediately after. The DON looked at the resident's progress notes and said she would have to find out where the measurements were documented. She would expect the medical record to be complete and accurate. She did not know if the facility had the documentation somewhere else. Other staff will know about the issues if it is not documented in the progress note because it is written on the report sheet and staff have shift to shift report. After the initial assessment is completed, the nurse should complete the treatment per order and monitor the site daily to ensure the dressing is intact and to check the skin around the dressing to be sure it is good. This is documented in the progress notes. The treatment change is done by the wound nurse. When the wound nurse is not at the facility, the nurse on the floor would check it. Staff also assessed the resident for pain. During an interview on 9/10/25 at 5:05 P.M., the Regional Nurse Consultant (RNC) said she expected staff to follow the facility's policy for coffee temperatures which were to serve coffee at temperatures greater than 135 degrees F. It was just an accident. Residents have the right to have hot coffee. On 9/11/25 at 12:45 P.M., the RNC said the 24-hour nurse report was for Quality Assurance only. No copy would be provided to the state surveyors. The DON made a mistake by saying they were available.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to label, date, and cover food and failed to ensure an expired gallon of milk was discarded as indicated. The facility also failed to ensure kitchen equipment and the floor were kept clean during three of five days of observation. In addition, the facility failed to maintain records of dish washing temp logs as well as chloride testing logs. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 79. 1. Observation of the kitchen on [DATE] at 11:37 A.M., [DATE] at 3:33 P.M., and [DATE] at 11:15 A.M., showed the following: -Dry storage room: -A bucket of peanut butter without a date; -An opened bottle of lemon juice without a date; -A bag of egg noodles, with a twist tie at the end without a date; -A bag of brown sugar, opened at the end, not closed and exposed to air without a date; -A bag of powder sugar wrapped in plastic and without a date; -A bag of macaroni noodles wrapped in plastic and without a date; -A bag of spaghetti noodles wrapped in plastic and without a date; -Two opened bottles of honey without a date; -Two packages of white powdery substances wrapped in plastic and without a date; -An opened bottle of soy sauce without a date; -A bag of toffee, opened and folded over and without a date; -A opened package of marshmallows wrapped in plastic wrap without a date.; -Freezer: -Two packages of waffles, opened at the end, not closed and exposed to air without a date; -A zip locked bag contained chicken breast without a date; -A box contained a blue bag of frozen carrots which was opened and exposed to air; -A blue bag contained frozen peas, opened and exposed to air; -A bag of frozen mixed vegetables, opened and exposed to air. Observation on of the dry storage [DATE] at 11:37 A.M. and [DATE] at 3:33 P.M., showed: -An opened bottle of Worchester sauce, without a date; -An opened package of pork flavored gravy wrapped in plastic without a date; -An opened package of brown gravy wrapped in plastic no date. 2. Observations of the walk-in cooler on [DATE] at 11:37 A.M., and [DATE] at 3:33 P.M., showed a gallon of whole milk with a expiration date of [DATE]. Observation of the walk-in cooler on [DATE] at 11:37 A.M., [DATE] at 3:33 P.M., and [DATE] at 11:15 A.M., showed an opened container of grated parmesan cheese without a date. 3. Observations of the stand-alone cooler on [DATE] at 11:37 A.M., and [DATE] at 3:33 P.M., , showed: - An opened bottle of buttermilk dressing without a date; -An opened tub of soft spread margarine without a date. 5. Observation of the kitchen on [DATE] at 11:37 A.M. and [DATE] at 3:33 P.M., and [DATE] at 11:15 A.M.,showed the following: -The stove: -Heavy caked-on stains on the stove burners; -Heavy caked-on stains along the front of the stove; -The oven: -Heavy caked-on stains along the front inside door; -Heavy caked -on stains along the bottom, and sides of oven; -The floor dirty with debris and stains on the floor; -The floor dirty with debris and food in beside the stove and under the sink. 7. Observation of the kitchen on [DATE] at 11:37 A.M. and [DATE] at 3:33 P.M., [DATE] at 11:15 A.M., and [DATE] at 11:35 A.M., showed no temperature testing strips for the dishwasher nor any logs for temperature testing. During an interview on [DATE] at 11:45 A.M., Dish Service Worker (DSW) GG said he/she did the dishes and he/she didn't use chloride strips. They were out. He/She also said he/she didn't record anything on a log sheet. 8. During interviews on [DATE] at 10:43 A.M. and 11:55 A.M., the Dietary Manager (DM) said he did not have a February or [DATE] cleaning schedule. He had been trying to get things together. The general cleaning of the equipment in the kitchen was done daily. They wipe down the stations, swept and mopped the floor as well as mopped the walk-ins and the dry storage room. They tried to do the deep cleaning on Mondays, Wednesdays, and Fridays. On Fridays, staff pulled everything out the coolers and freezer and cleaned the racks and organized those areas. Normally the MD and [NAME] HH would do this. He would expect for all food and drinks to be properly labeled, dated and stored, and for all expired items to be discarded. He would expect for all kitchen equipment to be clean and floors to be clean and free of debris. The DM said he didn't know why DSW GG said they didn't have any strips. He did have chloride test strips, which were used to test chloride in the water. They should test the chloride and record it on a log sheet. The last time temperatures were taken was last Friday. They were supposed to record temperatures during the cleaning cycles after every meal. The temperature log sheets wouldn't be up to date. He didn't have a copy of the temperature log sheet. He couldn't remember what the temperatures should read at during the wash and rinse cycles. He didn't have any copies of the logs for testing the chloride.

Based on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 10 CNAs who worked for the facility for at least one year. Eight CNAs (CNA U, CNA V, CNA W, CNA X, CNA Y, CNA J, CNA Z, CNA H), and two Certified Medication Technicians (CMTs), (CMT L and CMT AA) were sampled. The facility failed to document the length of time the training was provided for all sampled staff. The census was 79. 1. Review of CNA U's employee file showed: -Date of hire: 10/19/21; -One in-service was completed; -The in-service failed to show the length of time the training was provided. 2. Review of CNA V's employee file, showed: -Date of hire: 10/19/21; -Twelve in-services were completed; -The in-services failed to show the length of time the training was provided. 3. Review of CMT L's employee file, showed: -Date of hire: 10/19/21; -Thirteen in-services were completed; -The in-services failed to show the length of time the training was provided. 4. Review of CNA W's employee file, showed: -Date of hire: 4/11/22; -Ten in-services were completed; -The in-services failed to show the length of time the training was provided. 5. Review of CNA X's employee file, showed: -Date of hire: 8/15/22; -Three in-services were completed; -The in-services failed to show the length of time the training was provided. 6. Review of CNA Y's employee file, showed: -Date of hire: 10/27/22; -Seven in-services were completed; -The in-services failed to show the length of time the training was provided. 7. Review of CNA J's employee file, showed: -Date of hire: 5/22/23; -Seventeen in-services were completed; -The in-services failed to show the length of time the training was provided. 8. Review of CNA Z's employee file, showed: -Date of hire: 7/2/23; -Two in-services were completed; -The in-services failed to show the length of time the training was provided. 9. Review of CNA H's employee file, showed: -Date of hire: 9/21/23; -Six in-services were completed; -The in-services failed to show the length of time the training was provided. 10. Review of CMT AA's employee file, showed: -Date of hire: 10/2/23; -Six in-services were completed; -The in-services failed to show the length of time the training was provided. 11. During an interview on 3/11/25 at 1:59 P.M., the Director of Nursing (DON) said the facility did not track the time for the in-services and they would not be able to tell if the CNAs or CMTs had received the required 12 hours of education or not. She said the facility provided in-services for the CNAs every month and every class was allotted for one hour, but there was no duration of in-services tracked or documented. Some of the sampled staff did not have the 12 hours in-services in a year. She expected staff to have the required education and for the hours to be tracked.

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for five staff members. A sample of eight employees hired were reviewed. The facility hired at least 80 new employees since the last survey. The census was 79. Review of the facility's Staff Screening policy, dated 10/22/24, showed the following: -Policy: The Facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers; -Prior to employment or commencement of a contract, the Facility will verify and document or obtain a copy, if applicable, of the following information that may include, but not limited to: -Previous and/or current employer regarding work history, allegations of abuse against resident, employee or others; -Criminal Background Checks; -National Sex Offender Public Website; -Office of Inspector General (DIG) Exclusion Screening; -State exclusion screening, if applicable; -Current Licenses and Certifications; -References; -Disclosure of information (i.e., self-disclosure of any criminal convictions or actions that exclude them from any government healthcare program; -The Facility will not employee or engage with an individual who has been found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law or who has a finding in the state nursing aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, or has had a disciplinary action in effect taken again his/her professional license. 1. Review of Employee's D's file, showed the following: -Hire date: 9/4/24; -No CNA registry check performed. 2. Review of Employee's C's file, showed the following: -Hire date: 10/3/24; -No CNA registry check performed. 3. Review of Employee B's file, showed the following: -Hire date: 12/23/24; -No CNA registry check performed. 4. Review of Employee A's employee file, showed the following: -Hire date: 1/12/25; -No CNA registry check performed. 5. Review of Employee's E's file, showed the following: -Hire date: 1/22/25; -No CNA registry check performed. 6. During an interview on 3/11/25 at 12:00 P.M., the Human Resources employee said he/she is responsible for completing the employee background check upon hire. He/She was unaware of the CNA registry check. 7. During an interview on 3/11/25 at 3:41 P.M., the Administrator said Human Resources completes the background checks and if something triggers, management should be notified. She expected the CNA registry to be checked upon hire.

Based on interview and record review, the facility failed to provide eight hours of Registered Nurse (RN) coverage on 18 out of 30 days reviewed for staffing. This had the potential to cause unmet health needs for all residents. The census was 79. Review of the Nursing Department - Staffing, Scheduling & Postings policy, revised 10/24/22, showed the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days per week, unless a waiver applies. Review of the facility's daily staffing schedule, dated 2/10/25 through 3/11/24, showed no RN coverage on the following dates: 2/11/25, 2/12/25, 2/14/25, 2/15/25, 2/16/25, 2/18/25, 2/19/25, 2/20/25, 2/23/25, 2/24/25, 2/27/25, 2/28/25, 3/1/25, 3/4/25, 3/5/25, 3/6/25, 3/9/25 and 3/10/25. During an interview on 3/11/25 at 8:52 A.M., the Human Resources (HR) personnel said the facility did not have RN coverage for at least 8 hours a day on some days due to no RNs were available to work. She said the facility should have an RN at least 8 hours a day, seven days a week. During an interview on 3/11/24 at 2:33 P.M., the Director of Nursing (DON) said aside from her, RN S was the only regular RN in the facility. RN T worked on some days as a Quality Assurance (QA) nurse. There were no RNs in the facility when RN S and RN T were not scheduled to work. The DON said they were actively hiring for RNs. She expected the facility to have RNs at least 8 hours a day, 7 days a week. MO00247075 MO00250058 MO00249603

Based on interview and record review, the facility failed to assure they followed their policy to act on any irregularities noted by the pharmacist during the monthly Medication Regimen Review (MRR), which affected five out of five residents sampled for unnecessary medications review (Residents #53, #42, #6, #38 and #51). The census was 79. Review of the facility's Drug Regimen Review policy, dated 10/24/22, showed: -Policy: The pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications; -The pharmacist will report any irregularities to the attending physician and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon; -Procedure: The pharmacist must review each resident's medication regimen at least once a month; -The pharmacist performing the DRR will review the resident's medical record to appropriately monitor the medication regimen and verify the medication each resident is taking is clinically indicated; -The Consulting Pharmacist will note in the resident's medical record that the pharmacy medication review regimen was completed; -If no irregularities were identified during the review, the pharmacist includes a signed and dated statement to that effect; -The consulting Pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the Facility's Medical Director, Director of Nursing, and the Attending Physician; -Irregularities must be addressed in a separate, written report. The report will include the resident's name, the relevant drug, and the irregularity the pharmacist identified; -The report may be in paper or electronic form; -The report will be submitted within 3 business days of review, unless the irregularity is an emergent issue requiring immediate action. If the irregularity is emergent, the Attending Physician will be contacted as soon as practicable from the time the irregularity is identified; -The pharmacist does not need to document a continuing irregularity in the report each month if the Attending Physician has documented a valid clinical rationale for rejecting the pharmacist's recommendations, unless warranted by a change in the resident's condition or other circumstances; -The Attending Physician will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it; -The Medical Director and DON will also review the pharmacist's report if any irregularities are identified. 1. Review of Resident #53's medical record, showed: -Diagnoses included psychotic disorder with delusions due to known psychotic condition; -An order, dated 5/21/24, Aripiprazole (antipsychotic) oral tablet 5 milligram (mg). Give 5 mg by mouth in the morning related to psychotic disorder with delusions due to known physiological condition; -An order, dated 12/20/23, Sertraline (antidepressant) HCI oral tablet 50 mg. Give one tablet by mouth in the evening related to psychotic disorder with delusions due to known physiological condition. Review of the resident's care plan, in use during survey, showed: -Focus: Resident uses psychotropic medications; -Goal: Resident will be/remain free of psychotropic drug related complications; -Interventions: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift; -Educate resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. Review of the resident's Pharmacy Consultant Notes, dated 10/22/24, 11/22/24, 12/16/24 and 1/27/25, showed see report. Review of the resident's medical record, showed no documentation of the resident's pharmacy recommendations. 2. Review of Resident #42's medical record, showed: -Diagnoses included aphasia (language disorder), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder and insomnia; -An order, dated 1/14/25, Trazodone (antidepressant and sedative) HCI tablet 50 mg. Give one tablet by mouth at bedtime for insomnia every bedtime for sleep; -An order, dated 12/10/24, Clozapine (antipsychotic) oral tablet 100 mg. Give one tablet by mouth, two times a day related to undifferentiated schizophrenia; -An order, dated 12/10/24, Duloxetine (antidepressant) HCI capsule delayed release particles 20 mg. Give one capsule by mouth, one time a day for depression related to major depressive disorder. Review of the resident's care plan, in use during survey, showed: -Focus: Resident takes medications with black box warnings: Anticonvulsants and Antipsychotics; -Goal: Resident will not suffer from adverse reactions to these medications; -Interventions: All nursing staff to be aware of black box warning. These can be found under Physician's Orders Sheet (POS)/Medication Administration Record (MAR) of the medications; -Medications as ordered; -Assess resident and intervene if adverse reactions occur; -Abnormal Involuntary Movement Scale (AIMS, rating scale to measure involuntary movements) assessments quarterly and as needed. Review of the resident's Pharmacy Consultant Notes, dated 9/17/24, 10/21/24, 11/20/24, 12/13/24 and 1/27/25, showed see report. Review of the resident's medical record, showed no documentation of the resident's pharmacy recommendations. 3. Review of Resident #6's medical record, showed: -Diagnoses included major depressive disorder; -An order, dated 1/2/24, Amitriptyline (antidepressant) HCI oral tablet 50 milligram (mg). Give one tablet mg by mouth at bedtime related to depression with pain; -An order, dated 9/26/23, Lorazepam (antianxiety) oral tablet 0.5 mg. Give one tablet by mouth two times a day related to anxiety disorder related to post traumatic stress disorder (PTSD). Review of the resident's care plan, in use during survey, showed: -Focus: Resident uses psychotropic medications related to depression and anxiety; -Goal: Resident will be/remain free of psychotropic drug related complications; -Interventions: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. -Educate resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. Review of the resident's consultant pharmacist's medication review, dated 9/17/24, showed the following recommendation: -Resident has been taking amitriptyline (anti-depressant). Please evaluate the current dose and consider a dose reduction; -Resident with good response, maintain the current dose. Review of the resident's medical record, from 9/1/24 to current, showed monthly medication reviews completed on 9/17/24 and 1/27/25. Further review of the resident's medical record, showed no further documentation of monthly medication reviews or pharmacy recommendations 4. Review of Resident #38's medical record, showed: -Diagnoses included traumatic subarachnoid hemorrhage (tSAH, is a bleeding into the space between the brain and the arachnoid membrane), bipolar disorder and anxiety disorder; -An order, dated 1/26/25, Caplyta (antipsychotic) oral capsule 42 mg. Give 42 mg by mouth at bedtime related to bipolar disorder, current episode depression, mild or moderate severity; -An order, dated 8/23/22, Clonazepam (antidepressant) tablet 0.5 mg. Give 1 tablet by mouth two times a day for anxiety; -An order, dated Risperidone (antipsychotic) tablet 1 mg. Give 1 mg by mouth at bedtime related to bipolar disorder; -An order of Trazodone (antidepressant) tablet 100 mg. Give 1 tablet by mouth at bedtime related to bipolar disorder. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has psychiatric diagnosis which will affect his/her mood at times; -Goal: Resident will demonstrate effective coping behavior; -Interventions: Assess the resident for suicidal tendencies as needed, assess medication, psychiatric evaluation as needed; Review of the resident's Pharmacy Consultant Notes, dated 9/19/24, 10/21/24, 11/20/24, 12/13/24 and 1/27/25, showed MRR complete- See report. Review of the resident's medical record, showed no follow-up documentation of the resident's pharmacy report or recommendations on the dates stated above. 5. Review of Resident #51's medical record, showed: -Diagnoses included major depressive disorder (MDD), and schizoaffective disorder (mental health condition including schizophrenia and mood disorder (bipolar) symptoms); -An order, dated 7/1/24, Divalproex Sodium (used to treat the manic phase of bipolar disorder) oral tablet 250 mg. Give 1 tablet by mouth one time a day related to MDD; -An order, dated 6/14/24, Olanzapine (antidepressant) oral tablet 10 mg. Give 1 tablet by mouth in the evening related to MDD; -An order, dated 8/20/24, Risperdal (Risperidone) tablet 1 mg. Give 1 tablet by mouth at bedtime for depression related to MDD; -An order of Trazodone tablet 50 mg. Give 1 tablet by mouth at bedtime related to MDD. Review of the resident's care plan, in use during survey, showed: -Focus: Resident uses psychotropic medications related to sleep, depression and mood; -Goal: Resident will remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension (low blood pressure) gait disturbance, constipation/impaction or cognitive/behavioral impairment; -Interventions: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly. Discuss with physician, family regarding ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Review of the resident's Pharmacy Consultant Notes, dated 9/17/24, 10/21/24, 11/20/24 and 12/13/24, showed MRR complete- See report. Review of the resident's medical record, showed no follow-up documentation of the resident's pharmacy report or recommendations on the dates stated above. 6. During an interview on 3/11/25 at 12:58 P.M., the Regional Nurse Consultant (RNC) said the facility did not have a tracking system of pharmacy reviews. She expected the pharmacy consultant and facility staff to complete the documentation and/or report following the pharmacy monthly reviews. 40291 45083

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility had two medication rooms, six medication carts and one treatment cart. Both medication rooms, three medication carts and the treatment cart were reviewed, and issues were found with all. The census was 79. Review of the facility's Medication Storage Policy, dated 2007, showed: -Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Intravenously (IV, administered into a vein) administered medications are stored separately from orally administered medications, under appropriate temperature and sterility conditions, and following the manufacturer's recommendations; -Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Opened insulin pens should be stored at room temperature; -Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal; - Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken. 1. Observation and interview on 3/6/25 at 10:30 A.M., showed the medication room on the west side had one liter of 0.45% on Sodium (Na) Chloride (Cl) (Intravenous (IV) fluids) (used to replenish lost water and salt in your body), with an expiration date of 10/24. The medication refrigerator freezer was observed frosted over, with very thick build-up of ice. About a half-full bottle of Coke soda was placed in the freezer. Licensed Practical Nurse (LPN) A said the soda did not belong to a resident. The refrigerator door had approximately a centimeter opened gap when locked due to the thick ice build-up in the freezer. The refrigerator also had a one liter bag of NaCl 0.9% IV fluids. LPN A said he/she was not aware if it was an active order, and IV bags should not be in the refrigerator. 2. Observation and interview on 3/6/25 at 10:56 A.M., showed the Certified Medication Technician (CMT) cart on the west side, in the top drawer, had 2 brown pills in an unlabeled medication cup. CMT L said they were for himself/herself. In the bottom drawer, the following medication bottles were observed: -A 200 tablet bottle of sodium chloride 1 gram, opened and undated, expired 2/25; -A 300 tablet bottle of aspirin (used for pain and helps prevent heart attack or stroke) 81 milligram (mg), unopened, expired 12/24; -A 300 tablet bottle of allergy relief 10 mg, opened, undated, expired 2/25; -A 6 tablet bottle of calcium + D3 (calcium supplement) 600 mg/10 microgram (mcg), opened 2/25, expired 11/24. 3. Observation and interview on 3/6/25 at 11:00 A.M., showed the nurse's medication cart on the west side had two open vials of insulin, and eight out of 21 insulin pens were undated. LPN A said he/she did not know when the insulin was opened. One of the undated insulins pen's date must have rubbed off and another insulin pen must have come in last night and was put on the cart instead of the refrigerator. LPN A said insulin should be dated when it was opened by the person who opened it. If insulin was not dated, the nurse could possibly give expired insulin. When insulin was received from the pharmacy, it should be placed in the refrigerator until it was opened. 4. Observation and interview on 3/6/25 at 11:20 A.M., showed the the top drawer of the nurse medication cart on the east side in had one pink pill in an unlabeled medication cup, six open vials of insulin with no date and 10 out of 12 opened undated insulin pens. LPN B said he/she did not know what the pre-popped medication was or who it belonged to. If a medication was popped and not administered, the medication cup should be labeled with the resident's name on it. If the medication was refused, the medication should be discarded. Insulin should be dated by whomever opened the insulin. He/She did not know when the insulin was opened. 5. Observation on 3/6/25 at 11:23 A.M., showed the treatment cart had four tubes of Dermasyn (antibacterial wound gel), opened and undated. Three of the tubes were dated 10/24. 6. Observation on 3/6/25 at 11:38 A.M., showed the medication room refrigerator's freezer on the east side was frosted over with a very thick ice build observed. A pint-size ice cream was stuck in the freezer's ice buildup. 7. During an interview on 3/10/25 at 3:44 P.M., and on 3/11/25 at 3:41 P.M., the Director of Nursing (DON) said insulin pens and vials should be dated when opened and used within 28 days after opening. The stock medications should also be dated when opened and should be within manufacturers' expiration dates. Staff should not pre-pop and not leave unlabeled medications in the medication cart drawers. Staff should discard expired medications. The DON would expect for medications to be stored per manufactures guidelines and per the facility's policy and she would expect for staff to follow the policies and procedures. 45083

Based on interview and record review, the facility failed to ensure a process was in place for physician ordered laboratory tests to be completed and results received in a timely manner for four residents (Residents #42, #18, #46 and #11). The sample was 18. The census was 79. Review of the facility's Laboratory, Diagnostic, and Radiology services policy, dated 10/24/22, showed: -Policy: Laboratory, diagnostic and radiology services will be coordinated pursuant to an order by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with the scope of practice under state law; -The Facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider; -The ordering practitioner will be notified of results that fall outside of clinical reference or expected normal ranges per the ordering practitioner's order; -The Facility will assist in making transportation arrangements, as indicated, to and from the applicable provider; -Procedure: Laboratory, diagnostic and radiology services ordered will be documented on the 24-Hour Report or electronic health record, to ensure that services are coordinated and results are received timely; -Any orders labeled STAT (immediately) will be followed up on during the same shift; -The Director of Social Services or designee will coordinate transportation to and from the service provider, as indicated; -The ordering practitioner will be notified of results that fall outside of clinical reference or expected normal ranges per the ordering practitioner's order; -Critical values will be reported immediately to the ordering practitioner; -Critical values (also referred to as panic values or crisis values) are those that, if untreated, could be life threatening or place the resident at serious risk; -If the ordering practitioner does not immediately respond to communication of critical values, the licensed nurse will contact the Facility's Medical Director for direction and orders, as indicated; -The licensed nurse will document the time when results were reported to the ordering practitioner and the ordering practitioner's response or additional orders, if any; -Update resident's Care Plan as needed; -Laboratory, diagnostic and radiology results will be maintained as part of the resident's medical record. 1. Review of Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/25, showed: -Moderate cognitive impairment; -Diagnoses included high blood pressure, diabetes, arthritis, Alzheimer's disease, aphasia (language disorder), seizure disorder, depression, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly) and asthma; -Administered antidepressants and antipsychotic; -Antipsychotics were administered on a routine basis. Review of the resident's care plan, in use during survey, showed: -Focus: Resident takes medications with black box warnings: Anticonvulsants and Antipsychotics; -Goal: Resident will not suffer from adverse reactions to these medications; -Interventions: All nursing staff to be aware of black box warning (highest safety warnings). These can be found under Physician's Orders Sheet (POS)/Medication Administration Record (MAR) of the medications; -Medications as ordered; -Assess resident and intervene if adverse reactions occur. Review of the resident's Physician's Orders Sheet (POS), dated March 2025, showed: -An order, dated 11/25/24, for Clozapine (antipsychotic) every month. -An order, dated 12/10/24, Clozapine oral tablet 100 milligrams (mg). Give one tablet by mouth, two times a day related to undifferentiated schizophrenia. Review of the resident's medical record, showed: -On 9/25/24, Clozapine lab was completed and reported on 9/29/24 -No further documentation of a monthly Clozapine lab since September 2024. Review of lab results, received on 3/10/25 at 12:52 P.M., showed Clozapine lab was not completed. Review of the U.S. Food and Drug Administration (FDA) website, showed patients taking Clozapine require tests to detect emergent agranulocytosis or neutropenia (a life threatening condition that involves having severely low levels of white blood cells). 2. Review of Resident #18's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia, coronary artery disease (CAD, blocked or narrowed arteries), heart failure, hypertension (high blood pressure), renal failure, neurogenic bladder (condition that affects the bladder's ability to function properly), urinary tract infection, diabetes, hyperkalemia (high potassium levels in the blood), hyperlipidemia (high level of lipids in the blood), hemiplegia (paralysis or weakness on one side of the body), seizure disorder, malnutrition, asthma and respiratory failure; -Administered anticoagulants; -Receives continuous oxygen. Review of the resident's care plan, in use during survey, showed: -Focus: Resident utilizes medications with Black Box warning; -Goal: Resident will remain free of adverse reactions associated with utilizing black box medications; -Interventions: Administer medications as ordered; -Licensed nursing staff will monitor resident at least daily; -Licensed staff will report signs and symptoms adverse reactions to resident's provider immediately; -Focus: Resident has heart failure, CAD, and hypertension (high blood pressure); -Goal: Resident will be free of peripheral edema; -Interventions: Give cardiac medications as ordered; -Monitor/document/report as needed (PRN) any signs and symptoms of congestive heart failure. Review of the resident's POS, dated March 2025, showed an order, dated 1/31/25, for Complete Blood Count (CBC, blood test that provides information about cells in the body)/Comprehensive Metabolic Panel (CMP, blood test that measures 14 different substances in the body yearly, magnesium, uric acid, parathyroid hormone (PTH), lipid, and vitamin D. Review of the resident's medical record, showed no documentation of a CMP, CBC, magnesium, uric acid, PTH, lipid or vitamin D as of 3/11/25. 3. Review of Resident #46's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia, Crohn's disease (chronic inflammatory bowel disease), aphasia and malnutrition; -Receives antidepressant, opioid, antiplatelet and hypoglycemic (low blood sugar) medications. Review of the resident's POS, dated March 2025, showed: -An order, dated 1/14/25, please check thyroid-stimulating hormone (TSH), A1C, B12, folate, and vitamin D levels; -An order, dated 2/21/25, please check TSH, A1C (a blood test that reflects your average blood glucose levels over the past 3 months), vitamin D, B12, folate, iron levels. Review of the resident's care plan, in use during survey, showed: -Focus: Resident is on diuretic therapy; -Goal: Resident will be free of any discomfort or adverse side effects of diuretic therapy; -Interventions: Report pertinent lab results to physician (especially hematocrit (HCT, measures the percentage of red blood cells) Na+ (sodium), and K+ (potassium). Review of the resident's medical record, showed no documentation of a CMP, CBC, magnesium, uric acid, PTH, lipid, or vitamin D as of 3/11/25. Review of the resident's lab results, received on 3/10/25 at 12:52 P.M., showed on 2/20/25, a CMP and CBC lab was ordered. Resident refused (first attempt). Review of the resident's medical record, showed no recent lab result for TSH, A1C, vitamin D, B12, folate, iron levels as of 3/11/25. 4. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: dementia and seizure disorder. Review of the care plan, in use at the time of survey, showed: -Focus: resident is at risk for adverse side effects (ASE) of medications use as evidence by (AEB) by resident takes medication with black box warning-anti convulsant; -Goal: will not experience ASE of medication use through the review date; -Interventions: meds as ordered. Review of the order summary sheet, dated 3/5/25, showed -An order for: Divalproex Sodium ER 24 hour (Depakote, anticonvulsant), 500 milligrams, give two tablets by mouth at bedtime, start date was 10/17/24. Review of the progress notes, dated 11/5/24 through 11/11/24 showed: -On 11/9/24 at 3:20 P.M., the nurse was called to resident room. Resident was noticed having a seizure activity. Resident was coming around and went into another seizure, stayed with resident until resident was able to respond with telling his/her name and stated he/she wanted to go to bingo. Responsible Party (RP) notified, and the doctor was called and stated to send the resident to the hospital. 911 was called and arrived. Resident said he/she did not want to go. -On 11/11/24 at 11:48 A.M., NP note, chief complaint: resident evaluated for reports of seizure activity; Plan: Depakote level (blood test used to measures the amount of valproic acid (Depakote) is in the blood), CBC and CMP next lab day, -On 11/13/24 at 10:50 A.M., NP note, chief complaint: resident requested visit due to seizure activity; Plan: Depakote level, CBC and CMP next lab day. Review of the labs provided by the facility dated 11/1/24 through 11/30/24, showed, a Depakote level, CBC and CMP was completed on 11/8/24. There were no other labs for November provided. Review of the progress notes dated 12/11/24 showed at 11:50 A.M. NP note: chief complaint: resident evaluated for follow up following seizure; Plan: Depakote level. Review of the labs provided by the facility showed no Depakote level was drawn in December. During an interview on 3/11/25 at 8:30 A.M., the DON said the nurse practitioner who entered his/her notes in the progress notes plan was no longer at the facility. During an interview on 3/11/25 at 9:19 A.M., NP M said NP N was no longer with the company. When NP N was at the facility, he/she was placing orders in his/her plan of treatment but was not entering the orders into the system. NP N was responsible for entering his/her orders into the system. The orders written in NP P plan should have been placed into the system. During an interview on 3/11/25 at 3:41 P.M., the Director of Nursing (DON) said she would expect for the orders listed in the NP plan to be entered into the system. The NPs are no longer entering the orders into the system. They are writing all their orders on a piece of paper for the facility staff to enter into the system. The DON would expect for staff and providers to follow the facility's policies and procedures. 5. During an interview on 3/10/25 at 11:05 A.M. Licensed Practical Nurse (LPN) A said the nurse, or the unit manager entered the orders into the computer. Some of the Medical Doctors (MD)/Nurse Practitioners (NP)s will write a telephone order and give it to the staff to enter the order into the computer and some will give the nurse a verbal order. 6. During an interview on 3/10/25 at 12:08 P.M., LPN B said the MD/NP have access to the computer and they enter their own orders into the computer. The nurse entered the lab orders into the lab computer and binder. 7. During an interview on 3/11/25 at 12:35 P.M., the Director of Nursing (DON) and Regional Nurse Consultant said the Assistant Director of Nursing (ADON) and DON are responsible for entering the lab order into the system. At the end of the day, they print the log for blood draws on Monday, Wednesday, and Friday when lab tech arrives. They are placed into a binder so they know what labs are to be drawn and for which resident. They check daily for completed labs. They ensure that the results for the entire lab are completed for the physician to see, not partial results. If a resident refuses lab draw, the lab attempts three times and document it on the results. It will say resident refusal. Sometimes there is a progress note that the resident refused. The DON expected refusals to be documented in the nursing notes or in the lab result. She expected staff to refer to the policy in regards to when to contact the physician.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for one resident (Resident #15) with wounds requiring treatments, gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications) and when staff provided care for one resident on EBP (Resident #235) then provided care on another resident wearing the same gown (Resident #11) and when staff failed to perform hand hygiene between dirty and clean areas for one resident (Resident #37). The sample was 18. The census was 79. Review of the facility's Standard and Enhance Barrier Precautions Policy, dated 4/1/24, showed: -Purpose: To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents. -Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (feeding tube) and wounds or presence of unhealed pressure ulcers; -Standard Precautions refers to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents. -Standard Precautions apply to the care of all residents regardless of suspected or confirmed presence of infectious diseases; -Standard precautions: hand hygiene refers to hand washing with soap (anti-microbial or non-antimicrobial) or using alcohol-based hand rubs (gels, foams, rinses) that do not require access to water; Gloves (clean, non-sterile) are worn when direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material is anticipated; a gown is worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing; -EBP should be used for any residents who meet the above criteria, wherever they reside in the facility; -For residents whom EBP are indicated, EBP should be used when performing the following high contact resident care activities: dressing; providing hygiene; changing briefs or assisting with toileting. Review of the facility's Perineal Care Policy, dated 10/24/2022, showed: -Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown; -Procedure: wash hands, prepare equipment, provide privacy, put on gloves, provide peri care, turn resident to side, wash, rinse and dry buttocks, remove wet linen, provide dry linens/brief, remove gloves, put on clean gloves, clean and return all equipment to its proper place, placed soiled linen in proper container, remove gloves and wash hands. 1. Review of Resident #15's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/20/25, showed: -Moderately impaired cognition; -Had a feeding tube; -Diagnoses included stroke, heart failure, high blood pressure, diabetes, dementia, hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body). Review of the care plan, in use at the time of survey, showed: -Focus: EBP placement related to enteral nutrition (method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories)/colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall); -Goal: help to reduce or preventable spread of MDRO; -Interventions: handwashing before and after personal protective equipment (PPE) donning; provide PPE. Ensure that gowns, gloves and other PPE are readily available outside the room; signage posted outside of room door to indicate the type of precautions and required PPE. Observation on 3/5/25 at 11:22 A.M., showed an EBP sign on the resident's door. Certified Nurse Aide (CNA) O and CNA P entered the resident's room, performed hand hygiene and put gloves on. Then, staff rolled the resident side to side to perform peri care (care to the surface area between the thighs, extending from the pubic bone to tail bone) for the resident, without wearing a gown. 2. Review of Resident #235's admission MDS, dated [DATE], showed: -Should Brief Interview for Mental Status be conducted - attempt to conduct interview with all residents? blank; -Dependent-(helper does all the effort. Resident does none of the effort to complete the activity) for toileting hygiene and lower body dressing; -Had a feeding tube; -Diagnoses included stroke, high blood pressure, diabetes, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Review of Resident #11's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Dependent for toileting hygiene and lower body dressing; -Diagnoses included dementia and seizure disorder. Observation on 3/7/25 at approximately 6:15 A.M., showed Resident #235 lay in bed on his/her back. The resident was incontinent of bowel. CNA E and CNA D entered the resident's room, performed hand hygiene and put on gowns and gloves. Resident #235 was turned side to side and peri care was performed. CNA E gathered the trash and left the room with the trash, wearing his/her gown. CNA E discarded the trash and entered Resident #11's room, wearing the same gown. There was no EBP sign on the resident's door. CNA E put two pairs of gloves on, sprayed peri wash on the resident's peri area and performed peri care. CNA E removed the soiled brief from under the resident and removed one pair of gloves. Then, he/she tucked a new brief under the resident and assisted the resident to roll over and fastened the brief. CNA E removed his/her gloves, removed his/her gown and left the room. 3. Review of Resident #37's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Impairment on both sides of lower extremities; -Dependent on rolling left and right; -Dependent on activities of daily living (ADL); -Diagnoses included high blood pressure, neurogenic bladder (a condition that affects the bladder's ability to function), diabetes, and multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). Observation on 3/7/25 at 10:18 A.M., showed Licensed Practical Nurse (LPN) G assisted LPN F to provide the resident's wound care. The resident had multiple wounds located on the buttocks, both legs/shins and heels. When LPN F provided the treatment for wounds on the resident's legs, LPN G lifted the feet and heels, touching the wounds, so LPN F could access the wound areas. After touching the affected areas, LPN G touched the resident and repeatedly rubbed the resident's back with dirty gloves on. He/She also touched the resident's bed and covered the resident with the clean linens after providing wound care, while still wearing the same dirty gloves. LPN G did not remove or change gloves in between contact with dirty and clean areas. 4. During an interview on 3/10/25 at 10:50 A.M., CNA I said he/she knew if a resident was on isolation by the sign on the door, he/she could check the chart, or the information is provided during their morning meeting. If a resident had an EBP sign on the door, he/she would wear gloves and a gown every time he/she entered the resident's room or if he/she provided catheter care. The gown should be taken off before leaving the room and should not be worn into another resident's room. Staff should not wear two pair of gloves at a time 5. During an interview on 3/10/25 at 12:08 P.M., LPN B said staff knew which residents are on isolation precautions by the stuff outside the door. If a resident was on EBP, staff should wear a gown and gloves while providing direct patient care. The gown should be removed before leaving the room. Staff should not double glove. 6. During an interview on 3/10/25 at 3:45 P.M., the Director of Nursing (DON) said the residents who had urinary catheters, wounds, intravenous lines (used to give medicines, fluids, blood products, or nutrition into the bloodstream), and on dialysis were required to be on EBP rooms. Staff should apply gloves and gown when providing care to residents in EBP rooms. The staff should not wear gowns in the halls and should not wear the same gowns from one room to the other. She expected staff to change gloves and apply hand hygiene in between contact with dirty and clean. On 3/11/25 at 3:41 P.M., the DON said she expected staff to follow the CDC guidelines for infection control and the facility's policies and procedures. 45083 MO00247075

Based on interview and record review, the facility failed to ensure two residents received an accurate assessment, reflective of the residents' status at the time of assessment, by failing to identify the residents' dialysis treatments (Residents #53 and #62). The sample was 18. The census was 79. Review of the facility's Resident Assessment Instrument (RAI) Process policy, dated 10/24/22, showed: -Purpose: To ensure that the Resident Assessment Instrument is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified; -The facility will utilize the Resident Assessment Instrument process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the Center for Medicare and Medicaid Services (CMS) RAI Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) 3.0 Manual; -The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts; -Each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed; -All information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD). 1. Review of Review #53's medical record, showed a diagnosis of acute renal failure. Review of the resident's quarterly MDS, dated [DATE], showed: -Diagnosis included renal failure; -Special treatments and programs: Dialysis was not documented. Review of the resident's Physician's Orders Sheet (POS), dated March 2025, showed: -An order, dated 12/29/23, dialysis location, Monday, Wednesday, Friday at 5:30 chair time, first day of treatment 1/3/24; -An order, dated 12/29/23, for regular diet, regular texture, liberal renal diet, no bananas or orange juice; -An order, dated 10/3/24, enhanced barrier precautions related to dialysis; -An order, dated 10/29/24, to monitor bruit (swooshing sound heard with a stethoscope) and thrill (vibration felt by palpation), signs and symptoms of infections, bleeding every shift; -An order, dated 2/7/25, to monitor dialysis site dressing for drainage, bleeding, or signs and symptoms of infection. Check bruit and thrill every shift. Report any drainage, bleeding or signs and symptoms of infection to dialysis provider and primary physician; -An order, dated 2/7/25, to monitor vital signs before and after dialysis treatment. Complete communication form, send with resident, collect form upon resident return. Report any abnormalities to dialysis provider and primary physician two times a day, every Monday, Wednesday and Friday. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has renal failure and on dialysis at dialysis location on Monday, Wednesday, and Friday, 5:30 chair time; -Goal: Resident will have no signs and symptoms of complications related to fluid overload; -Interventions: Dietary consult to regulate protein and potassium intake; -Give medications as ordered by physician; -Monitor lab reports of electrolytes and report to physician. 2. Review of Resident #62's quarterly MDS, dated [DATE], showed: -admitted to the facility: 11/28/23; -Diagnoses included stroke, end stage renal disease (ESRD, chronic irreversible kidney failure), heart failure, diabetes; -Special treatment and services received while a resident: Dialysis, left blank. Review of the resident's physician order sheet, dated 3/7/25 showed an order for dialysis on Mondays, Wednesdays, and Fridays with a chair time at 11:00 A.M., start date 11/28/23. Review of the resident's care plan, showed: -Problem: Resident needs hemodialysis related to chronic kidney disease, end stage renal disease, dependence on renal dialysis at a local dialysis center. An outside contracted transportation company is used to transport the resident who attends Mondays, Wednesdays, and Fridays with a chair time of 11:00 A.M.; -Goal: Resident will have no signs or symptoms (s/sx) of complications from dialysis through the review date; -Interventions included: Do not draw blood or take blood pressure in arm with graft. Monitor for dry skin and apply lotion as needed. Monitor labs and report as needed (PRN) any s/sx of infection to access site: Redness, swelling, warmth or drainage. Monitor/document/ report PRN for s/sx of the following: Bleeding, hemorrhage, bacteremia (infection in the blood), septic shock. Monitor/document/ report PRN new/worsening peripheral edema (is a condition of abnormally large fluid volume in the circulatory system or in tissues between the body's cells (interstitial spaces)). Work with the resident to relieve discomfort for side effects of the disease and treatment (cramping, fatigue, headache, itching, anemia, bone demineralization, body image change and role disruption.) 3. During an interview on 3/11/25 at 12:35 P.M., the Director of Nursing (DON) and Regional Nurse Consultant said the Administrator and regional corporate staff were responsible for completing the MDS at this time. The facility does not have an MDS Coordinator. The DON would expect the MDS to be accurate. 4. During an interview on 3/11/25 at 3:31 P.M., the Administrator said she would expect all resident MDS assessments to be accurate. 40291

Based on observation, interview and record review, the facility failed to ensure the physician orders were accurately recorded and updated for three sampled residents (Residents #46, #18 and #6) out of 18 sampled residents. The facility failed to serve Resident #46 with physician ordered double portions. The facility also failed to ensure oxygen tubing was dated and oxygen equipment was covered per infection control standards for Resident #18. In addition, the facility failed to obtain documentation of Resident #18's cardiology progress notes from the most recent appointment when Resident #18 received a blood pressure machine that reported results directly to the cardiologist. The facility also failed to ensure Resident #6's neurological checks (medical assessments used to evaluate the function and health of the nervous system) were completed and maintained in the medical record. The census was 79. Review of the facility's Physician's Orders policy, dated 10/24/22, showed: -Purpose: This will ensure that all physician orders are complete and accurate; -Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary; -Telephone Orders: A Licensed Nurse will record telephone orders on the telephone order sheet with the date, time and signature of the person receiving the order or in the Electronic Health Record (EHR); -The Medical Record Department staff mails an original copy to the physician promptly for signature; -The order is transcribed onto the Physician's Order Form at the time the order is taken; -A copy of the Physician Order form that was sent to the Attending Physician is maintained in the medical record until the form signed by the physician is returned; -Once the signed copy is returned to the Facility, it is taped to the telephone order sheet in the resident's medical record by the Medical Record Department staff; -The copy is then removed from the medical record by the Medical Record Department staff and destroyed; -Physician orders will include the following: Name of the prescriber; -The name of the resident; -The date and time the order was received; -The signature of the Licensed Nurse receiving and documenting the order, if by telephone; -Medication orders will include the following: Name of the medication; -Dosage; -Frequency; -Duration of order; -The route and the condition/diagnosis for which the medication is ordered, if applicable; -Other orders will include a description complete enough to ensure clarity of the physician's plan of care; -Physician orders will only include abbreviations that have been approved by the Facility; -Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. Review of the facility's Oxygen Administration policy, dated 10/24/22, showed: -Initiation of Oxygen: A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: -Oxygen flow rate; -Method of administration (e.g. nasal cannula); -Usage of therapy (continuous or PRN); -Titration instructions (if indicated); -Indication for use; -In an emergency situation or when a physician's order cannot be immediately obtained, oxygen may be initiated by a Licensed Nurse in the presence of acute chest pain or any other acute situation in which hypoxia is suspected; -A physician is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders; -Infection Control: All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: -Are for single resident use only; -Will be changed weekly and when visibly soiled, or as indicated by state regulation. -Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 1. Review of Resident #46's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/10/25, showed: -Cognitively intact; -Diagnoses included malnutrition; -Weight: 93 pounds; -Loss of 5% or more in the last month or loss of 10% or more in the last six months: No or unknown. Review of the resident's medical record, showed a diagnosis of severe protein-calorie malnutrition and body mass index (BMI) 19.9 or less (normal BMI, 18.5 and 24.9). Review of the resident's care plan, in use during survey, showed: -Focus: Resident has potential nutritional problem and has a diagnosis of malnutrition with interventions in place; -Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of (specify baseline), no signs and symptoms, and consuming at least 50% of at least two meals daily; -Interventions: Encourage intake at meal times to assist in weight maintenance 10/4/24; -Weigh per facility protocol; -Registered Dietician to evaluate and make diet change recommendations as needed. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated March 2025, showed an order, dated 3/26/24, for double portions at every meal. Review of the resident's progress notes, showed: -On 2/17/24, resident remains on weekly weights. Updated weight: 94.8 pounds. This is a 1.4 pound increase since last assessment. Registered Dietician (RD) recommended double portions last assessment. Will recommend again. Continue with house supplement and health-shake. Meal intakes vary between 0-100%, most documented at 51-100%. Continue with weekly weight checks. RD will continue to follow as needed (PRN); -On 2/27/25, resident with 11% weight loss since September 2024. Weight 105.2 pounds, down now to 93.6 pounds. Weight up and down a pound or so this month. Continues a regular diet with heath shake at meals and house supplement at bedtime. Also getting double portions at meals. Continues mirtazapine for appetite stimulation. Intakes have been 25-100% of meals lately. Will continue current interventions and double portions. Observation on 3/5/25 at 12:14 P.M., showed the resident in his/her room, assisted by staff with eating. He/She did not receive double portions. Observation and interview on 3/10/25 at 11:40 A.M., showed the resident in his/her room, assisted by staff with eating. The resident's meal ticket showed regular diet. Double portion was not documented on the meal ticket. During an interview at 11:57 A.M., Certified Nurse Aide (CNA) BB said the resident received regular diet with regular portions. During an interview on 3/11/25 at 12:35 P.M., the Director of Nursing (DON) and Regional Corporate Consultant said if there are diet order changes, the DON communicates to the Dietary Manager. The resident's diet order change to double portions was communicated to dietary. She expected the resident's diet order to be accurate on the meal time ticket and received as ordered. 2. Review of Resident #18's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia, coronary artery disease (CAD, blocked or narrowed arteries), heart failure, hypertension (high blood pressure), renal failure, neurogenic bladder (condition that affects the bladder's ability to function properly), urinary tract infection, diabetes, hyperkalemia (high potassium levels in the blood), hyperlipidemia (high level of lipids in the blood), hemiplegia (paralysis or weakness on one side of the body), seizure disorder, malnutrition, asthma and respiratory failure; -Administered anticoagulants; -Received continuous oxygen. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has heart failure, CAD, and hypertension (high blood pressure); -Goal: Resident will be free of peripheral edema (accumulation of fluid causing swelling in tissues perfused by the peripheral vascular system, usually in the lower limbs); -Interventions: Give cardiac medications as ordered; -Monitor/document/report as needed (PRN) any signs and symptoms of congestive heart failure. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed the following orders and administration: -An order, dated 1/5/25, change all oxygen tubing weekly on Sunday was documented as completed on 3/2 and 3/9/25; -An order, dated 3/9/25, clean C-Pap machine, tubing, and mask with soap and water, every night shift, every Sunday was documented as completed on 3/9/25. Review of the resident's progress notes, showed on 1/24/25, resident has a heart/vascular appointment on 1/28/25 at 12:45 P.M. Observation and interview on 3/6/25 at 2:53 P.M., showed the resident in bed with continuous oxygen. Oxygen was set at 2 liters (L) per nasal cannula. The oxygen tubing was not dated. The resident had a C-Pap machine and blood pressure machine on the night table. The C-Pap mask was uncovered. Observation and interview on 3/7/25 at 12:51 P.M., showed the resident in his/her room, eating his/her meal. The C-pap mask was on the night table, uncovered. The mask fell on the floor during observation. His/Her continuous oxygen was set at 2L per nasal cannula. The oxygen tubing was not dated. The resident said he/she had a blood pressure machine he/she received from the cardiologist during the January 2025 appointment. He/She was supposed to take his/her blood pressure and the results are sent to the cardiologist. They took the blood pressure once when he/she first received the blood pressure machine. Review of the resident's medical record, showed no documentation of the resident's heart/vascular appointment, blood pressure machine or instructions for usage. Review of the resident's progress notes, showed no further documentation of the resident's heart/vascular appointment on 1/28/25 through 3/9/25. During an interview on 3/11/25 at 12:35 P.M., the DON and Regional Corporate Consultant said they expected medical records to be accurate and complete. If a resident goes to an outside appointment, they expected staff to document it and save the documentation in the medical record if received. It depends on where they are going and what is being done. The progress notes from the outside physician are expected to be in the medical record. It is important for the facility to document outside medical visits and treatment plans so they can follow up with a plan. Missing documentation from an outside provider could impact the continuity of care. They expected staff to follow physician's orders. 4. Review of Resident #6 quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Set-up help only with eating -Independent with bed mobility; -Walking not attempted due to medical condition; -Diagnoses included heart disease, hypertension, hyperlipidemia, diabetes, peripheral vascular disease (PVD, poor circulation), dementia, malnutrition and depression. Review of the resident's fall risk assessments showed: -8/2/24, score was 13: The resident was a moderate fall risk; -8/20/24, score was 13; The resident was a moderate fall risk; -9/19/24, score was 15; The resident was a high fall risk; -9/24/24, score risk 19; The resident was a high fall risk. -10/17/24, score risk 7: The resident was a moderate fall risk. Review of the resident's progress notes, dated 9/24/24 at 1:12 P.M., showed the resident had an unwitnessed fall. Upon assessment, the resident was noted to be sitting upright in bed. The resident had a bloody mouth laceration to top and bottom lip. The resident also had had bruising and swelling to left cheek and discoloration near his/her left eye. Resident denied any pain. Resident stated he/she had fell out of his/her chair. He/She didn't go back. Vitals (VS) was taken and was within normal limits. Call placed to the Physician and responsible party, no answer. Nurse was awaiting return call. Resident placed on neuro checks for further monitoring. Resident rested in bed at that time. No other injuries noted at that time. Resident had call light and fluids within reach. Review of the neurological flow sheet, dated 9/19/24, showed one out of 14 opportunities to document neuro checks left blank. Review of the resident's progress notes, dated 9/19/24 at 3:08 P.M., showed the resident has had two falls this day. The resident was attempting to stand and transfer him/herself from the wheelchair and was unable to complete the transfer him/herself and this resulted in a fall. The resident had been educated and advised to ask for assistance with any transfers and resident had verbalized understanding. Call placed to the resident's family member to notify, answered following questions and concerns and the nurse was thanked for the call. The resident was noted to have no apparent injury. The call light remained within reach; no further concerns noted. Placed a call to the physician to notify and received new orders for labs. Lab requisition completed. Review of the neurological flow sheet, dated 9/24/24, showed four out of 14 opportunities to document neuro checks were left blank. During an interview on 3/10/25 at 11:08 A.M., Licensed Practical Nurse (LPN) A said if a resident fell , he/she would assess the resident and complete the fall risk assessment. If the fall was unwitnessed or if the resident hit their head, neuro checks should be completed every shift for three days. Neuro checks are completed on paper. MO00247075 MO00250058 MO00249603 40291

45083 Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for three residents by failing to ensure one resident received his/her showers as scheduled (Resident #38) and failed to ensure residents were clean and odor free (Residents #38, #2 and #6). The sample was 18. The census was 79. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/25, showed: -Cognitively intact; -Required substantial/maximal assistance with shower/bath; -Required set-up or clean assistance with personal hygiene; -Occasional urinary incontinence; -Frequent bowel incontinence; -Diagnoses included heart disease, high blood pressure, traumatic brain injury, anxiety disorder and manic depression. Review of the resident's care plan, in use at time of survey, showed: -Focus: Resident has an ADL self-care performance deficit; -Goal: Resident will maintain current level of function in ADLs; -Interventions: Limited assist in bathing/showering, bed mobility, dressing, oral care, toilet use, and transfer. Observation and interview on 3/5/25 at 12:50 P.M., showed the resident had a strong urine and body odor. The resident said he/she was supposed to have showers twice a week, on Mondays and Thursdays during the day shift, but did not have one on Monday, 3/3/25 due to a towel shortage. Observation and interview on 3/7/25 at approximately 1:30 P.M., showed the resident's hair was greasy and he/she continued to have strong body odor. He/She said he/she did not get a shower the day prior, 3/6/25. During an interview on 3/11/25 at 9:27 A.M., the resident said he/she received a shower on Monday, 3/10/25. He/She said he/she had a shower because there were state surveyors in the facility. He/She said it was an ongoing issue where staff did not provide showers and sometimes with no reasons explained. Review of resident's record, showed no shower sheets for 3/3/25 and 3/6/25. During an interview on 3/10/25 at 10:50 A.M., Certified Nurse Aide (CNA) I said the resident was compliant with showers. He/She said no resident missed their showers due to towels or linens shortage. He/She said the CNAs were responsible for providing the showers. Showers are given two to three times a week. If a resident refused his/her shower, CNA I would tell the nurse, document it in the chart and write it on the shower sheet. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Severe impairment; -Dependent on staff with shower/bath, personal hygiene, and toileting; -Always incontinent of bladder and bowel; -Rejection of care: behavior not exhibited; -Diagnoses included diabetes, seizure disorder, traumatic brain injury and malnutrition. Review of the resident's care plan, in use at time of survey, showed: -Focus: Resident has an ADL self-care performance deficit; -Goal: Resident will maintain current level of function through the review date; -Interventions: Resident requires dependent assist by staff with bathing, bed mobility, eating, dressing, personal hygiene, toilet use, and transfers. Observation on 3/10/25 at 11:34 A.M., showed the resident sat in his/her Broda chair (positioning chair), on top of a Hoyer pad (mechanical lift pad). His/Her disposable brief was heavily soiled, and shredded in multiple spots. A strong urine and body odor emanated from the resident. During an interview on 3/11/25 at 12:32 P.M., CNA FF said he/she was the resident's assigned staff that day. Yesterday, the resident's Hoyer pad smelled horribly like urine, so he/she changed the pad. The resident pulls on his/her clothes as well as his/her briefs and tears his/her briefs. CNA FF said the resident should be clean and odor free. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed: -Severe impairment; -Required substantial/maximal assistance with shower/bath; -Required supervision with personal hygiene; -Required partial/moderate assistance with toileting; -Rejection of Care: Behavior of this type occurred one to three days; -Occasionally incontinent of bladder; -Frequently incontinent of bowel; -Diagnoses included heart disease, high blood pressure, high cholesterol, peripheral vascular disease (PVD, poor circulation), diabetes, dementia and depression. Review of the resident's care plan, in use at time of survey, showed: -Focus: Resident has an ADL self-care performance deficit related to dementia and weakness; -Goal: Resident will maintain current level of function through the review date; -Interventions: Limited assist in bathing/showering and personal hygiene. Supervision with bed mobility, dressing, eating, toilet use, and transfer. Observations, showed: -On 3/7/25 at 10:15 A.M., the resident sat on his/her bed. A strong urine and body odor was noted; -On 3/10/25 at 3:15 P.M., the resident sat on his/her bed. A strong urine and body odor was noted; -On 3/11/25 at 10:54 A.M., the resident lay on his/her bed. A strong urine and body odor was noted; -On 3/11/25 at 12:20 A.M., the resident laid on his/her bed. A strong urine and body odor was noted. A heavily soiled bed mat was thrown across the foot rail of the resident's bed. It was covered with deep yellows spots/stains. Some appeared to be wet as well as dry. During an interview on 3/11/25 at 12:20 P.M., CNA OO said he/she worked the day shift. He/She was familiar with the resident and worked with him/her but was not assigned to him/her today. He/She said the room smelled like strong urine. CNA OO pointed to the bed mat, and said the smell could have possibly came from it. He/she said he/she would not touch it with his/her bare hands because it may not have been clean. The resident gets his/her showers, but most of the times, he/she refused them. The resident's favorite line was that his/her family member would be there and they would do it. The resident could dress him/herself so sometimes he/she may get something out of his/her dirty linen and put it back on. The linen is changed at least twice a week when the residents are showered on shower days and when they are messed up. During an interview on 3/10/25 at 11:08 A.M., Licensed Practical Nurse (LPN) A said residents get showers twice a week. If a resident refused their showers, he/she would notify the Assistant Director of Nursing (ADON), document it on the shower sheet and notify the family. During an interview on 3/10/25 at 12:08 P.M., LPN B said residents receive showers twice a week. If a resident refused, he/she would document it and notify the physician and family. 4. During an interview on 3/11/25 at 3:41 P.M., the Director of Nursing (DON) said she expected residents to be clean, dry and odor free. She was not aware of any issues with towels not being available. She expected residents to receive a shower at least twice a week.

Based on observation, interview and record review, the facility failed to ensure a motorized wheelchair was in working order after it was reported to facility staff that there were broken or missing parts (Resident #29). The sample was 18. The census was 79. Review of the facility's Maintenance Work Orders policy, dated 10/24/22, showed: -Purpose: To protect the health and safety of residents, visitors, and Facility Staff; -Policy: Maintenance work orders shall be completed in an effort to sustain maintenance services as a priority; -Procedure: To enable the Maintenance Department to prioritize tasks PE - 02 - Form A - Work Order Form or other similar document will be filled out and forwarded to the Director of Maintenance; -Department directors/supervisors are responsible for completing such work orders and forwarding them to the Director of Maintenance; -Work order requests are reviewed during stand-up meetings; -Emergency requests are given priority; -Emergency requests should be delivered directly to the Director of Maintenance; -The Director of Maintenance will maintain completed Work Orders chronologically in a binder in the Director of Maintenance's office. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/4/25, showed: -Cognitively intact; -Impairment on both sides of the lower and upper extremity; -Uses motorized wheelchair; -Diagnoses of neurogenic bladder, wound infection, paraplegia and malnutrition. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has limited physical mobility related to paraplegia due to prior gunshot wound; -Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury; -Interventions: Locomotion: The resident uses a motorized wheelchair independently; -Provide supportive care, assistance with mobility as needed. Document assistance as needed. During observation and interview on 3/10/25 at 11:35 A.M., the resident said he/she wanted his/her wheelchair fixed. He/She reported it to staff in the past two months. The left arm rest was broken off as well as the padding that rests against the back of the left arm. The resident pulled out a large bag of materials that came from the wheelchair. He/She said the parts are in the bag. The right wheel was busted open. There was approximately an 8 inch opening to the back of the wheel, exposing the inside material of the wheel. The resident said the battery does not work. It does not hold a charge. If it is not fully charged before taking it off the charger, the motorized wheelchair will not work or will stop working. It just dies. The resident had the motorized wheelchair for over a year. He/She was shot in the left arm, so he/she has muscle spasms. Since he/she cannot use the left arm rest, he/she had to rest his/her arm on his/her lap. It is uncomfortable. He/She also uses the foot board of his/her bed in place of the left arm rest to aid in positioning or transferring self from wheelchair to bed. The wheel makes the motorized wheelchair wobbly when in use. During an interview on 3/10/25 at 11:45 A.M., Certified Nurse Aide (CNA) CC said he/she reported the wheelchair on the resident's behalf during the time the resident reported it. He/She spoke to therapy, found the manufacturer book, and called them. The manufacturer company said they would only supply parts, not fix it. He/She told therapy what he/she was told, but they did not follow up. During an interview on 3/10/25 at 3:29 P.M., Physical Therapist Assistant (PTA) DD said if a resident had broken parts or missing parts to the wheelchair, they would do an evaluation. Therapy would help as a third party. They can also go to maintenance to see if they are able to help. They can go through Social Services, so they can direct them to a new chair. If the resident was in therapy, they would order it. He/She believed the resident's wheelchair was brought to their attention this past fall or winter. They tried to figure out who the manufacturer was. The resident did not have insurance with therapy. The resident had the wheelchair before he/she was admitted . They did not know who to call about the chair, either the manufacturer or the company that gave him/her the wheelchair, but the resident could not find it and did not have information for them. They tried to get ahold of the company on the resident's behalf. The last director was taking care of it, but he/she was not there anymore. During an interview on 3/11/25 at 3:36 P.M., the Social Services Director said he/she received the manufacturer book from the resident. The resident said it was under warranty and it needed to be fixed. He/She believed maintenance looked at it too, but could not find out what was wrong with it. He/She did not remember the arm rest was broken off and did not remember if it was like that back then. During an interview on 3/11/25 at 7:49 A.M., the Maintenance Director said it was not reported to him the resident had a wheelchair that needed repairs. If a resident needed a repair, they would check to see if the wheelchair was under warranty because he did not want to repair or mess with it if it messes up the warranty. He would also contact corporate to check what he would be able to do and ensure it was safe to make repairs on the wheelchair. During an interview on 3/11/25 at 12:35 P.M., the Director of Nursing (DON) said the resident comes to her office and he/she never mentioned anything about his/her wheelchair. The DON never noticed anything wrong with the wheelchair. If a resident needed repairs to their wheelchair, the DON would put it in TELs (web-based technology that helps with various aspects of building operations) and alert maintenance which alerts their phone. It could be therapy or the manufacturer that makes repairs. She expected staff to assist with helping the resident with fixing the wheelchair and give options to the resident on repairing the wheelchair. It is not appropriate for a resident to have a broken wheel or missing arm rests. She expected staff to ensure the resident was safe in the wheelchair. 40291

40291 Based on interview and record review, the facility failed to ensure residents who received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly) services had written communication with the dialysis center. The facility identified two residents who received dialysis services. Two residents were sampled (Resident #62 and #53), and issues were found with both residents. The sample was 18. The census was 79. Review of the facility's Dialysis Care policy, dated 10/24/22, showed: -Purpose: To provide care for residents diagnosed with renal disease requiring ongoing dialysis treatments; -Policy: -The facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing all non-dialysis needs of the resident including during the time period when the resident was receiving dialysis; -The facility maintains a contract with a dialysis service provider which addresses communications between the facility and the provider; -The facility will arrange dialysis care for residents as ordered by the attending physician; -Procedure: -Dialysis arrangements: -The facility will arrange for dialysis care for such residents as ordered by the attending physician; -The facility will arrange transportation to and from the dialysis provider, as well as for meals (if necessary), medication administration, and a method of communication between the dialysis provider and the facility; -Communication and Collaboration: -The nursing staff, dialysis provider staff, and the attending physician (dialysis staff) will collaborate on a regular basis concerning the resident's care as follows: -Nursing staff will communicate pertinent information in writing to dialysis staff which may include: -Any medication changes; -Any recent changes in condition; -The resident's tolerance of dialysis procedures; -The dialysis provider will communicate in writing to the facility: -The resident's current vital signs (blood pressure, pulse, respirations, and temperature); -Pre and post weight; and -Any problems encountered while the resident was at the dialysis provider; -Nursing staff may use NP-225-Form A- Nurse Dialysis communication record to convey information to the dialysis provider; -Documentation: -All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. Review of the facility's Matrix, received on 3/5/25, showed dialysis was not identified for Residents #53 and #62. 1. Review of Resident #62's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/25/24, showed: -admitted to the facility: 11/28/23; -Diagnoses included stroke, end stage renal disease (ESRD, chronic irreversible kidney failure), heart failure, diabetes, hypertension (high blood pressure), hyperlipidemia (high cholesterol), hemiplegia, or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles); -Special treatment and services received while a resident: Dialysis, left blank; Review of the resident's care plan, in use during the survey, showed: -Problem: Resident needs hemodialysis related to chronic kidney disease, end stage renal disease, dependence on renal dialysis at a local dialysis center. MTM transport and attends Mondays, Wednesdays, and Fridays with a chair time of 11:00 A.M.; -Goal: Resident will have no signs or symptoms (s/sx) of complications from dialysis through; -Interventions included: Do not draw blood or take blood pressure in arm with graft (permanent access point for dialysis). Monitor for dry skin and apply lotion as needed. Monitor labs and report as needed (PRN) any s/sx of infection to access site: Redness, swelling, warmth or drainage. Monitor/document/ report PRN for s/sx of the following: bleeding, hemorrhage, Bacteremia (bacteria in the blood), septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection). Monitor/document/report PRN new/worsening peripheral edema (swelling). Work with the resident to relieve discomfort for side effects of the disease and treatment. (Cramping, fatigue, headache, itching, anemia, bone, demineralization, body image change and role disruption.) Review of the resident's physician's order sheet (POS), dated March 2025, showed: -An order, dated 11/28/23, for dialysis on Mondays, Wednesdays, and Fridays with a chair time at 11:00 A.M.; -An order, dated 11/28/23, to monitor dialysis site right upper chest port dressing for drainage, bleeding, or signs and symptoms of infection. Notify physician of any changes every shift for ESRD. Report any drainage, bleeding or signs and symptoms of infection to dialysis provider and primary physician; -An order, dated 11/28/23, to monitor vital signs daily. Report any abnormalities to dialysis provider and primary physician every day and evening shifts every Monday, Wednesday and Friday. -An order, dated 9/24/24, enhanced barrier precautions related to dialysis; -An order, dated 2/5/25, for regular diet, regular texture, regular consistency. Review of the resident's medical record, showed dialysis communication sheets for the resident for 2/10/25, 3/5/25, and 3/7/25. Further review of the resident's medical record, showed no further written communication with the dialysis center. Review of the resident's progress notes dated 2/26/25 at 1:05 P.M., showed the resident left for dialysis with outside transport company. He/She was in no acute distress prior to transfer. The resident's access showed no signs or symptoms of infection, and no bleeding noted. Dressing to the access at right chest clean and dry. The resident's dialysis paperwork sent with him/her. During an interview on 3/6/25 at 12:38 P.M., the resident said he/she received dialysis treatment three times a week on Mondays, Wednesdays, and Fridays for ESRD. 2. Review of Resident #53's quarterly MDS, dated [DATE], showed: -Diagnosis included renal failure; -Special treatments and programs: Dialysis was not documented. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has renal failure and on dialysis at dialysis location on Monday, Wednesday, and Friday, 5:30 chair time; -Goal: Resident will have no signs and symptoms of complications relate to fluid overload; -Interventions: Dietary consult to regulate protein and potassium intake; -Give medications as ordered by physician; -Monitor lab reports of electrolytes and report to physician. Notify if serum potassium is over 5.5. Review of the resident's POS, dated March 2025, showed: -An order, dated 12/29/23, for regular diet, regular texture, liberal renal diet, no bananas or orange juice; -An order, dated 12/29/23, dialysis location, Monday, Wednesday, Friday at 5:30 chair time, first day of treatment 1/3/24; -An order, dated 10/3/24, enhanced barrier precautions related to dialysis; -An order, dated 10/29/24, to monitor bruit and thrill, signs and symptoms of infections, bleeding every shift; -An order, dated 2/7/25, to monitor dialysis site dressing for drainage, bleeding, or signs and symptoms of infection. Check bruit and thrill every shift. Report any drainage, bleeding or signs and symptoms of infection to dialysis provider and primary physician; -An order, dated 2/7/25, to monitor vital signs before and after dialysis treatment. Complete communication form, send with resident, collect form upon resident return. Report any abnormalities to dialysis provider and primary physician two times a day, every Monday, Wednesday and Friday. Review of the resident's progress notes, showed: -On 1/15/25, the resident went Leave of Absence (LOA) to dialysis this AM (morning); -On 2/21/25, the resident expressed concerns about his/her trips for dialysis. Social Services called transportation company and made his/her trips to dialysis to be indefinitely. Resident made aware. Review of the resident's medical record, dated 3/1/25 through 3/10/25, showed no dialysis communication sheets for dialysis appointments on 3/3/25, 3/5/25, and 3/7/25. 3. During an interview on 3/7/25 at 1:23 P.M., the Regional Nurse Consultant said if there were no dialysis communication sheets in the medical record, it was not completed. 4. During an interview on 3/11/25 at 12:35 P.M., the Director of Nursing (DON) and Regional Nurse Consultant said nursing was responsible for ensuring the dialysis communication sheets were completed. Nursing also addressed it in the nurse's notes. They would expect communication sheets to be in the medical record. The importance of the communication sheets was for nursing to know how the dialysis was tolerated and the condition the resident was in when returning to the facility.

Based on observation, interview and record review, the facility failed to provide an as needed (PRN) controlled pain medication, as ordered by the prescriber, to meet the needs of one sampled resident (Resident #38). The census was 79. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/25, showed: -Cognitively intact; -Required substantial/maximal assistance with shower/bath; -Occasional urinary incontinence; -Frequent bowel incontinence; -Diagnoses included heart disease, high blood pressure, traumatic brain injury, anxiety disorder and manic depression. Review of the resident's care plan, in use at time of survey, showed: -Focus: Resident is on pain medication therapy, opioid analgesics related to chronic neck pain, lower back pain, and right leg pain; -Goal: Resident will be free of any discomfort or adverse side effects from pain medication; -Interventions: Administer analgesic medications as ordered by physician. Review of the resident's order summary, dated 12/5/24, showed a physician order of oxycodone-acetaminophen (Percocet, used for moderate to severe pain) oral tablet 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for pain. Review of the resident's Medication Administration Record (MAR) for the month of March 2025, showed the ordered pain medication was last administered on 3/1/25 due to the resident's leg pain level of 8 (severe pain on a scale 0-10). During an interview on 3/5/25 at 12:50 P.M., the resident said he/she was in pain, but the Percocet medication was not available for a few days already. He/She likes to take it every six hours as ordered. He/She was told by the staff that they were waiting for the pharmacy to deliver the medication. He/She said Percocet was the only pain medicine that relieved his/her pain. The resident had an order for PRN Tylenol but said it did not do much with his/her pain. During an interview on 3/10/25 at 10:40 A.M., the resident said he/she had not received the Percocet yet due to unavailability. He/She asked the nurse every day and was told there was no delivery from the pharmacy. During an interview on 3/10/25 at 10:45 A.M., Licensed Practical Nurse (LPN) A said they were still waiting for the Percocet to be delivered by the pharmacy. He/She said there was no refill order from the physician, and usually took longer due to the resident had an outside provider who prescribed the pain medication. LPN A said the physician and pharmacy were contacted and followed-up. The resident had alternative pain medications such as Tylenol and Clonazepam (used as a muscle relaxant). LPN A explained the situation to the resident. The resident refused Tylenol when offered. Review of the resident's records, showed no documentation the physician and pharmacy had been contacted regarding the Percocet. During an interview on 3/10/25 at 3:45 P.M., the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) said they were not aware the resident's medication ran out and the resident had been asking for it. During an interview on 3/11/25 at 10:39 A.M., the pharmacy technician said the resident's Percocet was last refilled on 2/20/25, for 30 tablets. The pharmacy did not do automatic refills for PRN medications. The pharmacy technician said the facility did not request for a refill until this morning of 3/11/25. During an interview on 3/11/25 at 10:45 A.M., the RNC said when PRN medications needed refills, staff should contact the physician so the prescription will be sent to the pharmacy. She expected staff to follow-up and document in the progress notes. She said it was the first time she was made aware of the issue. The resident did not report to her personally. The RNC said she will follow-up with the DON and would check the nurses' documentation of the resident's pain assessment. During an interview on 3/11/25 at 10:55 A.M., the resident said it had been about two weeks not receiving Percocet. He/She was told by the nurse the medicine was not delivered yet. During an interview on 3/11/25 at 10:59 A.M., the DON was not aware of the issue prior to today. She interviewed LPN A, who reported that the resident never complained of pain. The DON showed a copy of the MAR that showed resident's pain levels were documented as zeros. The Assistant Director of Nursing (ADON) was responsible for following-up with pharmacy for medication refills. The facility had been having issues with the pharmacy not delivering the medications as ordered. During an interview on 3/11/25 at 11:03 A.M., the ADON said the physician and pharmacy had been notified about the resident's Percocet and the medication was on its way to the facility. The floor nurses had to report to her when PRN medications were depleted. It was documented in the resident's record that the facility contacted the physician and pharmacy regarding the issue. The ADON was unable to show or provide documentation prior to 3/11/25. The narcotic sheet of the Percocet was not provided per request from the ADON. Observation and interview on 3/11/25 at 11:30 A.M., showed the resident was in the dining area with his/her head down on the table. He/She was having sciatic pain, especially in the left leg. The facility did not provide a heat/cold pack. He/She repositioned him/herself in the wheelchair to alleviate the pain. The resident said he/she did not want to run out of Percocet again. The facility and the pharmacy should make sure it would not reoccur. During an interview on 3/11/25 at 12:14 P.M., the Strategic Account Manager (SAM) and the Pharmacist Director said they used to partial-fill medications, but as of 3/6/25, the pharmacy will fill the entire prescription. The facility requested cart audits but there is no one in the area. The pharmacy is working on scheduling the audit. When the facility receives a new order, the order is entered into the facility's electronic health records. The pharmacy then receives the order and it will be processed. Controlled medication refills are filled 30 days at a time. If the controlled medication was a PRN medication, the pharmacy will send 30 tablets at a time. The facility can call or fax over controlled medication refills. If there are no refills left on the script, the pharmacy will call and fax the physician to try to obtain a new prescription. If the facility calls the pharmacy to request a refill, the pharmacy will tell the facility to contact the physician also. If the pharmacy does not hear back from the physician, they will reach out again. A prescription is good for 6 months. If a prescription had 90 tabs, the pharmacy would send 30 tablets at a time for a PRN order. When the medication is refilled, they will send out 30 more tablets if the refill was requested within 6 months. The pharmacy received Resident #38's prescription on 1/28/25. A refill was requested on 2/20/25, the pharmacy sent out 30 tablets. The pharmacy received a new script on 2/26/25 for 100 tablets. The facility did not request a refill until this morning and the medication was sent out today. During an interview on 3/11/25 at 3:41 P.M., the DON said residents are assessed for pain every shift. The DON expected the resident's narcotic pain medication to be available. On 3/12/25 at 11:06 A.M., the DON said the facility had Percocet available in their emergency kit if the resident needed it. There was a prescription for Percocet of 100 tablets that was sent to the pharmacy on 2/20/25. She said the facility requested for refills on 2/28/25 but was notified it was too soon for refills. The DON said she would provide documentation of the facility's communication with the pharmacy. No documentation was provided.

45083 Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, three errors occurred during medication administration for one resident (Resident #7), resulting in a 10% error rate. The census was 79. Review of the facility's Medication Administration Policy, dated October 24, 2022, showed: -Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law; -Nursing staff will keep in mid the seven rights of medication when administrating medications: the right medication, the right amount, the right resident, the right time, the right route, the right indication and the right outcome; -Additional considerations: the resident has right to know what the medication does; the resident has the right to refuse the medication (unless court ordered) and the rule of three, the licensed nurse administering medications will perform three checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR); - The resident's MAR will be reviewed for allergies and/or special considerations for administration including accepted professional standards and principles and vital sign parameters and lab results as appropriate; -Any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication; -The licensed nurse will chart the drug; time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR; -Whenever a medication is held for any reason, the licensed nurse will initial the appropriate area on the MAR and circle his/her initials. The licensed nurse will document the reason the medication was held on the back of the MAR; -The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. Review of the facility's Medication Error policy, dated 10/24/2022, showed: -Definition: the preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; -A medication error may be the administration or omission of medication to the wrong resident, at the wrong time, at the wrong dose, via the wrong route or which is not currently prescribed; -Errors related to the administration of medications or treatments will be reported to the Director of Nursing (DON) services, the attending physician, and the Administrator. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/28/25, showed: -Cognitively intact; -Diagnoses included heart failure, high blood pressure, and stroke. Review of the order summary report, showed: -A physician order dated 1/22/25: Aldactone 25 milligrams (mg), give 12.5 by mouth one time a day for congestive heart failure; -A physician order dated 7/2/24: Jardiance 10 mg, give 10 mg by mouth one time a day for heart failure; -A physician order dated 8/16/23: senna 8.6 mg, give 8.6 mg by mouth in the morning for constipation. Review of the MAR, dated 3/1/25 through 3/31/25, showed: - A physician order for: Aldactone 25 mg, give 12.5 mg by mouth one time a day for congestive heart failure; -A physician order for: Jardiance 10 mg, give 10 mg by mouth one time a day for heart failure; -A physician order for: senna 8.6 mg, give 8.6 mg by mouth in the morning for constipation. Observation on 3/6/25 at 8:40 A.M., showed the resident's Jardiance and Aldactone blister pack cards were empty. No refill cards were available in the cart. Certified Medication Technician (CMT) Q said he/she would place an order to the pharmacy and would notify the nurse. The CMT marked the code number 9 (indicated Other/See Progress Notes) with his/her initials in the MAR for the medications, Aldactone and Jardiance. The CMT did not obtain the medication senna 8.6 mg from the cart. He/She marked a check with initials in the MAR, indicating it was given. The CMT administered the other medications to the resident and did not inform the resident of the unavailable medications, Aldactone and Jardiance. During an interview on 3/6/25 at approximately 9:05 A.M., the resident said he/she never missed any doses of medications, unless he/she chose not to take them. His/Her medications were always available as ordered. He/She only refused the inhalers today but took all his/her pills. Review of the resident's nursing notes, dated 3/6/25 at 10:34 A.M., showed staff documented the pharmacy was called to reorder medications Jardiance and Aldactone and requested for stat run. Observation and interview on 3/7/25 at 11:40 A.M., showed one blister pack card each of Aldactone 25 mg and Jardiance 10mg located in the cart. Each card had one tablet taken out. CMT R said he/she administered those two medications that morning. CMT R said they used a stock bottle of senna 8.6 mg for the resident. There was not a bottle of senna in the cart. He/She thought someone took the bottle from the cart. CMT R used the bottle from the other cart. During an interview on 3/10/25 at 11:08 and 11:27 A.M. Licensed Practical Nurse (LPN) A said if the medications ran out and were not given as scheduled, they marked the MAR as not given, then called the physician and the pharmacy. When administering the medications, he/she asked the resident if they would take their medication, if the resident said yes, he/she would check the physician order, pop out the medication, administer the medication and document it. If the resident refused or did not take the medication, he/she would use the key code on the MAR, to enter a code to indicate the reason the resident did not take the medication. A blank on the MAR would indicate the medication was not administered or someone forgot to document it. If the code said see a nurses note there should be a corresponding nurses note. The MAR would automatically generate a progress note. If the medication was out of stock, he/she would check the e-kit to see if the medication was available. LPN A said the facility always had stock bottles of senna and it should always be available. If the medication was not available in the e-kit, he/she would document the medication was not administered, and notify the physician and responsible party (RP), and call the pharmacy to reorder the medication. If the physician /RP was notified it would be documented in the progress notes. If a stat run was requested, the medications were supposed to be delivered to the facility immediately, but the pharmacy never delivered stat orders. During an interview on 3/10/25 at 3:44 P.M., the Regional Nurse Consultant (RNC) said medications should be refilled before running out. The DON said if medications were not available, staff should call the physician to request an alternative if needed, then call the pharmacy. During an interview on 3/12/25 at 10:06 A.M., the pharmacy technician said the resident's Jardiance 10 mg medication was delivered to the facility on [DATE] at 6:32 P.M., The resident's Aldactone 25 mg medication was picked up by the pharmacy driver on 3/6/25 at 12:25 P.M. The pharmacy technician was unable to provide the actual time the medication was delivered. During an interview on 3/11/25 at 3:41 P.M. the Director of Nursing said she would expect for the medication rate to be less than 5% and for medications to be administered timely and per physician orders.

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors. The facility failed to ensure one resident's (Resident #11) treatment plan was transcribed on the physician order sheet. This failure resulted in one anti-seizure medication not being adjusted for 46 days. The sample was 18. The census was 79. Review of the facility's Physician Order policy, dated 10/24/2022, showed: -Purpose: this will ensure that all physician orders are complete and accurate; -Telephone orders: a licensed nurse will record telephone orders on the telephone order sheet with the date, time and signature of the person receiving the order or in the electronic health record (EHR); -The order is transcribed onto the physician's order form at the time the order is taken; -Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order; -Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for the discipline; -The policy failed to show how new orders are entered into the EHR when the Physician (MD)/Nurse Practitioner (NP) visited the facility. Review of the facility's Medication Error policy, dated 10/24/2022, showed: -Definition: the preparation or administration of medications or biologicals which is not in accordance with accordance with: the prescribers order, accepted professional standards and principles which apply to professionals providing services; -Accepted professional standards and principles include the various practice regulations in the state, and current commonly accepted health standards established by the national organizations, boards, and councils; -A medication error may be the administration or omission of medication: at the wrong dose; -Errors related to the administration of medications or treatments will be reported to the Director of Nursing (DON) services, the attending physician, and the Administrator. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/25, showed: -Cognitively intact; -Diagnoses included: dementia and seizure disorder. Review of the care plan, in use at the time of survey, showed: -Focus: resident is at risk for adverse side effects (ASE) of medications use as evidence by: resident takes medication with black box warning (highest safety warning), anti convulsant; -Goal: will not experience ASE of medication use through the review date; -Interventions: meds as ordered; -Focus: resident had an actual fall on 12/27/24; -Goal: resident will resume usual activities without further incident through review date; -Interventions: emergency room evaluation; medication adjustments. During an interview on 3/10/25 at 9:45 A.M., the resident said he/she knew his/her medications and sometimes staff omitted some of his/her medications or part of the dose. The resident said he/she took two pills to equal the dose, and staff would only administer one pill. If his/her seizure medications were missed he/she might have a seizure. About three or four months ago he/she had seizure blackouts. Review of the progress notes, dated 11/9/24 through 11/13/24 showed: -On 11/9/24 at 3:20 P.M., the nurse was called to resident room. Resident was noticed having seizure activity. Resident was coming around and went into another seizure, stayed with resident until resident was able to respond with telling his/her name and stated he/she wanted to go to bingo. Responsible party notified, and the doctor was called and stated to send the resident to the hospital. 911 was called and arrived. Resident said he/she did not want to go; -On 11/11/24 at 11:48 A.M., NP N note, chief complaint: resident evaluated for reports of seizure activity. Context: resident observed having seizure and facility reported resident refused to go to the hospital. Plan: increase Keppra (anti-seizure medication) to 1000 milligrams (mg) by mouth twice daily (BID); -On 11/13/24 at 10:50 A.M., NP N note, chief complaint: resident requested visit due to seizure activity. Context: resident request medication review as he/she believes he/she did not receive an increase in seizure medication as discussed. Plan: increase Keppra to 100 mg by mouth BID. Review of the Medication Administration Record dated 11/1/24 through 11/30/24, showed: -A physician order for: levetiracetam (Keppra) 500 mg give one tablet twice daily for anticonvulsant. Start date was 12/16/23; -Documentation showed the medication was administrated 11/1/24 through 11/30/24; -Keppra was not increased to 1000 mg BID on 11/11/24. Review of the MAR, dated 12/1/24 through 12/28/24, showed: - A physician order for: levetiracetam 500 mg give one tablet twice daily for anticonvulsant. Discontinue date was 12/27/24; -Documentation showed levetiracetam 500 mg was administered BID from 12/1/24 through 12/27/24; -A physician order for: Keppra 500 mg give two tablets by mouth BID for seizures. Start date was 12/28/24. Review of the resident's progress notes dated 12/27/24 at 10:20 A.M., showed at approximately 10:00 A.M., resident noted lying on the floor supine (lying on his/her back) in front of wheelchair. Alert and responsive. Resident was transferred into wheelchair with two assists. Hematoma (a pool of blood that has leaked out of a blood vessel and is trapped in the surrounding tissues) noted on left side of skull. Resident began to clonic seizure (rhythmic jerking movements of the arms and legs) immediately after transfer lasting two minutes. Resident then came to and was wheeled to nurse station for evaluation. 911 was called. Paramedics arrived to transfer resident to hospital at 10:15 A.M. Resident arrived at facility about 9:00 P.M. via ambulance accompanied by emergency medical service (EMS). Only change in orders was Keppra 500 mg take two tablets (1000 mg) BID. MD notified. During an interview on 3/10/25 at 9:45 A.M., the resident said his/her Keppra was increased in December after he/she returned from the hospital. During an interview on 3/11/25 at 9:19 A.M., NP M said NP N was no longer with the company. When NP N was at the facility, he/she placed orders in his/her plan of treatment, but did not enter the orders into the EHR. NP N was responsible for entering his/her orders into the system. The orders written in NP N's plan of treatment should have been placed into the system. During an interview on 3/10/25 at 11:05 A.M. Licensed Practical Nurse (LPN) A said the nurse or the unit manager entered the orders into the EHR. Some of the MDs/NPs would write a telephone order and give it to the staff to enter the order. Some would give the nurse a verbal order to enter into the system. During an interview on 3/10/25 at 12:08 P.M., LPN B said the MD/NP had access to the EHR and they entered their own orders. The nurse entered the lab orders into the lab computer and binder. During an interview on 3/11/25 at 3:41 P.M., the DON said she would expect for the orders listed in the NP's plan to be entered into the system. The NPs no longer enter their orders into the system. They write their orders on a piece of paper for the facility staff to enter into the system. The DON would expect for staff and providers to follow the facility's policies and procedures.

Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse. On the evening of 9/19/24, the resident became upset with Licensed Practical Nurse A (LPN A) when he/she removed the resident's oxygen concentrator from the room. The resident, who had diagnoses of anxiety and chronic obstructive pulmonary disease (COPD- a common lung disease that makes it difficult to breathe by restricting airflow in the lung), was observed following LPN A out of his/her room telling LPN A he/she needed the oxygen. The resident became angry, yelling and cursing, and hit LPN A in the face at least twice. LPN A forced the resident to the ground and placed a knee on top of the resident. After pulling the resident up to a standing position, LPN A forced the resident back to his/her room. LPN A then contacted the Director of Nurses (DON), who contacted the resident's psychiatrist, and received an order for a Haldol (an antipsychotic) injection. LPN A later entered the resident's room and administered the Haldol and Benadryl (antihistamine that can be used to induce sleep) while the resident was calm and no longer yelling, cursing or hitting. Five residents were sampled. The census was 89. The Administrator was notified on 10/1/24 at 1:37 P.M., of the Immediate Jeopardy (IJ) past non-compliance, which occurred on 9/19/24. The facility provided training and in-servicing that began on 9/20/24 and ended on 9/21/24, for all staff regarding their policies on Abuse and Neglect, Unnecessary Restraints, and De-escalating Situations. The IJ was corrected on 9/21/24. Review of the facility Abuse Prevention and Prohibition Program policy revised on 10/24/2022, showed: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff; -The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems -Procedure: -The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the Facility; -Covered individuals will be trained through orientation and on-going training sessions, no less than annually, on the following topics included: -Abuse prevention; -Identification and recognition of signs and symptoms of abuse/neglect; -Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. The Facility involves qualified psychiatrists and other mental health professionals to help Facility Staff manage difficult or aggressive residents. Identification and recognition of signs of burnout, frustration and stress that may lead to abuse. Review of the facility Behavioral - Management policy revised on 8/2022, showed: -Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. To ensure that facility staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care; -Policy: The concept of behavior management is an interdisciplinary process. The key components of this process are: Identifying residents whose behaviors may pose a risk to self or others. Developing individual and practical care strategies based on assessed needs. Implementing the behavior management program. Ongoing assessment, monitoring, and evaluation of the effectiveness of psychoactive drugs; -The goal of any behavior management process is to maintain function and improve quality of life. The goal of the interdisciplinary team (IDT) is to promptly identify behavior management issues and develop an effective management program; -It is important to understand that behavior management is not behavior modification. Behavior management means the interdisciplinary team seeks to accommodate the resident with behavioral problems as much as is practical in the facility; -When a resident displays adverse behavioral symptoms (e.g., crying, yelling, hitting, biting etc.), Licensed Nursing Staff will assess the behavioral symptoms to determine possible causal factors, contact the Attending Physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s); -The facility must provide necessary behavioral health care and services which include: Ensuring necessary care and services are person centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Ensure that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. Providing an environment and atmosphere that is conducive to mental and psychosocial well-being. Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated; -Assess Casual Factors: In assessing the resident for potential casual factors, Licensed Nursing Staff will consider the following factors and document their findings in the medical record: -Psychosocial or emotional stressors (e.g., change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, lack of support system); - Medical conditions that require treatment (e.g., diabetes mellitus (high or low blood sugar levels), heart disease, COPD, infection); -Implementation of Interventions to Alleviate Possible Casual Factors: Possible non-psychotherapeutic drug interventions to consider, include, but are not limited to: -Environmental conditions - approach resident calmly, address resident by name, speak in clear tones (do not yell or act excited), touch the resident in a comforting manner if appropriate, use short simple sentences; -Psychosocial stressors - determine resident's preferred routine, offer comfort items, determine cause of frustration, determine if resident is upset regarding treatment by staff or other residents and address concern; - Medical Conditions - check oxygenation if COPD; -In trying to manage the behavioral problem: Work to build a positive, trusting relationship with the resident. Use effective verbal and non-verbal communication techniques. Encourage independence of the resident. Avoid arguing, having yes/no battles, or [NAME] with the resident. Obtain physician order if indicated to include but not limited to the use of physical or chemical restraints. Redirect or divert the resident's attention to a positive topic, activity, or object. Review of the facility De-Escalating policy, undated, showed: -Importance of De-Escalating: It is important that we de-escalate issues. You can do this by: 1. Recognizing and assessing the situation; 2. Responding calmly and showing concern; 3. Listening; 4. Show respect; 5. Avoid confrontation, remove triggers; -Ensure all residents are removed and safe; -Report all violence immediately to the Administrator/Director of Nursing (DON). Review of the facility LPN job description, undated, showed: -Responsibilities (include): Record resident's medical history accurately. Observe residents under treatment to identify progress, side-effects of medications, etc. Monitor resident's condition. Provide emotional and psychological support when needed. Communicate with residents' family or friends to provide advice, comfort and release instruction. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 7/22/24, showed: -Clear speech, distinct intelligible words; -Makes Self Understood. Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Ability to Understand Others. Understanding verbal content, however able: Understands, clear comprehension; -Moderately impaired cognition; -Physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited. -Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited; -Rejection of Care: Behavior not exhibited; -Mobility Devices: Wheelchair; -Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space: Supervision or touching assistance; -Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as resident completes activity; -Diagnoses of Parkinson's disease (a chronic, progressive brain disorder that causes movement problems, stiffness, and other symptom), anxiety, depression, psychotic disorder (other than schizophrenia), asthma, COPD, or chronic bronchitis, or chronic lung diseases (e.g., chronic bronchitis and restrictive lung diseases such as asbestosis), and respiratory failure; -Respiratory Treatments: Oxygen therapy - blank. Review of the resident's care plan, located in the electronic healthcare record (EHR), showed: -9/17/24, Focus: Resident has emphysema (COPD). Goal: Resident will be free from signs/symptoms of respiratory infections. Interventions: Head of bed elevated or out of bed upright during episodes of difficulty breathing. Monitor for difficulty breathing on exertion. -6/4/24, Focus: Resistive to care related to anxiety and psych diagnosis. Interventions: Allow resident to make decisions about treatment regime, to provide sense of control. Educate resident/family of the possible outcomes of not complying with treatment or care; -2/5/24, Focus: Potential to be verbally aggressive related to mental/emotional illness. Interventions: Administer medications as ordered. Assess resident's understanding of the situation and allow time for resident to express self and feelings towards the situation. Review of the resident's physician's order sheet (POS), located in the EHR showed: -8/11/24: Tiotropium Bromide Monohydrate (a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs) 1 capsule inhale orally one time a day for COPD; -9/4/24: Ipratropium-Albuterol solution (bronchodilators) inhale orally every 6 hours as needed (PRN); -9/4/24: Lorazepam (antianxiety) give 0.25 mg by mouth every 4 hours PRN; -9/10/24: Amitriptyline (antidepressant) 25 mg. Give 2 tablets at bedtime for insomnia; Review of the resident's physician's order sheet (POS), located in the EHR showed on 9/4/24, the resident may have Hospice consult due to failure to thrive; Review of the resident's Hospice Notification letter, dated 9/13/24, showed the resident began Hospice services on 9/4/24. Review of the resident's physician's order sheet (POS), located in the EHR showed no order for oxygen 2-3 lpm prior to 9/21/24, and no order to check the resident's oxygen saturation prior to 9/23/24. During a telephone interview on 10/8/24 at 12:55 P.M., the resident's family said the resident had used oxygen on and off since he/she had been at the facility. During an interview on 9/27/24 at 11:00 A.M., Resident #2 lay in bed with oxygen infusing per nasal cannula. The resident said a few nights ago, LPN A said he/she did not need his/her oxygen concentrator and took it away which made the resident mad. The resident followed LPN A into the hall and he/she hit LPN A in the face two times. LPN A put his/her arm around the resident's head and took him/her to the floor. Being forced to the floor hurt, but he/she was not injured. After being on the floor for about a minute, LPN A let the resident up and made him/her go back to his/her room. He/She told the DON the next day about what happened. The DON said it wouldn't happen again and the Administrator was investigating what happened. He/She had not seen LPN A since that night. He/She was afraid of LPN A now and did not want to see him/her again. The resident's roommate saw what happened. During an interview on 9/27/24 at 11:27 A.M., Resident #1 said he/she was in his/her room when he/she heard the resident hollering from the hall. He/She stepped into the hall and saw the resident on his/her back on the floor. LPN A had his/her knee on the resident's chest. There were other staff present but he/she did not see them trying to break up what was going on. LPN A seemed to be mad, yelling and telling the resident to stay down and he/she was going to take his/her oxygen concentrator. Resident #1 went back inside of the room while the resident was still on the floor. Review of the resident's progress note's, located in the EHR, showed, LPN A documented: -9/19/24 at 7:46 P.M.: Resident noted to be acting inappropriately this evening and this nurse attempted to educate resident on not changing the settings of how much oxygen is delivered via nasal cannula. Resident is noted to have oxygen saturation level of 99% (normal range is 95-100%) on room air. Resident insists that he/she be allowed to wear the supplemental oxygen and was ordered to have PRN oxygen at 2-3 lpm. Resident has been observed turning up the oxygen to 5 lpm. Resident has been educated and advised not to do this and continues to turn the oxygen up. Since resident does not appear to be in respiratory distress and has an oxygen level of 99% on room air, a decision was made to remove the oxygen concentrator from resident's room. Resident followed this nurse out of his/her room into the hallway. Resident's brief fell off as he/she was walking. This nurse turned and attempted to assist resident replacing his/her brief and resident swung and hit this nurse several times. Staff members present in the hallway at the time immediately intervened and assisted this nurse. Resident was then taken to his/her room and this nurse exited the resident's room to follow per facility protocol. When this nurse returned to the resident's room this nurse was notified that the resident had hit his/her roommate in the face. The resident was noted to be standing in the doorway of his/her room again with no brief on. Staff assisted to place appropriate articles of clothing on the resident and the DON and Administrator were notified. Both residents were separated for safety. -LPN A did not document if the resident's physician or hospice had been consulted prior to removing the resident's oxygen concentrator. During an interview on 9/27/24 at 9:13 A.M., CNA D said he/she worked on the evening of 9/19/24. CNA D witnessed LPN A take the resident's oxygen concentrator out of his/her room. The resident followed LPN A out of the room and into the hall. LPN A took the oxygen concentrator to the nurse's station, but the resident stopped halfway down the hall. The resident was telling the nurse he/she could not breathe without the oxygen concentrator. The resident was yelling and cursing at LPN A. LPN A walked back to the resident who was still standing in the hall and they were facing each other. LPN A was holding the resident's hands to prevent the resident from hitting him/her. He/She was standing right there and was trying to get the resident to go back to his/her room, but the resident refused to go back. The resident's incontinent brief fell down, LPN A bent down and pulled it back up. That's when the resident punched LPN A in the face. LPN A put one of his/her arms behind the resident's head, then placed his/her hand on the resident's face and pushed the resident backwards and onto the floor. He/She did not hear a thud when the resident reached the ground. While on the ground, the resident was on his/her side and LPN A used one hand to hold the resident's hand down, and had a phone in his/her other hand. LPN A placed his/her knee on top of the resident to hold the resident down. The resident was still cursing. LPN A stood up and the resident went from his/her side to his/her back. LPN A bent down, placed his/her hands underneath the resident's armpits from behind the resident and pulled the resident up to a standing position. LPN A then let the resident go, but the resident stumbled. LPN A placed his/her hands back under the resident's armpits and dragged the to the resident's room and put the resident in bed. The resident was kicking and screaming and did not want to go to his/her room. No one at the facility had inserviced him/her on resident take down techniques. He/she sent the DON a statement that same evening. Review of CNA D's written statement, undated and unsigned (the CNA typed his/her name at the bottom of the statement), showed he/she was standing in the hallway when the resident followed LPN A into the hall. When the resident walked up on LPN A he/she swung and hit LPN A and called him/her a racial slur. LPN A walked away and said the resident can't hit people and he/she was going to call the doctor. After LPN A walked back up, the resident stated that he/she was going to hit LPN A again and LPN A said the resident had to stop. When LPN A bent down and came back up, the resident punched LPN A in the mouth and LPN A took the resident down to the ground. During an interview on 9/27/24 at 10:12 A.M., CMT E said he/she worked on the evening shift on 9/19/24. CMT E saw LPN A take two oxygen concentrators from the resident's room to the nurse's station and lock them up. The resident followed LPN A out into the hall and stopped in the hall about two or three doors away from his/her room, which was about halfway to the nurse's station. This surprised him/her because he/she had never seen the resident walk that far without assistance before. The resident was angry. He/She thought the resident was beginning to calm down while LPN A was at the nurse's station. LPN A walked from the nurse's station to where the resident was standing, and LPN A and the resident began yelling at each other. LPN A told the resident he/she did not need his/her oxygen concentrator because his/her oxygen saturation level was 98%. When the resident's incontinence brief fell down, LPN A bent down to pull the brief back up and that was when the resident hit LPN A twice in the face. LPN A was upset and tried to stop the resident from hitting him/her. CMT E tried to get LPN A to allow him/her to help de-escalate the situation, but LPN A would not allow CMT E to help. LPN A said no he/she had this. After the resident hit LPN A, LPN A placed one arm around the back of the resident's neck and placed his/her other hand on the resident's face. LPN A pushed the resident backward and took the resident to the floor. This all escalated quickly and it looked like LPN A and the resident were in tussle. The resident was on his/her back on the floor and LPN A put his/her knee on the resident's chest telling the resident to calm down. The resident was yelling at LPN A to get off of him/her. The resident was on the floor about 30 seconds. LPN A got up and told the resident he/she was going to his/her room. The resident sat up at that time and LPN A went behind the resident, placed his/her hands underneath the resident's armpits and lifted the resident up to a standing position. LPN A forced the resident to his/her room and put the resident in bed. He/She reviewed his/her statement where it showed the resident fell to the floor and said that was not correct. LPN A forced the resident to the floor. He/She had never seen the resident punch anyone in the past. As far as CMT E was aware, the facility did not train staff on resident take down techniques. Review of the resident's progress note's, located in the EHR, showed, LPN A documented: -9/19/24 at 7:46 P.M.: A call was placed to the Psychiatrist and new orders received for PRN medication, as per medication administration record the medication was administered as tolerated with staff assistance. No further concerns noted at this time. Review of the resident's physician's order sheet (POS), located in the EHR showed no documentation of a one-time order dated 9/19/24 on the POS for Haldol (antipsychotic) 5 milligrams (mg) intramuscular (IM) or Benadryl (antihistamine that can be used to induce sleep) 25 mg by mouth (PO). During an interview on 9/27/24 at 9:13 A.M., CNA D said a short time after Resident #2 was taken to his/her room by LPN A, CNA D was in the room when LPN A came in and gave the resident an injection. The resident was not combative at that time. The resident told LPN A he/she could give the resident the injection but it was not going to work. LPN A gave the resident the injection at that time. CNA D said he/she did not think any of this had to happen had LPN A not taken the resident's oxygen concentrator away. During an interview on 9/27/24 at 10:12 A.M., CMT E said he/she walked into the resident's room after LPN A made the resident get into bed, but before the resident was given an injection. The resident was calm at that time, was laying on top of his/her bed. The resident took his/her evening medications from CMT E with no problems. He/She did not think the resident needed an injection at that point. He/She was not present when LPN A came back and gave the resident the injection. Review of the resident's Psychiatrist written statement dated 9/27/24, showed: This is to confirm that we discussed on 9/19/24 the status of the behavior of the resident, who in the midst of the manic episode demonstrated exacerbation of psychosis, and as a result struck a nurse several times in the hallway with other residents around. Order for temporary manual hold were given as well as Haldol 5 mg IM and Benadryl 25 mg by PO. This was effectively administered. During a telephone interview on 9/30/24 at 2:52 P.M., the resident's Psychiatrist who wrote the note dated 9/27/24, said he recalled a nurse calling him but was not sure who. The nurse told him the resident was swinging at staff and out of control. The nurse did not tell him the resident's oxygen concentrator had been removed against the resident's wishes causing the resident to get upset. Based on that information it seemed like the resident's behavior was provoked and not due to a manic episode. Had he been aware of that he would not have ordered the Haldol IM or Benadryl. He probably would have recommended the nurse give the oxygen concentrator back to the resident. If the resident was not agitated when the nurse went to give the Haldol IM and the Benadryl, the nurse should have withheld the medications. Review of the facility investigation dated 9/19/24 and completed by the Administrator, showed: - Name of Alleged Abuser: Licensed Practical Nurse A; -Initial Investigation: Resident #2 is diagnosed with multiple conditions, including but not limited to acute and chronic respiratory failure, COPD, psychotic disorder with delusions, and Parkinson's disease with dyskinesia (the inability to control movements). Cognition is moderately impaired. On September 19, 2024, the Administrator was notified by the DON about an evening incident involving Resident #2 and LPN A, during which Resident #2 struck LPN A on the head several times. The Administrator was also notified Resident #2 attempted to hit his/her roommate; -Initial Intervention: The resident was put on 1:1 supervision. Roommates were separated. Staff members were questioned. Residents were interviewed. Facility wide Abuse and Neglect in-servicing was conducted. -Conclusion of facility investigation: The investigation concluded that the resident struck LPN A several times out of frustration after his/her oxygen concentrator was removed. Witnesses stated LPN A held the resident's arms to avoid being struck, while trying to assist the resident with his/her brief before guiding the resident back to his/her room. The resident also attempted to make contact with his/her roommate on his/her face. To prevent potential issues, the resident's room assignments were adjusted, and staff continued to monitor the resident closely. No further incidents have been reported since. All residents' feel safe at the facility. LPN A acted in self-defense after being hit multiple times. The IDT team questions if LPN A acted without incorporating all possible de-escalation tactics that could have avoided the need for restrain. For this reason, LPN A will be terminated. In this case the question begs as to why LPN A did not remove himself/herself from the scene and allow another employee an attempt at calming the resident down. During an interview on 9/27/24 at 11:45 A.M., CNA C said he/she was not present when the incident between the resident and LPN A occurred. He/She had taken care of the resident several times. The resident was alert and oriented. He/She had never seen the resident hit anyone before. During a telephone interview on 10/1/24 at 6:42 A.M., LPN I said he/she worked the night shift on 9/19/24 and replaced LPN A. During shift report, LPN A did not say anything to him/her about what had happened on the evening shift with the resident. The resident had been using the oxygen for quite a while. The resident could walk short distances. The facility trained staff to de-escalate tense situations. They did not train staff to do resident take downs and it was not part of their policy as far as he/she knew. LPN I would not have taken the resident to the floor. He/She would have just walked away until the resident calmed down. He/She would not have removed the resident's oxygen without speaking to the physician first. During an interview on 10/1/24 at 1:54 P.M., LPN K said he/she would not have removed the resident's oxygen concentrator without first speaking to the physician. He/She would not have confronted the resident about the oxygen. If a resident hit him/her, he/she would remove himself/herself from the situation. The facility provided in-services on de-escalation techniques but not resident take downs. LPN K would not have tried to take the resident down to the floor. He/She would not force a resident to go to their room if the resident was not willing to go. LPN K would not have given the resident the Haldol IM and Benadryl if the resident had calmed down and no longer needed it. During an interview on 9/30/24 at 2:30 P.M., the MDS/Care Plan Coordinator said she had worked at the facility since 8/22/24. She was not sure about the resident's background, but as far as she was aware, the only physical altercation the resident had been involved in was with LPN A on 9/19/24. She thought an intervention to that situation would have been for LPN A to have backed off when he/she knew the resident was upset and allowed the resident to calm down. During an interview on 9/30/24 at 3:25 P.M., CNA G said he/she worked the same hall where the resident resided but was not assigned to care for the resident on the evening of 9/19/24. LPN A took the resident's oxygen concentrator out of the resident's room. The resident was standing in the hall. LPN A went down the hall and told the resident he/she could not turn his/her oxygen all the way up. That was when the resident hit LPN A. He/She saw LPN A put the resident onto the floor but it did not appear harsh. He/She did not see LPN A hold the resident's hands down. CNA G did see LPN A put his/her knee on the resident's back. He/She was not sure if LPN A forced the resident into his/her room or not because everything he/she saw was from the nurse's station and there were other staff in the hall at the time. During a telephone interview on 10/4/24 at 10:20 A.M., LPN A said the resident had two oxygen concentrators in his/her room, and was using one of them on the evening shift of 9/19/24. The resident was turning his/her oxygen up to 5 lpm when his order was for 2-3 lpm. The resident's oxygen saturation level was 99% on room air so LPN A decided the resident did not need the oxygen. LPN A told the resident he/she did not need the oxygen or he/she would hyperinflate his/her lungs. LPN A did not consult the resident's physician prior to removing the oxygen concentrators out of the resident's room. When he/she removed the concentrators, the resident followed him/her into the hall. The resident was able to walk, but used a wheelchair for long distances. The resident did not object that he/she removed the oxygen concentrators. The resident was not mad, did not yell or curse. LPN A continued to the nurses' station and put the concentrators in the storage room. The resident was standing in the hall about halfway between the resident's room and the nurse's station when the resident's incontinent brief fell down. He/She walked back to the resident and pulled the resident's incontinent brief up. That's when the resident hit him/her. The resident was not yelling or cursing at LPN A, and he/she was not yelling at the resident. LPN A said he/she had been in-serviced at the facility on de-escalation techniques, but not take-down techniques for residents with behavioral issues. He/She did not attempt de-escalation techniques like walking away from the resident because the resident was swinging on him/her. There were other staff in the hall but no one offered to help de-escalate the situation. LPN A's first response was to do a takedown of the resident, not de-escalate. He/She placed one hand on the resident's back and one hand on the resident's chest. He/She pulled the resident forward and the resident went down to his/her knees, then onto his/her stomach. He/She did not put his/her knee on the resident to keep him/her down. The resident was not angry or cursing while on the floor. The resident was on the floor for less than a minute when he/she helped the resident to stand up. He/She did not pull the resident up by placing his/her hands under the resident's armpits. He/She did not drag the resident backwards to his/her room or force the resident to go to his/her room. The resident was calm once he/she stood up and he/she walked with the resident back to his/her room and the resident got into bed. The resident was calm and no longer swinging at him/her at this time. After he/she left the resident's room, LPN A placed a call to the resident's physician and Psychiatrist. He/She also called the DON and left a message for the resident's family. LPN A told the DON he/she put the resident onto the floor because the resident had hit him/her. The DON told LPN A to document what happened and to monitor the resident to make sure he/she was alright. LPN A forgot to document about forcing the resident onto the floor. He/She did not speak to the resident's psychiatrist; the DON spoke to the psychiatrist. She called LPN A with the orders for the Haldol IM and Benadryl. When

Based on interview and record review, the facility failed to immediately notify the Department of Health and Senior Services (DHSS) as required by state and federal regulations, when an allegation of staff to resident abuse was made. On the evening shift of 9/19/24, Licensed Practical Nurse (LPN) A forced a resident (Resident #2) onto the floor, held the resident's hands down and placed his/her knee on the resident to keep the resident on the floor. After pulling the resident up off the floor and to a standing position, the LPN forced the resident to go to his/her room. The abuse was witnessed by nursing staff on the unit and a nurse aide provided a statement to the Director of Nursing showing the resident was took to the ground by LPN A, however, clarification was not sought until the evening of 9/20/24, when staff at the nurses' station were overheard discussing LPN A holding the resident's hands down and forcing the resident onto the floor. The facility began an investigation on the evening shift on 9/20/24, however, did not notify DHSS of the allegations. Five residents were sampled. The census was 89. Review of the facility Abuse Prevention and Prohibition Program policy revised on 10/24/2022, showed: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: -Investigation: -The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, or criminal acts; -Reporting/Response: Facility Staff are Mandatory Reporters: -All covered individuals will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be physical abuse, isolation or other treatment resulting in physical harm or pain or mental suffering. The facility will not impede or inhibit a Facility Staff member's reporting duties, nor will Facility Staff be reprimanded or disciplined for reporting abuse. The facility has a non-retaliation policy for good faith reporting. Failure to report suspected or known abuse may result in legal action against the individual(s) withholding information; -Administrator, or designee, as Abuse Coordinator: In order to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or designee, shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities. Facility Staff will report known or suspected instances of abuse to the Administrator, or his/her designee; -The Facility will report known or suspected instances of physical abuse, and criminal acts to the proper authorities by telephone or through confidential Internet reporting tool as required by state and federal regulations. Immediately, but no later than 2 hours after informing the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. No later than 24 hours after forming the suspicion - if alleged violation does not result in serious bodily injury to the state survey agency adult protective services, law enforcement, and the Ombudsman. Reporting requirements are based on real clock time, not business hours. The Administrator will provide the state survey agency, law enforcement and the Ombudsman with a copy of the investigative report within 5 days of the incident. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 7/22/24, showed: -Adequate hearing; -Impaired vision, sees large print, but not regular print in newspapers/books; -Clear speech, distinct intelligible words; -Makes Self Understood. Ability to express ideas and wants, consider both verbal and non-verbal expression: Understood; -Ability to Understand Others. Understanding verbal content, however able: Understands, clear comprehension; -Moderately impaired cognition; -Behavioral Symptoms: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited; -Diagnoses of Parkinson's Disease (chronic, progressive neurological disease that affects the central nervous system and causes movement problems), anxiety, depression, psychotic disorder (other than schizophrenia), asthma, chronic obstructive pulmonary disease (COPD), or chronic lung diseases (e.g., chronic bronchitis and restrictive lung diseases such as asbestosis), and respiratory failure. Review of the resident's care plan, located in the electronic healthcare record (EHR), showed: -9/1/23, Focus: Activity of daily living self-care performance deficit related to Parkinson's. Interventions: Transfer with total assist using sit to stand (a machine used to transfer a resident that can bear weight); -11/9/23, Focus: Limited physical mobility related to Parkinson's and behaviors. Interventions: Ambulation (walking) supervision with short distances. Independent in wheelchair. Provide supportive care, assistance with mobility as needed; -2/5/24, Focus: Potential to be verbally aggressive related to mental/emotional illness. Interventions: Administer medications as ordered. Assess resident's understanding of the situation and allow time for resident to express self and feelings towards the situation; -5/10/24, Focus: Impaired cognitive function related to Parkinson's. Interventions: Administer medications as ordered. Communicate with resident/family regarding resident's capabilities and needs; 6/4/24, Focus: Resistive to care related to anxiety and psych diagnosis. Interventions: All resident to make decisions about treatment regime, to provide sense of control. Educate resident/family of the possible outcomes of not complying with treatment or care; -9/17/24, Focus: Resident has emphysema/COPD. Goal: Resident will be free from signs/symptoms of respiratory infections. Interventions: Head of bed elevated or out of bed upright during episodes of difficulty breathing. Monitor for difficulty breathing on exertion. Review of the resident's progress note's, located in the EHR, showed, LPN A documented: -9/19/24 at 7:46 P.M.: Resident noted to be acting inappropriately this evening and this nurse attempted to educate resident on not changing the settings of how much oxygen is delivered via nasal cannula. Resident is noted to have oxygen saturation level of 99% (normal range is 95-100%) on room air. Resident insists that he/she be allowed to wear the supplemental oxygen and was ordered to have PRN oxygen at 2-3 lpm. Resident has been observed turning up the oxygen to 5 lpm. Resident has been educated and advised not to do this and continues to turn the oxygen up. Since resident does not appear to be in respiratory distress and has an oxygen level of 99% on room air, a decision was made to remove the oxygen concentrator from resident's room. Resident followed this nurse out of his/her room into the hallway. Resident's brief fell off as he/she was walking. This nurse turned and attempted to assist resident replacing his/her brief and resident swung and hit this nurse several times. Staff members present in the hallway at the time immediately intervened and assisted this nurse. Resident was then taken to his/her room and this nurse exited to follow facility protocol. When this nurse returned to resident's room this nurse was notified that resident had hit his/her roommate in the face. Resident was noted to be standing in the doorway of his/her room again with no brief on. Staff assisted to place appropriate articles of clothing on resident and DON and Administrator were notified. Both residents were separated for safety. A call was placed to the Psychiatrist and new orders received for PRN medication, as per medication administration record medication was administered as tolerated with staff assistance. No further concerns noted at this time; -9/20/24 at 11:22 A.M.: Further investigation into the reported incident has been conducted. After interviewing all parties involved, and those individuals who observed the activity, it has been determined Resident #1 was not struck in the face. An attempt to strike Resident #1 was made by Resident #2, however physical contact was not made. Resident #1 continues to state he/she feels safe in this environment and does not feel threatened. No further concerns noted at this time; -No documentation DHSS was notified. During an interview on 9/27/24 at 11:00 A.M., the resident lay in bed with oxygen infusing at 5 lpm per nasal cannula. The resident said a few nights ago, LPN A said he/she did not need his/her oxygen concentrator, but he/she did. LPN A took it away which made the resident mad. He/She followed LPN A into the hall and he/she hit LPN A in the face two times. LPN A put his/her arm around the resident's head and took him/her to the floor. Being forced to the floor hurt, but he/she was not injured. After being on the floor for about a minute, LPN A let the resident up and made him/her go back to his/her room. He/She told the DON the next day about what happened. The DON said it wouldn't happen again and the Administrator was investigating what happened. Review of the facility investigation dated 9/19/24 and completed by the Administrator, showed: - Name of Alleged Abuser: Licensed Practical Nurse A; -Initial Investigation: Resident #2 is diagnosed with multiple conditions, including but not limited to acute and chronic respiratory failure, COPD, psychotic disorder with delusions, and Parkinson's disease with dyskinesia (the inability to control movements). Cognition is moderately impaired. On September 19, 2024, the Administrator was notified by the DON about an evening incident involving Resident #2 and LPN A, during which Resident #2 struck LPN A on the head several times. The Administrator was also notified Resident #2 attempted to hit his/her roommate; -Conclusion: The investigation concluded that the resident struck LPN A several times out of frustration after his/her oxygen concentrator was removed. Witnesses stated LPN A held the resident's arms to avoid being struck, while trying to assist the resident with his/her brief before guiding the resident back to his/her room. LPN A acted in self-defense after being hit multiple times. The IDT team questions if LPN A acted without incorporating all possible de-escalation tactics that could have avoided the need for restraint. For this reason LPN A will be terminated. In this case the question begs as to why LPN A did not remove himself/herself from the scene and allow another employee an attempt at calming the resident down; -The investigation did not show DHSS was made aware of the incident. During an interview on 9/27/24 at 9:13 A.M., CNA D said he/she worked on the evening of 9/19/24. CNA D witnessed LPN A take the resident's oxygen concentrator out of his/her room. The resident followed LPN A out of the room and into the hall. LPN A took the oxygen concentrator to the nurse's station, but the resident stopped halfway down the hall. The resident was telling the nurse he/she could not breathe without the oxygen concentrator. The resident was yelling and cursing at LPN A. LPN A walked back to the resident who was still standing in the hall and they were facing each other. LPN A was holding the resident's hands to prevent the resident from hitting him/her. He/She was standing right there and was trying to get the resident to go back to his/her room, but the resident refused to go back. The resident's incontinent brief fell down, LPN A bent down and pulled it back up. That's when the resident punched LPN A in the face. LPN A put one of his/her arms behind the resident's head, then placed his/her hand on the resident's face and pushed the resident backwards and onto the floor. He/She did not hear a thud when the resident reached the ground. While on the ground, the resident was on his/her side and LPN A used one hand to hold the resident's hand down, and had a phone in his/her other hand. LPN A placed his/her knee on top of the resident to hold the resident down. The resident was still cursing. LPN A stood up and the resident went from his/her side to his/her back. LPN A bent down, placed his/her hands underneath the resident's armpits from behind the resident and pulled the resident up to a standing position. LPN A then let the resident go, but the resident stumbled. LPN A placed his/her hands back under the resident's armpits and dragged the to the resident's room and put the resident in bed. The resident was kicking and screaming and did not want to go to his/her room. A short time later CNA D was in the room when LPN A came in and gave the resident an injection. The resident was not combative at that time. The resident told LPN A he/she could give the resident the injection but it was not going to work. LPN A gave the resident the injection at that time. CNA D said he/she did not think any of this had to happen had LPN A not taken the resident's oxygen concentrator away. He/she sent the DON a statement that same evening. During an interview on 9/27/24 at 10:12 A.M., CMT E said LPN A forced the resident to his/her room and put the resident in bed. CMT E walked into the resident's room after LPN A made the resident get into bed, but before the resident was given an injection. The resident was calm at that time, was laying on top of his/her bed. The resident took his/her evening medications from CMT E with no problems. He/She did not think the resident needed an injection at that point. He/She was not present when LPN A came back and gave the resident the injection. As far as he/she was aware LPN A worked the remainder of the shift. He/She did not report the incident that night because he/she did not know who to report it to since LPN A was his/her supervisor. He/She worked the following day and LPN A worked on the same hall the resident resided on, but he/she did not see any problems that day. He/She reviewed his/her statement where it showed the resident fell to the floor and said that was not correct. LPN A forced the resident to the floor. He/She had never seen the resident punch anyone in the past. During an interview on 9/27/24 at 11:45 A.M., CNA C said he/she was not present when the incident between the resident and LPN A occurred. He/She had taken care of the resident several times. The resident was alert and oriented. He/She took care of the resident the day after the incident occurred. The resident told him/her the resident LPN A got into it the night before, but he/she did not say anything about LPN A putting him/her on the floor. The resident did not say anything else and he/she did not ask the resident to elaborate. Had the resident told CNA C that LPN A put him/her in the floor, he/she would have told the nurse at that time. He/She had never seen the resident hit anyone before. During an interview on 9/30/24 at 3:25 P.M., CNA G said he/she worked the same hall where the resident resided but he/she was not assigned to care for the resident on the evening of 9/19/24. He/She saw LPN A put the resident onto the floor but it did not appear harsh. He/She did not see LPN A hold the resident's hands down. CNA G did see LPN A put his/her knee on the resident's back. During interviews with the Administrator and DON on 9/30/24 at 8:41 A.M., and 11:01 A.M., and 10/1/24 at 1:02 P.M., the DON said LPN A phoned her on the evening of 9/19/24. She spoke to the LPN and Certified Nurse's Aide (CNA) D. LPN A told her the resident had hit him/her. LPN A did not tell her he/she took the resident to floor, held his/her hands down and put his/her knee on top of the resident while he/she was on the floor. LPN A did not say anything about forcing the resident to go back to his/her room. CNA D did send her a statement that evening but she was not clear as to what the CNA meant by took to the ground and she did not ask the CNA to explain. On the evening of 9/20/24, she overheard staff at the nurses' station talking about the LPN holding the resident's hands down and forcing the resident onto the floor. She could tell staff felt the LPN's actions were inappropriate. When the staff began to tell her everything that occurred she began in-servicing staff immediately on abuse/neglect and how to de-escalate tense situations. She told the Administrator and the Administrator began an investigation at that time. The Administrator said resident take downs are not part of the facility's behavioral management program, only verbal de-escalation. The DON said they did not notify the Department of Health and Senior Services of the investigation because they did not think LPN A abused the resident and was not injured. During a telephone interview on 10/9/24 at 2:49 P.M., the Medical Director said he expected staff to follow facility policies. MO00242697

Based on interview and record review, the facility failed to provide basic life support in a timely manner, including cardiopulmonary resuscitation (CPR, an emergency lifesaving technique used when someone's breathing or heartbeat has stopped) for one of four sampled residents who was a full code (all life saving measures to be performed) and found by staff without a pulse (Resident #1). The census was 91. The Administrator was informed on [DATE] at 3:18 P.M. of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's policy titled, Medical Emergencies-Code Blue, revised [DATE], showed the purpose of the policy was to ensure the prompt and effective response by facility personnel during medical emergencies through the use of the code blue procedure. A medical emergency was defined as conditions requiring immediate medical intervention and the initiation of the code blue procedure including respiratory or cardiac arrest, hemorrhage (excessive, uncontrolled bleeding), severe respiratory distress, serious injury accidental or self-inflicted, and severe allergic reaction. The facility was to perform CPR in accordance with the guidelines set forth by the American Heart Association. Once CPR was initiated, it was to continue until paramedics arrived. The first of facility personnel to arrive and find the resident with any of the above conditions was to: call for help, send available staff to call a code blue and retrieve emergency medical equipment, assess the resident's level of consciousness, circulation, airway and breathing, begin CPR according to current practice. Note: the first responder should not leave the victim, to call for help, unless absolutely necessary according to the situation. When the second responder arrives, have the second responder place the cardiac arrest board under the resident and assist with two-rescuer CPR. Subsequent responder(s) were to activate the emergency response system-call 911, direct all needed personnel to the code blue site, send a staff member to the entrance door to wait where the ambulance was expected to arrive. The first Registered Nurse (RN) to respond will lead the code unless responsibility is transferred to another licensed staff member (RN or MD). Note: one person CPR will be maintained, until there is a second responder available to begin two person CPR. CPR will continue until the paramedics arrive and assume responsibility. Any available nursing staff was to complete the first responder and subsequent responder tasks. Other staff (social workers, security, housekeepers, etc.) will be available to assist in placing phone calls and/or keeping residents away from the area. Review of the facility's policy titled, Cardiopulmonary Resuscitation, revised [DATE], showed CPR was instituted in cases of recognized cardiac and/or pulmonary arrest to support a resident's cardiac and/or pulmonary function(s) until medical emergency personnel were available to take over the resuscitation efforts. CPR was instituted on all residents except those designated as no code or no CPR. In the absence of a DNR order, CPR was to be performed by individuals certified in basic CPR. The facility will perform CPR in accordance with the guidelines set forth by the American Heart Association. Review of the 2015 American Heart Association guidelines update for CPR and emergency cardiac care (ECC) facility training materials, showed if the victim was unresponsive with absent or abnormal breathing, the rescuer and dispatcher should assume that the victim is in cardiac arrest. Look for no breathing or only gasping and check pulse simultaneously. Healthcare Professionals (HCPs) must shout or use a mobile device to call for nearby help upon finding the victim unresponsive. The recommended sequence for a single rescuer has been confirmed: the single rescuer was to initiate chest compressions (to restore blood circulation) before giving rescue breaths (Compressions-Airway (tilt the victims head back and lift the chin to open the airway)-Breathing (give mouth-to-mouth rescue breaths) (C-A-B) rather than Airway-Breathing-Compressions (A-B-C)) to reduce delay to first compression. The single rescuer should begin CPR via cycles of 30 chest compressions followed by two breaths (one breath every five to six seconds, or about ,d+[DATE] breaths per minute). The number and duration of interruptions in chest compressions should be minimized to less than 10 seconds. Review of the facility's policy titled, Emergency Medical Supplies, revised [DATE], showed the secondary responder to a medical emergency was to bring the emergency cart to the scene. Review of Resident #1's undated face sheet, showed the following: -Responsible party: self; -Initial admitted : [DATE]; -Admission type: skilled (in-patient rehabilitation and medical treatment and care provided by trained registered LPNs (Licensed Practical Nurses) in a medical setting under a physician's supervision). Review of the resident's hospital history and physical, dated [DATE], showed the resident had recently been discharged from the hospital, having been transferred for many hour episodes of non-responsiveness for which cardiac evaluation was negative. In the emergency department (ED), he/she was flaccid (soft, limp) and unresponsive, but did open his/her eyes and regard occasionally. The resident was back to his/her baseline within 10 minutes. The differential diagnosis (analysis of a patient's history and physical examination to arrive at the correct diagnosis) was psychogenic unresponsiveness (state of unconsciousness in which voluntary motor response is absent, muscle tension and deep tendon reflexes remain normal, all brain stem reflexes are preserved and vital signs are usually not affected), transient neurogenic episodes (brief disturbances in motor, somatosensory (sensory system concerned with the conscious perception of touch, pressure and pain), visual or language functions) due to possible cerebral amyloid angiopathy (CAA, condition in which proteins build up on the walls of the arteries of the brain causing bleeding into the brain and dementia) or much less likely atypical (and uncaptured) seizure. Review of the resident's physician's orders, showed a full code order, dated [DATE]. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included unspecified atrial fibrillation (a-fib, an abnormal heart rhythm (quivering or irregular) characterized by rapid and irregular beating), heart failure, high blood pressure, Type II diabetes mellitus, malnutrition, morbid (severe) obesity due to excess calories; -Required set up or clean up assistance with eating and oral hygiene; -Required substantial/maximal assistance with personal hygiene, rolling right/left; -Dependent on full staff performance of toileting, showering/bathing, dressing hygiene, sit-to-lying, lying-to-sitting in bed, chair/bed-to-chair transfer; -One-sided impairment of upper extremity; -Wheelchair mobility. Review of the resident's undated care plan, showed the following: -Full code status; -The resident has a-fib; -Administer medications as ordered; -Monitor for edema (swelling due to accumulation of excess watery fluid collecting in the cavities or tissues of the body); -If the resident goes into cardiac arrest, perform CPR, and call 911. Review of the resident's progress notes, dated [DATE], showed the following: -1:01 P.M., the resident remains on antibiotics (ABT) for right arm swelling with no noted adverse reactions to therapy and no change in status noted. Observed sleeping sound at this time. No signs or symptoms of pain or distress noted. Call light within reach. During an interview on [DATE] at 11:29 A.M., the resident's family member said on [DATE], the resident was up and speaking like normal at 8:00 P.M., asking the family member to bring the resident something to eat the next day. On [DATE], the family visited for an hour and left the facility at 3:00 P.M. The resident had been previously hospitalized for periods of unresponsiveness. Review of Certified Nurse Aide (CNA) C's written statement, dated [DATE], showed the resident was still alive and breathing at 3:00 P.M., when CNA C did his/her rounds. During an interview on [DATE] at 1:52 P.M., CNA G said on [DATE], he/she performed rounds as an oncoming staff with CNA C. CNA G had gone into the resident's room at 7:30 A.M., at lunch time, and at 3:15 P.M. The resident had been awake and talking at lunchtime. At 3:15 P.M., the resident seemed fine. CNA G was on a smoke break when he/she received a call from CNA E saying they had a code. CNA E went inside and saw LPN B and CNA C performing CPR. CNA C was performing chest compressions and LPN B was relieving CNA C and providing chest compressions only. LPN A was at the nurses's station on the phone. Review of the resident's progress notes, dated [DATE], showed the following: -9:22 P.M., at approximately 5:00 P.M., LPN A entered the resident's room and found the resident unresponsive with no pulse and no respirations, warm to the touch. LPN B started CPR along with CNA C. LPN A called 911. Emergency Medical Services (EMS) arrived times four and took over CPR, while contacting their medical director, who gave time of death as 5:22 P.M. Staff notified the resident's family member and physician at 5:47 P.M. Review of LPN A's written statement, dated [DATE], showed at approximately 5:00 P.M., LPN A entered the resident's room and found him/her unresponsive with no pulse, no respirations warm to the touch. LPN B started CPR along with CNA C. LPN A called 911. EMS arrived and took over CPR, while contacting their Medical Director who gave time of death as 5:22 P.M. During an interview on [DATE] at 1:25 P.M., LPN A said on [DATE], LPN A started his/her shift at 3:00 P.M. LPN A did not conduct rounds at the beginning of his/her shift on [DATE]. He/She gave the CNAs their assignments. The CNAs always conducted the first rounds and then reported any concerns to LPN A. On [DATE], no one reported any concerns about the resident to LPN A. At 5:00 P.M., LPN A entered the resident's room for the first time that day to check the resident's blood sugar. The resident normally snored while asleep. On [DATE], he/she was not snoring when LPN A entered the room. LPN A got up close to the resident's mouth, which was more drooped than normal, and did not hear snoring. The resident also did not appear to be breathing. A sternal rub (painful stimulus performed by rubbing the knuckles of a closed fist firmly and vigorously on an unconscious resident's breastbone, in order to test his/her responsiveness) did not arouse him/her. The resident was warm to the touch. LPN A checked for a pulse and could not find one. Certified Medication Technician (CMT) D was in the hallway of the resident's unit (on the East side of the building), when LPN A exited the resident's room. LPN A asked him/her if the other LPN was on the other side of the building. CMT D said, yes. LPN A ran to get LPN B. LPN A did not instruct CMT D to go and get the LPN. LPN A went and found LPN B, telling him/her the resident was unresponsive, that LPN A could not get a pulse or wake the resident up and the resident was a full code. LPN A did not call a code blue (full code announcement) and return to the room to start CPR, because he/she was never trained or instructed during orientation that it was a facility policy or procedure to call a code blue. LPN A had never been shown how to operate the facility's loudspeaker. LPN B entered the room, confirmed the resident had no pulse, and began performing chest compressions. LPN A left the room and called 911. There was no one else who could have made the call to 911, because the resident's medical information had to be pulled up in the database to answer the 911 operator's questions. A CNA would not be able to access that information in the database. LPN A also attempted to phone the resident's family member multiple times. While on the phone, LPN A waited by the door for about two minutes to see if the ambulance was coming. LPN F arrived at the facility, asked LPN A what was happening and asked if LPN A had called the resident's family member. LPN F started helping contact the resident's family member. While LPN A was at the nurse's station, LPN B had sent CNA E to get the crash cart. CNA E started walking to the other side of the building. LPN A said, no there's one on this side. LPN A pulled out the crash cart and the two of them returned to the resident's room. LPN B performed chest compressions. CNA C was not helping while LPN A was present. However, LPN A later found out that CNA C had stepped in to relieve LPN B. LPN B took the AMBU bag and laid it on the bed next to the resident's head. LPN A gave LPN B a break and did compressions for two minutes, while LPN B provided rescue breaths with the AMBU bag for two to three minutes. Then LPN B resumed compressions, LPN A went out and opened the door for EMS. EMS asked a few questions, including when the last time had been that staff saw the resident breathing. CNA C said the resident was breathing when he/she conducted his/her first round at 3:00 P.M. That is why EMS documented the onset of the resident's change in condition as 3:00 P.M. EMS started compressions and contacted their Medical Director. Review of LPN B's written statement, dated [DATE], showed LPN B was rushed into the resident's room with LPN A. The resident was observed lying in bed supine (lying face upward), eyes closed, no respirations, no pulse, warm to the touch. Chest compressions were initiated immediately. CNA C assisted. CPR lasted approximately seven minutes before EMS arrived and took over. LPN B then assisted with family members at the resident's bedside. During interviews on [DATE] at 9:17 A.M. and 2:34 P.M., LPN B said at dinnertime on [DATE], he/she was on the [NAME] side of the building at the opposite end of the hall from CMT D. LPN B was setting up glucose meter checks. LPN A came over to their unit and asked CMT D, where is the LPN? LPN A came and told LPN B that LPN A had a concern with the resident, who did not appear to be breathing. In a situation like that, staff normally made a code blue announcement over the loudspeaker. No one made a code announcement on [DATE]. LPN B rushed to the resident's room with LPN A and assessed the resident, who had no respirations, no pulse, was warm to the touch and had his/her eyes closed. The resident did not respond to a sternal rub. LPN B immediately started chest compressions. LPN A left the resident's room and returned with the crash cart. CNA C entered the room less than a minute later and took over providing chest compressions. LPN B got the AMBU bag out and administered rescue breaths. LPN B administered 30 chest compressions and two breaths, alternating with CNA C and checking for a pulse. They did about 10 rounds of CPR without stopping until EMS arrived. The resident's body was warm head-to-toe, but was not responding to the CPR. During interviews on [DATE] at 7:19 A.M. and [DATE] at 7:27 A.M., CMT D said on [DATE], he/she worked on the [NAME] side of the building, opposite from the East side where the resident resided. It was dinnertime (which starts at 5:00 P.M.) when LPN A walked over to the [NAME] side of the building, stood, looked up and down the hallway and left. A minute or two later, LPN A returned and walked over to CMT D who was on the opposite end of the hall from the dining room passing medications. LPN A asked CMT D if the other LPN was on the unit. LPN A asked, is the other LPN over there?, indicating the opposite end of the hallway. LPN B was in the dining room. LPN A went and got LPN B, then they walked very fast towards the East side of the building. No one made a code announcement. During an interview on [DATE] at 8:10 A.M., CNA E said at around 5:00 P.M. on [DATE], CNA E, CNA C and LPN A were sitting at the nurse's station. CNA E got up to get ice for a resident and returned about two minutes later. LPN A and CNA C were gone from the nurses's station. Then LPN A ran up to the nurses's station and used the phone. No code blue announcement or shout for help had been made, so CNA E did not know what was going on until another resident informed him/her. CNA E went down to Resident #1's room and saw LPN B and CNA C alternately doing chest compressions. Staff only provided chest compressions. LPN A was on the phone attempting to contact the resident's family member. Review of the facility's incident investigation, dated [DATE], showed: -The resident was at baseline with no issues noted and was speaking to his/her family during CNA's initial rounds at 3:00 P.M. CNA C reported the resident did not appear to be distressed. -At 5:00 P.M., LPN A noted while rounding the resident appeared not to be breathing. Code status was verified as full code and CPR was started immediately. -LPN B stated the resident was lying supine in bed. LPN B initiated CPR while LPN A went to get the crash cart and call EMS. The crash cart was delivered. CNA C arrived to assist with CPR. LPN B stated he/she initiated one full round of CPR prior to assistance coming and LPN A assisted as well. -The code was run for approximately seven minutes with LPN B and CNA C rotating rounds of CPR. -EMS arrived, placed telemetry (an observation tool that allows continuous monitoring and display of a patient's vital signs) on the resident, and confirmed there was no heartbeat. EMS contacted the (hospital) physician and called time of death at 5:22 P.M. -Staff notified the resident's family, physician, coroner, and funeral home. -Upon conclusion of the investigation, staff responded appropriately to the code. Supplies needed for the code were available on the crash cart (a wheeled container storing medicine and equipment for use in critical care situations). Staff notified EMS in a timely manner. Staff also notified the resident's family and physician, who voiced no concerns. Review of the resident's EMS patient care record, dated [DATE] showed the following: -Onset time: 3:00 P.M.; -Dispatcher notified: 5:09 P.M.; -En route: 5:11 P.M.; -Primary impression: cardiac arrest; -Skin: trunk remains warm to touch with cold hands and feet; -Eyes: right and left 3 mm (millimeters), nonreactive; -Lung sounds: breath sounds absent; -5:16 P.M. unresponsive, Pulse=0, respiratory rate (RR)=0, advanced life support (ALS) assessment patient response: unchanged, complication: altered mental status, apnea (cessation of breathing); -5:17 P.M., unresponsive, Pulse=0, RR=0, 3-lead electrocardiogram (ECG, non-invasive device that records the electrical activity of the heart), patient response: unchanged; -Resident found lying supine in bed. CPR being performed by nursing home staff. The resident was pulseless and apneic. Staff reports last well check was at 3:00 P.M. Nursing home's staff came in about 15 minutes ago to check the resident's blood sugar and noticed that he/she was unresponsive, did not have a pulse and was not breathing. Staff went to get paperwork. CPR continued. He/She remained pulseless and apneic. Hands and feet were cold to the touch with no cap refill (capillary refill; the time it takes for color to return to a network of blood vessels after pressure is applied to temporarily obstruct blood flow to that area). Pupils were fixed and non-reactive. The hospital was contacted and the physician gave orders to cease resuscitation and pronounce (death) in the field. No obvious signs of trauma. Staff reported that he/she had no complaints today during previous well checks. During interviews on [DATE] at 10:22 A.M. and [DATE] at 11:05 A.M., the Director of Nursing (DON) said the code announcement policy was discussed with staff during orientation. Staff were shown how to use the intercom system to make code announcements and the location of the crash carts. Staff orientation was not documented, nor did staff sign an acknowledgement that they received and understood what was discussed. When staff found a resident unresponsive, they were expected to check for a pulse and call out, hey, I need help. I need help. Next, they were to look out of the room and if no one was there, then they had to go and get help. LPN A went and found LPN B, telling him/her the resident was unresponsive, that LPN A could not get a pulse or wake the resident up and the resident was a full code. During an interview on [DATE] at 1:59 P.M., the Regional RN Consultant said the facility did not have a policy regarding making overhead code announcements. However, staff were expected to yell out that there was a code blue. Staff were taught to immediately perform CPR on an unresponsive full code resident who was not breathing and pulseless. During interviews on [DATE] at 10:35 A.M. and 1:59 P.M., the resident's physician said there was a low chance of survival once staff found the resident unresponsive with no pulse or respirations. However, staff should have started right away with chest compressions and rescue breaths. During an interview on [DATE] at 10:05 A.M., the Administrator said if staff found a resident unresponsive, the expectation was that they would assess the resident (for pulse and respirations), call for help and stay with the resident. They were to have the staff who responded to the call for help, verify the resident's code status and get the crash cart. If the resident was full code, then the staff who were CPR certified were expected to immediately provide CPR. Note: At the time of the complaint investigation, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review, it was determined the facility had implemented corrective action to address and lower the violation at that time. A revisit/final revisit will be conducted to determine if the facility is in substantial compliance with the 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 198.0261 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO00231777 MO00231834

Based on interview and record review, the facility failed to document administration of enteral feedings as ordered and to document assistance provided to a resident who required assistance with meals/fluids for one of three sampled residents (Resident #1) in August of 2021. On 8/24/2021, the resident was transferred to the hospital and admitted to the intensive care unit with blood work that was consistent with significant dehydration and acute renal (kidney) dysfunction. The census was 89. The administrator was notified of past non-compliance, which occurred on 8/5/21. The facility provided training and in-services for all staff regarding the facility's change of condition and enteral feeding policies prior to the onsite. The noncompliance was removed and corrected on 1/12/22. Review of the facility's acute condition change policy, revised on March 2018, showed the following: -The nursing staff shall assess and document/report changes in baseline information; -Direct care staff will be trained on recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate the changes to the nurse; -The nursing staff will contact the physician based on the urgency of the situation; -The nurse and physician will discuss and evaluate the situation; -The physician will help identify and authorize appropriate treatment; -The staff will monitor and document the resident's progress and responses to treatment and the physician will adjust treatment accordingly. Review of the facility's enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract) policy, revised November 2018, showed the following: -Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered; -The recommendation to initiate use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies; -The dietician monitors residents who are receiving enteral nutrition, and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings; -The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, high or low blood sugar, and altered electrolytes. The nursing staff and provider also monitor the residents for worsening of conditions that place the resident at risk for the above; -Enteral feedings are scheduled to try to optimize resident independence whenever possible. Review of Resident #1's care plan, dated 6/2/21, showed the following: -The resident will receive tube feedings via gastrosmy tube (g-tube, a surgically placed device used to give direct access for hydration, nutrition and medications), and pureed diet; interventions included the resident's diet will be followed. Review of the resident's medical record, showed the following: -An order dated 6/2/21, for a pureed diet, nectar consistency, super cereal (a high caloric cereal), and whole milk three times a day; -Lab results, dated 7/14/21 at 4:08 A.M., showed the resident's sodium level was high at 151 and his/her albumin level was low at 3.4; -An order, dated 7/19/21, for 200 milliliter (ml) of water four times a day per g-tube; -Lab results, dated 7/22/21 at 2:30 A.M., showed the resident's sodium level was high at 146, white blood count was low at 3.2, and his/her albumin level was normal at 3.5. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/23/21, showed: -admitted on [DATE]; -Severe cognitive impairment; -Required extensive assistance of one person for bed mobility; -Total dependence for eating, dressing, toileting, and transfers; -Required a feeding tube for over 51% or more of caloric needs; -Received 501 cubic centimeters (cc) of fluid per day by tube feeding; -Diagnoses included non-traumatic brain dysfunction, seizures, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and post-traumatic stress disorder. Further review of the resident's medical record, showed the following: -An order, dated 8/4/21, for Jevity 1.5 (a calorically dense, fiber fortified therapeutic nutrition that provides complete, balanced nutrition), give 65 milliliters per hour (ml/hr) every 16 hours from 5:00 P.M. to 9:00 A.M. continuously per the g-tube. Review of the resident's dietary note, dated 8/5/21 at 3:54 A.M., showed the resident received a pureed diet with whole milk three times a day and super cereal every A.M. The resident also received g-tube feeding of Jevity 1.5 at 65 ml/hr every 16 hours with 200 ml of water every four hours. The order was increased on 8/4/21. Tube feed provides 1040 ml of formula, 1560 calories, and 66 grams of protein and total (with flush) 1990 ml of water. Review of the resident's treatment administration record (TAR), dated 8/1/21 through 8/31/21, showed the following: -An order, dated 8/4/21 at 5:00 P.M., for Jevity 1.5, give every 16 hours for nutrition 65 ml/hr per G-tube from 5:00 P.M. to 9:00 A.M. continuous; -The facility did not document Jevity 1.5 was initiated at 5:00 P.M. on the following days: 8/4, 8/5, 8/7, 8/15, 8/17, 8/19, 8/20, 8/21, and 8/23. Review of the resident's activities of daily living, dated August 2021, showed the following: -Under nutrition amount consumed and fluids, the facility did not document (the documentation was blank) they assisted the resident with eating pureed food on the following days and times: -On 8/4 at 6:00 P.M.; -On 8/5 at 9:00 A.M., 1:00 P.M., and at 6:00 P.M.; -On 8/6 at 9:00 A.M., and 1:00 P.M.; -On 8/7 at 9:00 A.M., 1:00 P.M., and at 6:00 P.M.; -On 8/8 at 6:00 P.M.; -On 8/10 at 6:00 P.M.; -On 8/11 at 9:00 A.M., 1:00 P.M., and at 6:00 P.M.; -On 8/12 at 9:00 A.M., and 1:00 P.M.; -On 8/13 and 8/14 at 9:00 A.M., 1:00 P.M., and at 6:00 P.M.; -On 8/15 at 6:00 P.M.; -On 8/16 at 9:00 A.M., and 1:00 P.M.; -On 8/20 at 9:00 A.M., and 1:00 P.M.; -On 8/21 at 9:00 A.M., 1:00 P.M., and at 6:00 P.M.; -On 8/22 at 9:00 A.M., 1:00 P.M., and at 6:00 P.M. Further review of the resident's medical record showed the following: -An administration note, dated 8/16/21 at 6:50 A.M., Jevity 1.5, give every 16 hours for nutrition 65 ml/hr per g-tube from 5:00 P.M. to 9:00 A.M. continuous was given; -There were no other notes regarding administration of the enteral feeding order after 8/16/21; -A weekly skin note, dated 8/22/21 at 11:55 P.M., the resident's skin turgor (skin elasticity, a test used to check for dehydration) showed tenting (skin very slow to return to normal can indicate severe dehydration) due to a delay in return of skin; -Further review of the resident's medical record showed no documentation the physician was notified of the change in skin turgor; -A note, dated 8/24/21 at 9:35 A.M.,the resident was lying in bed not responding to sternal rub (a commonly used method of assessing response to painful stimuli in assessing the neurological status of an individual), appears not to be in distress, non-verbal when his/her name was called. A call was placed to the hospital, a 911 call was made for transfer. Review of the resident's hospital medical records, dated 8/24/21, showed the following: -The resident lab work, dated 8/24/22, showed high sodium at 159 (hypernatremia, acute condition of severe dehydration), high chloride 121 (sign of dehydration), high blood urea nitrogen at 58 (BUN, kidneys not functioning properly could be due to dehydration), high creatinine at 2.07 (showing kidney dysfunction), and low Albumin at 2.5 (shows malnutrition, or a sign of liver and/or kidney damage). -A note, dated 8/24/21 at 10:51 P.M., blood work reviewed, consistent with significant dehydration, sodium at 159, chloride of 121, with acute renal (kidney) dysfunction. During an interview on 7/12/22 at 1:38 P.M., the Assistant Director of Nursing (ADON), said the following: -She did not work with the resident much during his/her stay at the facility. The resident received nutrition via his/her g-tube; -She could not remember if the resident was able to eat food by mouth; -She could not remember much about the resident except he/she was very dependent on staff and often pulled at his/her g-tube. During an interview on 7/13/22 at 9:47 A.M., Nurse A said the following: -He/she did not care for the resident during his/her stay at the facility; -Nurses were responsible for administering enteral tube feedings to the residents; -When a resident did not receive nutrition as ordered, it increased risk of dehydration and overall decline of health; -Signs of dehydration included dry mouth, dry lips and poor skin turgor; -Dehydration was a change of condition; -If a resident had a change of condition, he/she would assess the resident's vitals, offer fluids, check the resident's blood sugar, and monitor for changes. He/she would also inform the physician and the resident's family and document all in the resident's medical record. During an interview on 7/13/22 at 4:17 P.M., the ADON said the following: -The resident's August TAR for the order of Jevity 1.5, give every 16 hours for nutrition 65 ml/hr per g-tube from 5:00 P.M. to 9:00 A.M. continuous, documentation was very confusing; -The order should have only had documentation listed for 5:00 P.M. and 9:00 A.M. to show when the nurses turned on the tube feed at 5:00 P.M., and turned it off at 9:00 A.M. the next morning; -She was not sure why the TAR had two places for documentation on each day for 9:00 A.M. and 5:00 P.M.; -The system automatically put in the time underneath nurses' initials in the spot labeled 16 h showing when nurses documented; -It appeared that the resident did not receive his/her tube feed as ordered per the documentation on the TAR, but she could not be sure. During an interview on 7/22/22 at 11:11 A.M., the primary care physician, said the following: -He no longer was the medical director for the facility but was during the resident's stay; -He reviewed the resident's medical file before the interview with the surveyor; -The facility failed to give the resident his/her enteral tube feedings for almost two weeks which directly affected his/her health demise; -Lack of nutrition and hydration directly affected the resident's albumin level which increased his/her mortality (the state of being mortal, death rate); -Failure to administer nutrition to the resident severely complicated the resident's health. During an interview on 7/22/21, at 1:33 P.M., the Administrator and Director of Nursing (DON), said the following: -They were not present during the resident's stay at the facility; -Nurses were expected to follow facility policies and procedures; -The DON and ADON audited the TARs weekly and if they saw a resident was missing documentation of administrations, they will notify the nurse, find out if it was done, then notify the physician and family to inform them if and when the order was not followed; -They expected nurses to follow physician orders and administered tube feeds as ordered; -The risk of missed tube feedings included malnutrition, dehydration, imbalance of electrolytes, increased risk of wounds and altered mental status; -Administering tube feedings as ordered was considered basic nursing care. MO00190187 MO00190030

Based on observation, interview, and record review, facility staff failed to consistently provide routine pain medication and failed to address pain on the resident's care plan for one resident (Resident #16) who frequently had pain. The facility census was 71. 1. Review of the chart codes on the MAR and TAR for the facility showed if a medication was not administered, staff were to document one of the following: - 1 = Absent from home without meds; - 2 = Drug Refused; - 3 = Absent from home with meds; - 4 = Vitals Outside of Parameters for Administration; - 5 = Hold/See Progress Notes; - 6 = hospitalized ; - 7 = Sleeping; - 8 = Nauseated/Vomiting; - 9 = Other/See Progress Notes. Review of the resident's Minimum Data Set, a federally mandated assessment instrument, dated 11/20/18, showed staff assessed the resident as: - Received an opioid seven out of the last seven days; - Received [MEDICAL TREATMENT]; - Received scheduled pain medication; - Received PRN (as needed) pain medication; - Had occasional pain in the past five days. Review of the resident's care plan, initiated 8/14/18, showed staff documented the resident had behaviors of refusing medications, refusing [MEDICAL TREATMENT] and being resistive to care; the resident's overall demeanor is angry and grumpy. Staff were directed to observe behavioral episodes and attempt to determine underlying cause and remove hindrance if possible. Review showed staff did not update the resident's care plan to include the resident had pain and did not include any interventions for pain. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated (MONTH) 2019, showed the following: - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 on 1/6, 1/13, 1/15, 1/19, 1/20 1/23, 1/27 and 1/30 (a total of eight times); - An order (dated 1/11/19) for [MEDICATION NAME] (an opioid pain medication) 50 mg scheduled to be given by mouth every eight hours for pain. Staff did not document the administration of the medication and instead documented a code of 9 twice on 1/12, on 1/14, 1/20, 1/21 and 1/28 (a total of six times); - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 twice on 1/1, twice on 1/2, 1/19, twice on 1/21, on 1/23, three times on 1/24, three times on 1/25, twice on 1/26, twice on 1/27 and twice on 1/29 (a total of 20 times); - Staff documented the resident had pain every day this month (31 out of 31 days). Review of the resident's progress notes for (MONTH) 2019 showed staff documented the following: - 1/1 at 4:57 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/1 at 6:50 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/2 at 5:12 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/2 at 5:13 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/2 at 12:25 P.M. - [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg given. Spoke with physician and made aware of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg not available. Received a new order for [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg to be given by mouth every six hours until the dosage of 5-325 mg comes in from pharmacy; - 1/2 at 6:03 P.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg came in, order for [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg discontinued; - 1/3 at 8:51 A.M. - Called [MEDICAL TREATMENT] to inform them the resident is refusing [MEDICAL TREATMENT] treatment today. The resident is cursing and yelling; - 1/6 at 10:06 P.M. - [MEDICATION NAME] 75 mg on order; - 1/9 at 9:03 P.M. - [MEDICATION NAME] 75 mg medication not given on order; - 1/12 at 5:20 A.M. - [MEDICATION NAME] HCL 50 mg New order. Awaiting delivery; - 1/12 at 5:38 P.M. - [MEDICATION NAME] HCL 50 mg Medication isn't available; - 1/13 at 9:54 P.M. - Staff did not document why the [MEDICATION NAME] was not given; - 1/14 at 6:49 A.M. - [MEDICATION NAME] HCL 50 mg Medication was n/a; - 1/15 at 1:08 P.M. - Resident refused to go to [MEDICAL TREATMENT] today. Staff educated the resident on the importance of keeping the scheduled [MEDICAL TREATMENT] treatments and the resident started yelling and cursing. The resident continues to be verbally abusive toward staff when asked if he/she needs any assistance with activities of daily living. The resident continues to reject care at times; - 1/15 at 7:44 P.M. - Staff did not document why the [MEDICATION NAME] was not given; - 1/19 at 12:59 P.M. - Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg was not given; - 1/19 at 8:48 P.M. - [MEDICATION NAME] 75 mg on order; - 1/20 at 4:32 A.M. - Staff did not document why the [MEDICATION NAME] HCL 50 mg was not given; - 1/20 at 11:59 P.M. - [MEDICATION NAME] 75 mg on order; - 1/21 at 4:04 A.M. - [MEDICATION NAME] HCL 50 mg Medication not available; - 1/21 at 6:40 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order; - 1/21 at 6:43 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Med N/a; - 1/21 at 12:51 P.M. - Pain noted of 10/10 on pain scale. The resident is in bed and states left arm in excruciating pain. Nurse tried to touch the resident's left arm and the resident yelled out in pain. Scheduled pain medication was given at 11:00 A.M.; - 1/21 at 1:17 P.M. - Notified physician of the resident's left arm pain. Received a new order for an x-ray to left arm and for staff to give a dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 now for pain. - 1/21 at 1:20 P.M. - One time dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 given at this time. The resident's pain level is still 10 out of 10; - 1/22 at 4:37 P.M. - Spoke to [MEDICAL TREATMENT] nurse regarding resident's progress at [MEDICAL TREATMENT]. Nurse explained even when the resident attends [MEDICAL TREATMENT] sessions, he/she still requests to come off the pump early. Nurse also informed this writer the resident would be following up with the vascular physician regarding pain in arm, nurse believes it has something to do with the [MEDICAL TREATMENT] assess; - 1/23 at 6:46 P.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order; - 1/23 at 7:22 P.M. - [MEDICATION NAME] 75 mg Med is n/a; - 1/24 at 5:10 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense, pharmacy fixing problem; - 1/24 at 6:33 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense, pharmacy fixing problem; - 1/24 at 8:21 A.M. - Resident is refusing to go to [MEDICAL TREATMENT] this am; - 1/24 at 2:45 P.M. - Placed call to physician's office and notified someone from the office the resident was out of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. The person stated he/she would notify the physician. Oncoming nurse made aware; - 1/25 5:12 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication did not dispense. Pharmacy fixing problem. Day shift to follow up; - 1/25/2019 at 6:39 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication did not dispense. Pharmacy working to fix problem; - 1/25 at 11:52 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication unavailable. Placed call to the physician and spoke with somebody who stated he/she would notify physician to return call to facility; - 1/25 at 1:39 P.M. [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication not available. MD aware. NO given, see MAR. - 1/25 at 2:58 P.M. - Placed call to pharmacy regarding [MEDICATION NAME]-[MEDICATION NAME], spoke with pharmacist. Pharmacist stated that he will contact the physician to obtain emergency pain medication order for the resident and will return call to facility. Awaiting call from pharmacist. Will notify oncoming nurse; - 1/26 at 4:30 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on order; - 1/26 at 5:21 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on order; - 1/27 at 6:03 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A; - 1/27 at 6:04 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A; - 1/27 at 10:25 P.M. - [MEDICATION NAME] 75 mg Medication has not arrived. Not available in E-KIT (emergency supply of medications) or (automated medication dispensing system).; - 1/28 at 9:40 A.M. - Spoke with [MEDICAL TREATMENT] nurse today and she states on Saturday (1/26/19) the resident requested to be removed from pump early and began yelling. She explained the resident was upset he/she arrived to the [MEDICAL TREATMENT] treatment late and used that as a reason to stop to session early; - 1/28/19 at 11:36 P.M. - [MEDICATION NAME] HCL 50 mg Medication not given. (Onsite medication dispensing) machine malfunctioning. Medication not dispensing. Staff unable to properly fix machine; - 1/29 at 5:08 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Unable to dispense. Pharmacy called to fix problem; - 1/29 at 7:10 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 mg Medication not dispensing. Pharmacy fixing problem; - 1/30 at 9:39 P.M. - [MEDICATION NAME] 75 mg Medication not available. - 1/31 at 9:19 A.M. - The resident refused [MEDICAL TREATMENT] today. The resident said he/she is tired of it and doesn't need it; Review showed staff only contacted the physician four times to notify him/her medications were not available for the resident. Review showed 34 dosages of pain medication was not given for (MONTH) 2019. Review on 2/12/19 of the resident's MAR and TAR, dated (MONTH) 2019, showed the following: - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 on 2/6, 2/9, three times on 2/10, three times on 2/11 and two times on 2/12. In addition, staff did not document the administration of the medication and left the box blank/without a code once on 2/10. Staff did not document the administration of this medication a total of 11 times; - Staff documented the resident had pain on 2/1, 2/2, 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/10, 2/11 and 2/12 (11 out of a possible 12 days). Review of the resident's progress notes for (MONTH) 2019 showed staff documented the following: - 2/6 at 6:30 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Meds on order; - 2/9 at 6:00 P.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication isn't available; - 2/10 at 2:26 A.M. - Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME] was not given; - 2/10 at 6:12 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication n/a; - 2/10 at 6:27 A.M. - Resident having pain at a number 7 on a scale 1-10; - 2/10 at 11:11 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication isn't available; - 2/11 at 3:35 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Med N/A; - 2/11 at 3:35 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A; - 2/11 at 5:31 A.M. - Resident pain at a 7 on a 1-10 pain scale; - 2/11 at 6:25 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med n/a; - 2/11 at 12:41 P.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication unavailable at this time; - 2/12 at 4:53 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication reordered; - 2/12 at 5:03 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication reordered; - 2/12 at 8:27 A.M. - Resident refuses to attend [MEDICAL TREATMENT] today. Resident states that he is having vomiting episodes with nausea. Resident observed dry heaving with no stomach contents being emptied, just spitting in basin. Anti-nausea medication given to resident. Physician notified of resident's noncompliance with [MEDICAL TREATMENT] treatment, nausea and vomiting; - 2/12 at 5:11 P.M. - The resident is is bed and has complaints of fever and chills, no sweating observed. The resident reports that he/she has generalized pain as well as pain in stomach (cramping) and rates pain 10/10. Blood pressure 148/109, heart rate 97, respirations 20, temperature 99.8, and oxygen saturation 98% on 2 liters of oxygen. Physician notified that the resident missed [MEDICAL TREATMENT] treatment today. Received an order to send the resident to the hospital for evaluation and treatment. Resident given [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg for pain, medication somewhat effective. The resident reports pain at 6/10 after administration. Ambulance in route. Review showed staff did not did not document they notified the physician of the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg being unavailable. During an attempted interview on 2/11/19 at 5:06 P.M., the resident yelled at the surveyor to leave him/her alone. Observation on 2/12/19 at 5:15 P.M. showed the resident lay in bed on his/her back. The resident raised his/her hands in the air and said in a loud voice Please Lord, just take me. During an interview on 2/14/19 at 10:11 A.M., the Director of Nurses (DON) said the pharmacy the facility uses is in Indiana and they have used them for about a year. They have an onsite medication dispensing machine that dispenses some of the medications. They have had issues with the pharmacy providing them medications. During an interview on 2/14/19 at 1:30 P.M., Certified Medication Technician (CMT) B said the following: - If staff do not document the administration of a scheduled medication on the MAR or TAR then they are supposed to document why the medication was not given. - The pharmacy they currently use is in the state of Indiana. They have to call that pharmacy frequently and let them know they are out of medications. The pharmacy tells them the medicines are ordered but they don't come in. Whenever a medication is not available he/she notifies the DON or administrator. During an interview on 2/14/19 at 5:15 P.M., Licensed Practical Nurse (LPN) A said the following: - The resident gets scheduled [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg ever six hours for severe pain; - Staff have repeatedly tried to get this pain medication for the resident. - When a medication is not available, staff should notify the resident's physician and the pharmacy. When staff contact the pharmacy or physician about a medication not being available, they should document this in a progress note. During an interview on 2/14/19 at 5:15 P.M., the Assistant Director of Nursing (ADON) said the following: - He expects staff to provide non pharmacological interventions for pain when a residents pain medication is not available; - Staff should notify the physician when a medication is not available and document this in a progress note along with any new orders the physician gives for the resident; - If a resident's pain medication was unavailable and the resident's pain was unbearable, then they would send they resident to the hospital. During an interview on 2/14/19 at 7:00 P.M., the MDS Coordinator said pain should be addressed on the resident's care plan. During an interview on 2/14/19 at 7:30 P.M., the DON said the following: - The resident frequently complains of pain. The resident has a hernia that causes pain. - Pain should be addressed on the resident's care plan; - She is not aware if any staff asked a physician for an alternative pain medication for the resident. They had a different dose of the [MEDICATION NAME]-[MEDICATION NAME] available in the Ekit, it was a mater of the nurses not checking the Ekit. - If a medication is not available staff should notify the physician and document this in a progress note along with any alternative orders the physician gave. If it is more than a one time thing that the medication is not available then they should get an order from the physician for the medication to be held and see if the physician wants any alternative medications ordered; - If a medication is not given, staff should document why it was not given in a progress note; - She is unsure what staff mean when they document N/A. To her, that would mean not applicable, but it does not make sense to put this for a scheduled medication. She is unsure if staff mean the medication was not available when they documented N/A in the progress notes. - Staff are always calling the pharmacy about medications not being available; - If staff do not document they gave a medication then it is considered not given because she can not prove they gave it.

Based on observation, interview, and record review, facility staff failed to consistently provide several routine medications (including an anticoagulant, a medication for elevated potassium levels, a medication for high blood pressure and three different pain medications) for one resident (Resident #16) which resulted in elevated blood pressure and increased pain. Staff also failed to consistently provide multiple medications per physician's orders [REDACTED].#173), which included the resident's antibiotics, antianxiety, anticoagulant, muscle relaxants, and two different pain medications. The facility census was 71. 1. Review of the chart codes on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the facility showed if a medication was not administered, staff were to document one of the following: - 1 = Absent from home without meds; - 2 = Drug Refused; - 3 = Absent from home with meds; - 4 = Vitals Outside of Parameters for Administration; - 5 = Hold/See Progress Notes; - 6 = hospitalized ; - 7 = Sleeping; - 8 = Nauseated/Vomiting; - 9 = Other/See Progress Notes. 2. Review of the American Heart Association High Blood Pressure Guidelines showed the following: - Normal: Less than 120/80 mm Hg; - Elevated: Systolic between 120-129 and diastolic less than 80; - Stage 1: Systolic between 130-139 or diastolic between 80-89; - Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg; - Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage. Review of the Resident #16's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/20/18, showed staff assessed the resident as: - Cognitively intact; - diagnosed with [REDACTED]. - Received an anticoagulant seven out of the last seven days; - Received an opioid seven out of the last seven days; - Received [MEDICAL TREATMENT]; - Received scheduled pain medication; - Received PRN (as needed) pain medication; - Had occasional pain in the past five days. Review of the resident's care plan, initiated 8/14/18, showed staff documented the following: - The resident takes an anticoagulant because he/she has a history of a stroke. Staff were directed to administer the anticoagulant as ordered by the physician; - The resident receives [MEDICAL TREATMENT] three times per week. Staff were directed to encourage the resident to go to scheduled [MEDICAL TREATMENT] appointments and work with the resident to relieve discomfort for side effects of the disease and treatment (cramping, headaches, fatigue, itching); - The resident had behaviors of refusing medications, refusing [MEDICAL TREATMENT] and being resistive to care; the resident's overall demeanor is angry and grumpy. Staff were directed to observe behavioral episodes and attempt to determine underlying cause and remove hindrance if possible. Review of the resident's MAR, dated (MONTH) 2019, showed the following: - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 on 12/3, 12/4, twice on 12/8, 12/11, 12/13, 12/14, and 12/17 (a total of eight times); - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 on 12/3 and 12/10 (a total of two times). The order was discontinued on 12/21/18.; - An order (dated 12/21/18) for Calcium Acetate 667 mg to be given by mouth with meals for [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]). Staff did not document the administration of the medication and instead documented a code of 9 on 12/23, twice on 12/25 and 12/26 (a total of four times); - An order (dated 12/4/18) for [MEDICATION NAME] 60 mg to be given by mouth two times a day for high blood pressure. Staff did not document the administration of the medication and instead documented a code of 9 twice on 12/8, on 12/9, 12/10, twice on 12/11, twice on 12/12, 12/13, 12/14, twice on 12/15, 12/16, twice on 12/17, 12/18 and 12/20 (a total of 17 times). The order was discontinued on 12/20/18. Blood pressure readings were documented including elevated readings of 151/ 85 and 146/82 on 12/8, 152/86 and 164/70 on 12/9, 160/88 on 12/10, 132/78 and 148/68 on 12/11, 173/150 on 12/12, 157/93 and 160/97 on 12/14, 166/73 and 148/79 on 12/15, 140/40 and 132/58 on 12/16, 158/93 on 12/17, 153/59 and 146/76 on 12/18 and 165/77 on 12/19. Review of the resident's progress notes for (MONTH) (YEAR) showed staff documented the following: - 12/3 at 6:10 P.M. - Calcium Acetate is on order; - 12/3 at 6:58 P.M. - Apixaban is out of stock; - 12/4 at 5:55 P.M. - Apixaban on order; - 12/8 at 10:17 A.M. - Staff did not document why the Apixaban was not given; - 12/8 at 10:19 A.M. - Staff did not document why the [MEDICATION NAME] was not given; - 12/8 at 7:57 P.M. - Apixaban on order; - 12/8 at 7:57 P.M. - [MEDICATION NAME] on order; - 12/9 at 6:36 P.M. - [MEDICATION NAME] on order; - 12/10 at 10:01 - Calcium Acetate reordered from pharmacy; - 12/10 at 5:17 P.M. - [MEDICATION NAME] not here; - 12/11 at 11:54 A.M. - [MEDICATION NAME] on order; - 12/11 at 7:18 P.M. - Apixaban on order; - 12/11 at 7:20 P.M. - [MEDICATION NAME] on order; - 12/12 at 11:03 A.M. - [MEDICATION NAME] not here; - 12/12 at 4:53 P.M. - [MEDICATION NAME] not here; - 12/13 at 5:04 P.M. - Apixaban on order; - 12/13 at 5:04 P.M. - [MEDICATION NAME] on order; - 12/14 at 5:33 P.M. - Apixaban on order; - 12/14 at 5:33 P.M. - [MEDICATION NAME] on order; - 12/15 at 9:35 A.M. - [MEDICATION NAME] on order; - 12/15 at 6:31 P.M. - [MEDICATION NAME] on order; - 12/16 at 11:10 A.M. - [MEDICATION NAME] not here; - 12/17 at 11:38 A.M. - [MEDICATION NAME] medication was not given unavailable nurse is aware; - 12/17 4:07 P.M. - [MEDICATION NAME] med not in; - 12/17 4:07 P.M. - Apixaban med not in; - 12/18 at 2:15 P.M. - [MEDICATION NAME] on order; - 12/20 at 3:02 P.M. - [MEDICATION NAME] not here; - 12/23 at 11:15 A.M. - Staff did not document why the Calcium Acetate was not given; - 12/25 at 9:29 A.M. - Calcium Acetate not available; - 12/25 at 2:52 P.M. - Calcium Acetate not here; - 12/26 at 10:15 A.M. - Calcium Acetate not here. Review showed staff did not document they notified the physician of the Calcium Acetate, [MEDICATION NAME] or Apixaban being unavailable. Review of the resident's MAR and TAR, dated (MONTH) 2019, showed the following: - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 on 1/6, 1/13, 1/15, 1/19, 1/20 1/23, 1/27 and 1/30 (a total of eight times); - An order (dated 1/11/19) for [MEDICATION NAME] (an opioid pain medication) 50 mg scheduled to be given by mouth every eight hours for pain. Staff did not document the administration of the medication and instead documented a code of 9 twice on 1/12, 1/14, 1/20, 1/21 and 1/28 (a total of six times); - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 twice on 1/1, twice on 1/2, 1/19, twice on 1/21, 1/23, three times on 1/24, three times on 1/25, twice on 1/26, twice on 1/27 and twice on 1/29 (a total of 20 times); - Staff documented the resident had pain every day this month (31 out of 31 days). Review of the resident's progress notes for (MONTH) 2019 showed staff documented the following: - 1/1 at 4:57 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/1 at 6:50 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/2 at 5:12 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/2 at 5:13 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order; - 1/2 at 12:25 P.M. - [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg given. Spoke with physician and made aware of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg not available. Received a new order for [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg to be given by mouth every six hours until the dosage of 5-325 mg comes in from pharmacy; - 1/2 at 6:03 P.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg came in, order for [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg discontinued; - 1/3 at 8:51 A.M. - Called [MEDICAL TREATMENT] to inform them the resident is refusing [MEDICAL TREATMENT] treatment today. The resident is cursing and yelling; - 1/6 at 10:06 P.M. - [MEDICATION NAME] 75 mg on order; - 1/9 at 9:03 P.M. - [MEDICATION NAME] 75 mg medication not given on order; - 1/12 at 5:20 A.M. - [MEDICATION NAME] HCL 50 mg New order. Awaiting delivery; - 1/12 at 5:38 P.M. - [MEDICATION NAME] HCL 50 mg Medication isn't available; - 1/13 at 9:54 P.M. - Staff did not document why the [MEDICATION NAME] was not given; - 1/14 at 6:49 A.M. - [MEDICATION NAME] HCL 50 mg Medication was n/a; - 1/15 at 1:08 P.M. - Resident refused to go to [MEDICAL TREATMENT] today. Staff educated the resident on the importance of keeping the scheduled [MEDICAL TREATMENT] treatments and the resident started yelling and cursing. The resident continues to be verbally abusive toward staff when asked if he/she needs any assistance with activities of daily living. The resident continues to reject care at times; - 1/15 at 7:44 P.M. - Staff did not document why the [MEDICATION NAME] was not given; - 1/19 at 12:59 P.M. - Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg was not given; - 1/19 at 8:48 P.M. - [MEDICATION NAME] 75 mg on order; - 1/20 at 4:32 A.M. - Staff did not document why the [MEDICATION NAME] HCL 50 mg was not given; - 1/20 at 11:59 P.M. - [MEDICATION NAME] 75 mg on order; - 1/21 at 4:04 A.M. - [MEDICATION NAME] HCL 50 mg Medication not available; - 1/21 at 6:40 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order; - 1/21 at 6:43 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Med N/a; - 1/21 at 12:51 P.M. - Pain noted of 10/10 on pain scale. The resident is in bed and states left arm in excruciating pain. Nurse tried to touch the resident's left arm and the resident yelled out in pain. Scheduled pain medication was given at 11:00 A.M.; - 1/21 at 1:17 P.M. - Notified physician of the resident's left arm pain. Received a new order for an x-ray to left arm and for staff to give a dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 now for pain. - 1/21 at 1:20 P.M. - One time dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 given at this time. The resident's pain level is still 10 out of 10; - 1/22 at 4:37 P.M. - Spoke to [MEDICAL TREATMENT] nurse regarding resident's progress at [MEDICAL TREATMENT]. Nurse explained even when the resident attends [MEDICAL TREATMENT] sessions, he/she still requests to come off the pump early. Nurse also informed this writer the resident would be following up with the vascular physician regarding pain in arm, nurse believes it has something to do with the [MEDICAL TREATMENT] assess; - 1/23 at 6:46 P.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order; - 1/23 at 7:22 P.M. - [MEDICATION NAME] 75 mg Med is n/a; - 1/24 at 5:10 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense, pharmacy fixing problem; - 1/24 at 6:33 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense, pharmacy fixing problem; - 1/24 at 8:21 A.M. - Resident is refusing to go to [MEDICAL TREATMENT] this am; - 1/24 at 2:45 P.M. - Placed call to physician's office and notified someone from the office the resident was out of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. The person stated he/she would notify the physician. Oncoming nurse made aware; - 1/25 5:12 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication did not dispense. Pharmacy fixing problem. Day shift to follow up; - 1/25/2019 at 6:39 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication did not dispense. Pharmacy working to fix problem; - 1/25 at 11:52 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication unavailable. Placed call to the physician and spoke with somebody who stated he/she would notify physician to return call to facility; - 1/25 at 1:39 P.M. [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication not available. MD aware. NO given, see MAR. - 1/25 at 2:58 P.M. - Placed call to pharmacy regarding [MEDICATION NAME]-[MEDICATION NAME], spoke with pharmacist. Pharmacist stated that he will contact the physician to obtain emergency pain medication order for the resident and will return call to facility. Awaiting call from pharmacist. Will notify oncoming nurse; - 1/26 at 4:30 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on order; - 1/26 at 5:21 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on order; - 1/27 at 6:03 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A; - 1/27 at 6:04 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A; - 1/27 at 10:25 P.M. - [MEDICATION NAME] 75 mg Medication has not arrived. Not available in E-KIT (emergency supply of medications) or (automated medication dispensing system).; - 1/28 at 9:40 A.M. - Spoke with [MEDICAL TREATMENT] nurse today and she states on Saturday (1/26/19) the resident requested to be removed from pump early and began yelling. She explained the resident was upset he/she arrived to the [MEDICAL TREATMENT] treatment late and used that as a reason to stop to session early; - 1/28/19 at 11:36 P.M. - [MEDICATION NAME] HCL 50 mg Medication not given. (Onsite medication dispensing) machine malfunctioning. Medication not dispensing. Staff unable to properly fix machine; - 1/29 at 5:08 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Unable to dispense. Pharmacy called to fix problem; - 1/29 at 7:10 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 mg Medication not dispensing. Pharmacy fixing problem; - 1/30 at 9:39 P.M. - [MEDICATION NAME] 75 mg Medication not available. - 1/31 at 9:19 A.M. - The resident refused [MEDICAL TREATMENT] today. The resident said he/she is tired of it and doesn't need it; Review showed staff only contacted the physician four times to notify him/her medications were not available for the resident. Review showed 34 dosages of pain medication was not given for (MONTH) 2019. Review on 2/12/19 of the resident's MAR and TAR, dated (MONTH) 2019, showed the following: - an order for [REDACTED]. Staff did not document the administration of the medication and instead documented a code of 9 on 2/6, 2/9, three times on 2/10, three times on 2/11 and two times on 2/12. In addition, staff did not document the administration of the medication and left the box blank/without a code once on 2/10. Staff did not document the administration of this medication a total of 11 times; - Staff documented the resident had pain on 2/1, 2/2, 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/10, 2/11 and 2/12 (11 out of a possible 12 days). Review of the resident's progress notes for (MONTH) 2019 showed staff documented the following: - 2/6 at 6:30 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Meds on order; - 2/9 at 6:00 P.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication isn't available; - 2/10 at 2:26 A.M. - Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME] was not given; - 2/10 at 6:12 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication n/a; - 2/10 at 6:27 A.M. - Resident having pain at a number 7 on a scale 1-10; - 2/10 at 11:11 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication isn't available; - 2/11 at 3:35 A.M. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Med N/A; - 2/11 at 3:35 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A; - 2/11 at 5:31 A.M. - Resident pain at a 7 on a 1-10 pain scale; - 2/11 at 6:25 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med n/a; - 2/11 at 12:41 P.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication unavailable at this time. Medication is not in (the onsite medication dispensing) machine for dispensing; - 2/12 at 4:53 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication reordered; - 2/12 at 5:03 A.M. - [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication reordered; - 2/12 at 8:27 A.M. - Resident refuses to attend [MEDICAL TREATMENT] today. Resident states that he is having vomiting episodes with nausea. Resident observed dry heaving with no stomach contents being emptied, just spitting in basin. Anti-nausea medication given to resident. Physician notified of resident's noncompliance with [MEDICAL TREATMENT] treatment, nausea and vomiting; - 2/12 at 5:11 P.M. - The resident is is bed and has complaints of fever and chills, no sweating observed. The resident reports that he/she has generalized pain as well as pain in stomach (cramping) and rates pain 10/10. Blood pressure 148/109, heart rate 97, respirations 20, temperature 99.8, and oxygen saturation 98% on 2 liters of oxygen. Physician notified that the resident missed [MEDICAL TREATMENT] treatment today. Received an order to send the resident to the hospital for evaluation and treatment. Resident given [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg for pain, medication somewhat effective. The resident reports pain at 6/10 after administration. Ambulance in route. Review showed staff did not did not document they notified the physician of the [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg being unavailable. During an attempted interview on 2/11/19 at 5:06 P.M., the resident yelled at the surveyor to leave him/her alone. Observation on 2/12/19 at 5:15 P.M., showed the resident lay in bed on his/her back. The resident raised his/her hands in the air and said in a loud voice Please Lord, just take me. During an interview on 2/14/19 at 5:15 P.M., Licensed Practical Nurse (LPN) A said the following: - The resident gets scheduled [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg ever six hours for severe pain; - Staff have repeatedly tried to get this pain medication for the resident. During an interview on 2/14/19 at 7:30 P.M., the Director of Nursing (DON) said the following: - The resident frequently complains of pain. The resident has a hernia that causes pain. - Pain should be addressed on the resident's care plan; - She is not aware if any staff asked a physician for an alternative pain medication for the resident. They had a different dose of the [MEDICATION NAME]-[MEDICATION NAME] available in the Ekit, it was a mater of the nurses not checking the Ekit. 3. Review of Resident #173's medical record showed the resident was admitted to the facility on [DATE]. Review of the resident's TAR, dated (MONTH) 2019, showed the following: -an order for [REDACTED]. Staff did not document administration of the medication on 2/9 and 2/10. Additionally, staff did not document administration of the medication and instead documented a code of 9 on 2/12/19. -an order for [REDACTED]. Staff did not document administration of the medication on 2/9 and 2/10. Additionally, staff did not document administration of the medication and instead documented a code of 9 on 2/12/19. -an order for [REDACTED]. Staff did not document administration and instead documented a code of 9 on 2/9 (am dose), 2/10 (am and pm doses), and 2/11 (am dose). Additionally, staff did not document administration of the medication on 2/9 (pm dose). -an order for [REDACTED]. Staff did not document administration of the medication on 2/11. -an order for [REDACTED]. Staff did not document administration of the medication on 2/9 (pm dose) and 2/10 (pm dose). -an order for [REDACTED]. Staff did not document administration and instead documented a code of 9 on 2/9 (am dose). Additionally, staff did not document administration of the medication on 2/9 (pm dose) and 2/11 (pm dose). -an order for [REDACTED]. Staff did not document administration of the medication on 2/9 (pm dose). -an order for [REDACTED]. Staff did not document administration of the medication on 2/9 (5:00 pm dose). -An order [MEDICATION NAME] HFA aerosol solution (opens up the airways in the lungs) 17 mcg/act, one puff via [MEDICAL CONDITION] three times daily. Staff did not document administration and instead documented a code of 9 on 2/9 (noon dose). Additionally, staff did not document administration of the medication on 2/9 (pm dose) and 2/11 (pm dose). -an order for [REDACTED]. Staff did not document administration and instead documented a code of 9 on 2/9 (1:00 am dose), 2/10 (5:00 pm dose) 2/11 (1:00 am dose and 9:00 am dose), and 2/12 (1:00 am dose). Additionally, staff did not document administration of the medication on 2/9 (5:00 pm dose), 2/10 (1:00 am dose), and 2/11 (5:00 pm dose). -an order for [REDACTED]. Staff did not document administration of the medication on 2/9 (pm dose). -an order for [REDACTED]. Staff did not document administration on 2/10 (bedtime dose). -an order for [REDACTED]. Staff did not document administration and instead documented a code of 9 on 2/9 (midnight dose, 4:00 am dose, 8:00 am dose and noon dose), 2/10 (4:00 pm dose), 2/11 (midnight dose, 4:00 am dose, 8:00 am dose and noon dose), 2/12 (midnight dose and 4:00 am dose), and 2/13 (midnight dose and noon dose). Staff did not document administration of the medication on 2/9 (4:00 pm dose), and 2/10 (midnight dose, 4:00 am dose and 8:00 pm dose). -an order for [REDACTED]. Staff did not document administration and instead documented a code of 9 on 2/9 and 2/12. Review of the resident's progress notes from his/her admission date of [DATE]-2/14/19, showed the following: -On 2/14/19 at 15:43, staff documented they placed a call to the resident's physician regarding the resident's [MEDICATION NAME] script. Staff documented the physician's office requested a faxed face sheet and medication list, which staff faxed at that time. -Staff did not otherwise document why the above medications were not administered. During an interview on 2/13/19 at 9:00 A.M., the resident said he/she was admitted on Friday (five days prior) and said staff have had trouble getting all of his/her medications in to the facility. During an interview on 2/14/19 at 9:11 A.M., the resident said he/she believed he/she received all of his medications that morning except they may still be waiting on his/her pain patch. The resident was unsure as to whether staff were substituting something for the patch. He/she said he/she had pain in his/her shoulders which seemed to be a little worse without the pain patch. During an interview on 2/14/19 at 11:31 A.M., LPN E said the facility had now received all of the resident's medications except for his/her [MEDICATION NAME]es. The LPN said the resident came from the hospital without any scripts. The LPN said he/she had to call the pharmacy when he/she arrived to the facility on Monday morning to get the resident's medications. The nurse practitioner signed the scripts and staff got them to the pharmacy and the facility received the resident's [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) on Tuesday (the 12th). The LPN said the nurse practitioner couldn't sign the script for the [MEDICATION NAME], so the LPN has called the resident's physician and asked to get a script for the resident's [MEDICATION NAME]. The LPN said he/she needed to call the pharmacy to see if the resident's physician had signed a script. The LPN said the facility's emergency kit of medication did not have [MEDICATION NAME] and the resident had exhausted the facility's supply of [MEDICATION NAME]. The LPN said he/she was unsure if anyone tried to get any of the resident's scripts prior to Monday. The LPN said the resident's routine medications came out of the onsite medication dispensing system. During an interview on 2/14/19 2:58 P.M., the administrator said they had some issues with the resident's scripts. The resident was admitted over the weekend from the hospital. The administrator said staff try to get the hospital to send hard scripts, but that doesn't always work out. 4. During an interview on 2/14/19 at 10:11 A.M., the DON said the pharmacy the facility uses is in Indiana and they have used them for about a year. They have a onsite medication dispensing machine that dispenses some of the medications. They have had issues with the pharmacy providing them medications. 5. During an interview on 2/14/19 at 1:30 P.M., Certified Medication Technician (CMT) B said the following: - If staff do not document the administration of a scheduled medication on the MAR or TAR then they are supposed to document why the medication was not given; - The pharmacy they currently use is in the state of Indiana. They have to call that pharmacy frequently and let them know they are out of medications. The pharmacy tells them the medicines are ordered but they don't come in. Whenever a medication is not available he/she notifies the DON or administrator. 6. During an interview on 2/14/19 at 5:15 P.M., LPN A said when a medication is not available, staff should notify the resident's physician and the pharmacy. When staff contact the pharmacy or physician about a medication not being available, they should document this in a progress note. 7. During an interview on 2/14/19 at 5:15 P.M., the Assistant Director of Nursing (ADON) said the following: - He expects staff to provide non-pharmacological interventions for pain when a residents pain medication is not available; - Staff should notify the physician when a medication is not available and document this in a progress note along with any new orders the physician gives for the resident; - If a resident's pain medication was unavailable and the resident's pain was unbearable, then they would send they resident to the hospital. 8. During an interview on 2/14/19 at 7:30 P.M., the DON said the following: - If a medication is not available, staff should notify the physician and document this in a progress note along with any alternative orders the physician gave. If it is more than a one time thing that the medication is not available, then they should get an order from the physician for the medication to be held and see if the physician wants any alternative medications ordered; - If a medication is not given, staff should document why it was not given in a progress note; - She is unsure what staff mean when they document N/A. To her, that would mean not applicable, but it does not make sense to put this for a scheduled medication. She is unsure if staff meant the medication was not available when they documented N/A in the progress notes; - Staff are always calling the pharmacy about medications not being available; - If staff do not document they gave a medication, then it is considered not given because she can not prove they gave it.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #45) of 17 sampled residents remained free of mental abuse when staff forced the resident to get out of bed against his/her will. Staff then placed the resident in his/her recliner, removed the resident's recliner remote control from his/her hand, and placed the resident in a reclined position to prevent the resident from rising. The facility census was 62. Review of the Facility's Abuse and Neglect policy dated 12/2016, showed the following: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. The facility desires to establish a resident sensitive and resident secure environment. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse as defined under 42CFR 488.301 is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain and/or maintain physical, mental, and psychological well-being. This presumes that all instances of abuse of all residents, even those in a coma, cause physical harm or pain or mental anguish. - Mental Abuse as defined under 42CFR 488.301 includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate residents. Involuntary Seclusion as defined under 42CFR 488.301 means separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will or the will of the resident's legal guardian. Neglect as defined under 42CFR 488.301 is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or to prevent the deterioration of a resident's physical or mental condition. 1. Review of Resident #45's most recent annual minimum data set (MDS), an assessment instrument required to be completed by facility staff, dated 12/11/17, showed staff assessed the resident as follows: - Brief interview of mental status showed a score of 15 indicating no cognitive impairment; - No mood or behavior problems; - Required extensive assist of one staff for bed mobility and transfers; - Total dependence on one staff for dressing; - Always incontinent of bowel and bladder; - Had a [DEVICE] for nutrition; - Independent with eating. During an interview on 01/23/18 at 10:40 A.M., Resident #45 said the following: - Did not participate in resident council; - Preferred to be in bed; - Did not participate in group activities, watched television and had an Ipad; - Required assist of two staff for activities of daily living; - A family member handled his/her financial affairs including his/her trust; - Staff treated him/her fine, respected his/her privacy and dignity; - Had one fall over six months ago; - Ate in his/her room; - Received a pureed diet; - No longer required tube feeding due to weight gain. During an observation on 01/25/18 at 2:30 P.M., Resident #45 repeatedly pointed at his/her computer almost knocking the computer off of the table when trying to point at a message on the screen. The resident urgently wanted the surveyor to read the message he/she sent to his family member and continued to point at the computer. The message addressed to a family member from Resident #45 read: Licensed Practical Nurse (LPN) A here is abusing me. LPN A made me get up in my recliner against my will and disconnected recliner controller and wouldn't give it back to me. I think you should call police and report LPN A. Only reason LPN A got me up in my chair was that I put my call light on because I was wet. I'm god damn mad. The Administrator is taking care of it. The resident recommended LPN A be fired to the Administrator when Administrator asked me. Resident #45 wrote he/she has got to get out of this place and go to a skilled nursing facility, so he/she can see psychiatrist and get out and back in community. Nurses here don't give a damn if you live or die. During an interview on 01/25/18 at 2:30 P.M., Resident #45 wrote/responded, by using his/her tablet, to surveyor questions as follows: - LPN A and Certified Nurses Aide (CNA) A both got him/her up; - Made him/her stay up for an hour; - Staff had done this before, (LPN A) forced him/her to get up before, but he/she did not report it to anyone; - Resident #45 does not receive tube feeding any longer; - Incident on 01/25/18, hurt him/her emotionally; - Different staff put him/her back to bed; - Resident #45 told LPN A he/she did not want to get up two times, but they transferred him/her to the recliner anyway; - He/She hadn't seen LPN A since he/she reported the incident to the Administrator; - Told Administrator it was okay to call his/her family member; - Resident #45 said he/she yelled out No and staff just went on and got him/her up; - He/She told the Administrator he/she thought LPN A should be fired. During an interview on 01/25/18 3:42 P.M., LPN A said CNA A needed help getting Resident #45 up and LPN A went to help. When LPN A went in to the resident's room, LPN A told the resident they were going to put him/her in his/her recliner. Resident #45 told LPN A No. LPN A said he/she told the resident the health benefits of getting up., to cough and breathe. Resident #45 said No. LPN A said he/she explained to Resident #45 again the health benefit of getting up to cough/breathe at least an hour or two. Resident #45 then said he/she wasn't going to help with the transfer. When LPN A was asked by the surveyor what the resident meant when he/she said he/she wasn't going to help, LPN A said help bear weight. LPN A said he/she thought the resident had given in to getting up. LPN A said that's when we pulled the covers back. LPN A had CNA A take the resident's legs and LPN A took the resident's arms to sit him/her up on the side of the bed. LPN A said Resident #45 picked up a cup and threw it at him/her and said he/she was being sadistic. LPN A said they let the resident sit on the side of the bed awhile and explained the benefits of getting up into the recliner. Resident #45 yelled LPN A was sadistic. LPN A said he/she and CNA A grabbed the resident under each arm and by the pants to support him/her for transfer from bed to recliner. LPN A said he/she reclined the resident's recliner back and put the recliner controller in the side pocket of the recliner (towards bottom of chair). LPN A said Resident #45 grabbed the controller out of the side pocket of the chair and said he/she was going to get up. LPN A took the controller away from the resident and disconnected it. LPN A then gave the resident his/her table, tablet, stylus and call light. LPN A said he/she had not received abuse/neglect training prior to the incident, but had been trained on resident's rights now and resident's right to refuse. LPN A confirmed Resident #45 told him/her No he/she did not want to get up two times. LPN A said after the incident, he/she went and let the Director of Nursing (DON) know. LPN A said Resident #45 did not say anything to CNA A, nor did CNA A say anything to the resident. LPN A said Resident #45 asked him/her to get therapy staff, as he/she liked the ladies in therapy. LPN A said now after counseling he/she saw it was not okay to make the resident get up. If a resident refused, staff should notify the family and see if they can talk with resident. LPN A said Resident #45 had not had any upper respiratory issues or aspiration in the past 6-8 months and his/her tube feedings was stopped in November or December 2017. Review of LPN A's employee file showed in-service training on resident rights and abuse/neglect signed by LPN A on 09/27/17. During observation and interview on 01/26/18 at 8:08 A.M., showed the DON in Resident #45's room talking with resident. The DON told the resident LPN A wanted to come in and apologize to him/her and left the room. Resident #45 told the surveyor the police were here last night and he/she did not say anything to them. Resident #45 said he/she was still upset about what happened yesterday with LPN A. The resident said LPN A had done this before, but he/she didn't say anything. The resident was still very shaky. During an interview on 01/26/18 at 8:30 A.M. the Administrator said Resident #45's family member called him and said the resident was upset with LPN A. The family member was not sure what was going on and the Administrator went to talk with resident. The Administrator said Resident #45 said he/she was upset with LPN A, because LPN A made him/her get up in the chair. The Administrator asked Resident #45 if LPN A hit or shook him/her and the resident said no. The Administrator asked the resident why he/she didn't want to get up. The Administrator asked the resident if he/she thought LPN A was doing this for the resident's health benefit. The Administrator said it was a resident's right issue regarding choices, if staff went ahead and made a resident get up. The Administrator saw the message the resident sent his/her family member that said he/she was being abused. The Administrator said he felt it was being done for the resident's benefit. The Administrator pulled LPN A off the floor. When asked who took LPN A's place since he/she was still in the building and staff on duty at the time said he/she was the charge nurse, the Administrator said he called the regional office and asked for advice and also spoke with the survey team leader regarding what to do. The Administrator said with an abuse allegation we try to get a statement and got a verbal statement from LPN A and CNA A. Pulled LPN A off the floor at 11:20 A.M., after leaving Resident #45's room. At 11:50 A.M., the Administrator returned a call to the resident's family member and relayed what he was told by staff. The family member said the resident's response was very typical of his/her mental illness from what he/she knew as a sibling. The Administrator said he did not consider LPN A's actions abusive. The facility educated LPN A on the resident's right to refuse regardless of treatment. The Administrator said the resident had thrown him/herself on the floor in past. LPN A was concerned that the resident would throw him/herself on floor, so it was a safety issue when LPN A disconnected resident's recliner controller. The Administrator said CNA A said he/she answered the call light, changed the resident and asked him/her to get up. The resident told CNA A no. CNA A then went to get LPN A to help transfer the resident. The Administrator said the resident was upset at first, but was having pleasant conversation at the end and had calmed down. The Administrator said the resident was very clear and calm when he/she spoke with him, but did indicate he/she was upset. When asked for copies of written statements from LPN A and CNA A, the administrator said he did not obtain written statements. He talks with the staff and writes up a summary of discussion. Review of LPN A's time card dated 01/25/18 showed he/she clocked in to work at 6:59 A.M., clocked out at 11:20 A.M. and clocked back in at 12:05 P.M. LPN A's shift ended at 11:48 P.M., a total of 15 hours and 30 minutes. Further review of LPN A's time card and observation on 01/26/18, showed LPN A worked 9 hours and 15 minutes. Review of LPN A's employee Education Form dated 01/25/18, with no time documented, showed under description of incident: employee assisted resident out of bed and into his/her recliner chair after the resident stated he/she did not want to get up. Resident upset afterward and complained to family member and Administrator. Education Provided: Provide encouragement, explain risk involved with non-compliant behavior to resident when refusing to allow care. Document refusal in progress note. Inform care plan nurse and family. Residents have the right to choose care, and to refuse care. Signed by LPN A and DON. During an interview on 01/26/18 at 11:00 A.M., CNA A said Resident #45 had turned on his/her call light and LPN A told CNA A to get the resident up. CNA A said the resident was wet, he/she provided incontinence care and told the resident the nurse wanted him/her to get up. Resident #45 said LPN A was being sadistic and he/she didn't want to get up. CNA A went to the nurses station and told LPN A the resident didn't want to get up. CNA A said LPN A said let's go get him/her up. LPN A and CNA A went to the resident's room and LPN A told the resident we are going to get you up. Resident #45 yelled he/she didn't want to get up. CNA A said LPN A removed the resident's sheet, the resident tried throwing a water pitcher at LPN A, yelled and swung his/her right arm. LPN A then held the resident's arms to keep from being hit by resident. LPN A grabbed the resident's arm and had CNA A grab the resident's feet to sit him/her up on side of bed. LPN A asked the resident if he/she was going to stand up and the resident said he/she was not going to help. LPN A and CNA A then transferred the resident to the recliner. CNA A said the resident wasn't swinging anymore and must have bore weight, as he/she wasn't dead weight during the transfer and they did not have to drag him/her to the recliner. While transferring Resident #45 into the recliner, the resident was yelling at LPN A calling him/her names. Once Resident #45 was in the recliner, he/she grabbed the recliner controller. LPN A told CNA A Resident #45 would throw him/herself out of chair. CNA A said LPN A took the controller out of the resident's hand and unhooked it from the chair and put it on a shelf. After that, Resident #45 calmed down. When asked how Resident #45 calmed down, CNA A said the resident was not yelling or cursing anymore. CNA A said he/she had no memory of LPN A explaining/talking to resident about health benefits/conditions of getting up in the chair. LPN A set up the resident's table with a laptop, stylus and phone. CNA A said while assisting the resident with eating lunch, he/she asked Resident #45 if he/she was still upset and the resident showed him/her the message the resident had sent to his/her family member on the computer. CNA A said he/she had worked at the facility one week, worked as needed every other day and normally worked nights. Review of CNA A's written statement provided to surveyor on 01/26/18, after the CNA's interview showed CNA A wrote the following: Resident #45 turned his/her light on. On my way to to answer the resident's light LPN A stopped me and told me to get the resident up. I went in and answered the resident's call light and the resident said he/she was wet, so I changed him/her. After that I told the resident that the nurse told me to get him/her up. The resident said no, he/she did not want to get up and LPN A had it out for him/her. I said okay and told the charge nurse (LPN A). When I told LPN A the resident said no, LPN A said let's get him/her up. When we got to the resident's room, LPN A told the resident that he/she had to get up and that we were getting him/her up. The resident yelled no and called LPN A by name. LPN A started gathering the residents things to make space to transfer him/her from bed to recliner. The resident then threw his/her cup/pitcher and clock at LPN A and started to hit LPN A. LPN A grabbed the resident's arms and CNA A grabbed his/her legs so we could transfer the resident to the recliner. The resident stopped fighting LPN A, but he/she tried to get the remote to the recliner and LPN A took it out of the resident's hand and unhooked it from the chair. LPN A told CNA A that the resident would throw him/herself on the floor the remote was left attached. At this time the resident was calm. LPN A set up the resident's bedside table and gave him/her the call light. Review of CNA A's typed facility written statement dated 01/31/18, (six days after the incident), showed CNA A documented the following information: On 01/25/2018, sometime before lunch, Resident #45 put his/her call light on, and I was going to answer it, when LPN A told me that the resident had to get up. I went to the resident's room, and he/she asked to be changed. I changed the resident as requested, and then told him/her LPN A wanted him/her to get up. The resident told me LPN A was sadistic and had it out for him/her. I went back to the nursing station to tell LPN A that the resident refused, and LPN A said, Come with me. We're going to get him/her up. When we arrived, LPN A said, He/She is going to help me get you up. The resident refused and cursed at LPN A. LPN A set up the resident's table and pulled his/her recliner closer for the transfer. LPN A did not curse or yell at the resident, and LPN A spoke calmly. LPN A mentioned that the resident did not like to get up. When LPN A finished setting up the resident's table, LPN A went to lift the resident's legs out of bed, and then LPN A said don't let the resident swing. CNA A interrupted the resident's arm in the middle of the swing, and the resident stopped punching. CNA A did not have to hold the resident's arm. CNA A helped position the resident's feet on the floor and moved the resident to a sitting position. CNA A placed an arm under the resident's right arm during the transfer and LPN A placed his/her arm under the resident's left arm. The resident squeezed CNA A's arm during the transfer, but did not break the skin. The resident bore weight and we completed the transfer to the recliner. When in the recliner, the resident reached for the remote. LPN A took the remote from the resident, reclined the chair, disconnected the remote, and put it in the resident's closet. LPN A set up the table with the resident's electronics, asked if the resident wanted a speaker, but he/she did not want it. LPN A gave the resident his/her call light, asked if the resident needed anything else and the resident said no. The resident got on his/her computer. CNA A and LPN A then left the room. During an interview on 01/29/18 4:11 P.M., the DON said the facility process for an allegation of abuse was to immediately notify the Administrator. The Administrator or person receiving the allegation could notify the police or the Department of Health & Senior Services. Anyone and everyone is a reporter. If a staff person is alleged to abuse a resident, that staff is suspended or removed from patient care till investigated. Investigation conducted per procedure and report to DHSS. When the facility received the report that Resident #45 was complaining the nurse made him/her get up out of bed, we pulled LPN A off the floor. The resident was interviewed by Administrator. Once determined that there wasn't abuse, allowed LPN A to go back to the floor. The Administrator gets statements (verbal) from staff involved and writes a summary. LPN A brought in a written statement today. CNA A to provide a written copy of his/her statement tomorrow (1/30/18). The DON said LPN A was taken off the floor, clocked him/her out and kept him/her in the office. The Administrator placed a call of concern to the regional office. The DON said Resident #45 never complained about LPN A to the DON or staff before. The DON said LPN A will take the time to keep encouraging Resident #45 to get up. The DON said they talked with the residents on Resident #45's hall Monday (1/29/18) and they all like LPN A. The DON said the residents think LPN A is a wonderful nurse and are upset at the thought LPN A might not come back. Abuse/neglect training is completed in group sessions/inservice's also by shifts, small groups till we have gotten everyone trained on what our policies and procedures. The DON said LPN A misunderstood the surveyors question if he/she had been trained on abuse/neglect and LPN A had been trained. Review of LPN A's facility written statement dated 1/29/18 (four days after the incident) showed the following: LPN A documented he/she instructed CNA A that Resident #45 had not been up, so go ahead and get the resident up into his/her recliner. CNA A said okay and left to go to the resident's room. Approximately five minutes later, CNA A returned and said the resident did not want to get up. LPN A documented the resident needs encouraging and encouragement to get up. LPN A walked to resident's room with CNA A to assist getting the resident up. Upon entering the resident's room, this nurse greeted the resident and explained that we were going to get him/her and sit him/her in the recliner for a little while. Resident #45 replied , No, I don't want to get up. LPN A explained to the resident the importance of sitting up and getting out of bed. The resident stated No I don't want to get up. LPN A continued to encourage the resident that he/she needed to change his/her position to prevent skin breakdown. The resident then said to LPN A, No, it's because you are a sadistic [***] . LPN A continued to educate and explain the benefits versus the risk of laying in bed all day and how easy he/she could begin to breakdown. The resident became quiet and just looked at LPN A when he/she was done talking. LPN A looked at the resident and said Okay? and the resident stated Well I'm not going to help you. LPN A replied that's okay, I have help with me and at this point I thought it was okay to proceed. LPN A and CNA A then sat the resident up on the side of the bed. LPN A was holding the resident's left shoulder with his/her right hand supporting the resident's shoulder and CNA A supporting the resident's right shoulder. LPN A bent down to make sure the resident's feet were flat on the floor and out of no where, the resident swung his/her fist at LPN A. LPN A was able to move and avoid being hit in head. At that point, LPN A asked CNA A to place his/her hand over the resident quickly so we could transfer the resident. CNA A then placed his/her left hand over the resident's right hand and slid his/her right arm under the resident's right arm and used his/her left hand to hold the back of the resident's pants. LPN A had his/her left arm under the resident's left arm and LPN A used his/her right hand to hold the back of the resident's pants. CNA A and LPN A then transferred the resident to his/her recliner without incident. LPN A then asked the resident if he/she wanted his/her tablet and phone, and the resident stated yes. LPN A reclined the resident in the recliner and put the remote in the side pocket of the chair. LPN A turned around to see the resident had his/her recliner remote lifting him/herself to an upright position, saying I'm getting up. This nurse is aware the resident does not walk, is too weak to stand and this nurse has not observed the resident walking or standing since being employed. So to prevent the resident from falling, LPN A got the remote and placed the resident back into a reclined position with no objection from the resident. LPN A stated you're going to fall and I don't want you to hurt yourself and disconnected the remote. LPN A then gave the resident his/her electronic devices and sat them up in front of the resident and clipped the call light to the resident's shirt within his/her reach. LPN A then asked if the resident wanted his/her Bluetooth speaker and the resident replied no. As we walked out of the door the resident replied he/she would like to see therapy staff. We replied okay and walked out of the room. Not once during this entire event did I feel the resident was extremely angry. After approximately 30 minutes the resident rang his/her call light requesting to lay down. LPN A instructed CNA A and another aide to lay the resident back to bed. During an interview on 01/30/18 3:30 P.M. the resident's family member said the Administrator called about the incident. He/She could not remember now what happened really or what he/she was told. He/She just knows the Administrator was taking care of it. The family member said it had to do with staff getting Resident #45 up and he/she didn't want to get up. Resident #45, who was present during the interview, confirmed again the incident upset him/her. The family member said the Administrator told him/her it was a training issue on how to deal with this kind of issue. The family member said the resident is stubborn, and wants what he/she wants. The family member said it would upset the resident if staff forced him/her to do something he/she didn't want to do. The family member said the resident can make his/her own decisions about care. Resident #45 indicated to the family member he/she wanted to go to another facility, so he/she could see a psychiatrist for emotional issues. Resident #45 wrote to the family member and surveyor they don't help. The family member said the resident had never said he/she wanted to move before. MO 248

Based on observation, interview and record review the facility failed to assess skin breakdown when identified that resulted in a facility acquired unstageable pressure ulcer (unable to assess the bottom of the wound bed due to dead tissue) and failed to update the comprehensive care plan to include interventions for the care, treatment and prevention of pressure ulcers for one resident (Resident #6). Further, the facility failed to prevent the development of facility acquired stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough; may also present as an intact or open/ruptured blister) and stage III pressure ulcers (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss and may include undermining or tunneling) and failed to update the comprehensive care plan to include interventions for the care, treatment, and prevention of pressure ulcers for one resident (Resident #2). The facility census was 67. 1. Review of the National Pressure Ulcer Advisory Panel Reference Guide 2014 showed the following standards for the assessment of pressure ulcers: -Assess the pressure ulcer initially and re-assess it at least weekly; -Document the results of all wound assessments; -Assess and document physical characteristics including: -location; -Stage; -size; -tissue type; -color; -periwound (skin surrounding wound) condition; -wound edges; -undermining(area open around and beneath the edge of the wound) -tunneling(channels extending into the surrounding tissue) -drainage; -odor. 2. Review of the facility's Skin Assessment Policy dated 11/2010 directed staff on the following: -At time of admission, a head-to-toe physical assessment of the resident's skin will be completed by a licensed nurse in conjunction with the admission nursing notes. The assessment will be documented within the nurse's notes or on the nursing admission form. -Residents who are determined to be "at risk" for the development of pressure ulcers will have daily skin observation conducted by either a licensed nurse or a Certified Nurse Aide (CNA) which will be documented on either the daily skin observation record, the Treatment Administration Record (TAR) or if a CNA daily documentation tool is used; -All residents regardless of risks will have a documented weekly observation of their skin condition during their shower. This observation will be completed by the CNA staff and documented on the Skin Attention Form, shower sheet, or bath record. 3. Review of Resident #6's Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/30/14 showed the staff assessed the resident as follows; -No cognitive impairment; -Dependent upon staff with bed mobility, transfers, dressing, toileting and personal hygiene; -Uses wheelchair for mobility; -At risks for the development of pressure ulcers; -No Stage I (an observable, pressure related alteration of intact skin) or higher unhealed pressure ulcer present; -Pressure reducing device on bed and chair. Review of the nursing admission assessment form, dated 12/23/14, showed staff documented the resident did not have any open areas on the coccyx or buttocks region. Review of the nurse's noted, dated 1/1/15, showed staff documented "three small open areas noted on buttocks, pink wound base." Staff notified the physician and received an order to apply Duoderm (adhesive gel forming, wafer-like dressing) every three days and as needed. Staff documented the Assistant Director of Nursing (ADON) was notified. Staff did not document wound measurements, specific location, or stage of the wound. Review of the nurse's notes, dated 1/12/15, showed staff documented the "sacral wound deteriorated" and staff notified the physician. Staff obtained orders from the physician to discontinue the Duoderm and apply Santyl (enzyme ointment used to remove dead tissue) to the wound bed, cover with gauze and ABD (thick pad used to cover a wound) pad every day. Staff did not document wound measurements, appearance, specific location, or stage of the wound. Review of the resident's comprehensive care plan, dated 1/2/14, directed staff on the following interventions for the risk of the development and prevention of pressure ulcers: -Reposition frequently to relieve pressure on wounds and bony areas; -Skin checks weekly as ordered; see physician's orders [REDACTED]. Further review showed staff did not update the resident's comprehensive care plan on 1/12/15 or after to include specific, patient-centered interventions to direct staff on the care and treatment of [REDACTED]. Review of the mobile wound physician's progress note, dated 1/14/15, showed the following documentation: -Sacral area is an acute necrotic tissue, unstageable pressure ulcer. Initial wound measurements are 5.5 cm (centimeters) x 8.2 cm x 0.4 cm (depth), moderate amount of serous (red drainage) drainage with no odor. The wound bed is 76-100% moist, black eschar (dead tissue). Review of the nurse's notes, dated 1/15/15, showed staff documented the resident refused to get up in the wheelchair. The ADON documented staff educated the resident on the risks involved for failure to reposition frequently. Further, staff documented the physician was notified and new orders were received to treat the sacral pressure ulcer. Staff documented the physician ordered to discontinue the Santyl and apply alginate (absorbent dressing that promotes healing) and silver (cream used to reduce bacteria) to the wound bed, cover with gauze, and change every day. Staff did not document wound measurements or appearance, specific location, or stage of the wound. Review of the TAR, dated 1/1/15-1/18/15, showed the licensed staff did not document weekly skin assessments were performed. Review of the resident's medical record showed CNA staff did not document daily skin assessments on the daily skin observation record, the TAR, or a CNA daily documentation tool for residents at high risk for the development of pressure ulcers. Review of the resident's shower sheets and/or skin attention forms, dated 1/6/15 and 1/30/15, showed CNA staff only completed two forms for the entire month of January 2015. The CNAs did not document the weekly skin assessments during the month of January on the shower sheets and/or skin attention forms. Review of the weekly wound reports showed staff documented the following information about the resident's coccyx pressure ulcer: -1/7/15- coccyx pressure ulcer measured 1.0 cm x 0.5 cm; coccyx pressure ulcer first identified on 1/1/14; area with excoriation; and Duoderm every three days ordered for the treatment. -1-14-15- coccyx pressure ulcer current measurement 5.5 cm x 8.2 cm x 0.4 cm depth; unstageable with 75-100% moist, black eschar present to wound bed. Observation on 2/4/15 at 1:45 P.M., showed the ADON entered the room to apply a treatment to the resident's sacral pressure ulcer. The ADON removed the soiled dressing and cleansed the wound. The pressure ulcer was a circular, dark area covered with eschar. The periwound was red and moist. No odor was present. The ADON measured the pressure ulcer as 9.5 cm x 10 cm and said it was unstageable. During an interview on 2/6/15 at 9:00 A.M., the ADON said the initial skin assessment is done upon admission then weekly by a licensed nurse. The ADON said the CNAs are expected to assess skin during the showers and while providing daily care. The ADON said the weekly skin assessments are expected to be completed by the licensed nurse and documented on the back of the TAR. The ADON said the charge nurse or CNAs should notify him/her when an open area is identified. The ADON said he/she then measures the wound and gives it a preliminary staging. The ADON said he/she documents the initial wound assessment and measurements in the nurse's notes. The ADON said the wound physician is notified to perform weekly assessments and give the final opinion of the wound stage. The ADON said he was not notified on 1/1/15 from staff about the open areas found on the resident's "buttocks." Further, the ADON said the care plan should be updated to include interventions for prevention and treatment and should be specific to each resident. The ADON said other staff can and have the ability to update the care plans. 4. Review of Resident #2's POS showed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's hospital history and physical, dated 5/7/14, showed the resident was admitted to the hospital for wound care for a large stage IV ischial pressure ulcer. The wound was treated with antibiotics and after completion the resident was sent to the hospital for a surgical flap closing of the stage IV pressure ulcer. Review of the physician's progress note, dated 12/16/14, showed the resident had a chronic pressure ulcer since November 2013. The physician assessed the pressure ulcer as follows: - Wound to the left buttock is a chronic stage IV pressure ulcer that measured 3 cm by 2 cm by 1 cm, with an area of moderate amount of serous drainage, no odor noted, no signs and symptoms of infection, and slowly improving. Review of the resident's most recent MDS, dated [DATE], showed staff assessed the resident as: - Independent cognitive skills for daily decision making; - Requires assistance of one for all activities of daily living (ADLs); - Foley catheter and ostomy present; - At risk for pressure ulcer development and has a stage IV pressure ulcer measuring 2.5 cm by 2.8 cm by 0.8 cm. Review of the resident's plan of care, updated 12/9/14, showed staff documented the resident had [DIAGNOSES REDACTED]. Staff documented the resident requires assistance with ADLs and transfers with a mechanical lift and the assistance of two staff members. The resident has ostomy and suprapubic catheter for toileting needs. Additionally, staff documented an undated handwritten entry that the resident "may refuse to keep weight off wound." Review of the plan of care directed staff as follows: - Assist with bed mobility; - Inspect skin while providing care; if open areas are seen without a dressing inform nurse; - Ask resident reason for refusal and try to resolve any issues; - Use pillows as needed to assist with positioning. Review of the resident's pressure ulcer weekly report, dated 12/23/14, showed staff assessed the following areas: - Previous measurement of Stage IV on left buttock measured 3 cm by 2 cm by 1 cm. - 12/23/14 Stage IV left buttock measured 2.5 cm by 0.5 cm by 1.5 cm and has improved; - Onset date 12/22/14, showed unstageable 4 cm by 1 cm with no depth on coccyx; - Onset date 12/22/14, a 4.2 cm by 6 cm area with no depth to the right buttock; -A note written under the new areas showed they were identified as a result of a malfunctioning air mattress. Review of the resident's current plan of care showed no updates or interventions addressing newly developed pressure ulcers. The plan of care did not include the resident's physician ordered treatment, that the resident is seen by the wound clinic, nor that the resident was non-compliant with repositioning and care. Review of the weekly Pressure Ulcer Report, dated 12/30/14, showed staff assessed the following pressure ulcers: -Stage IV on the left buttock measured 2.9 cm by 1 by 0.9 cm and is unchanged; -Stage III- onset date 12/22/14, measured 3.3 cm by 1.2 cm by 0.1 cm coccyx, area improved; -Stage III onset date 12/22/14 measured 5.2 cm by 6 cm by 0.1 cm on the right proximal buttock; status unchanged; -Stage II onset date 12/22/14, measured 2.5 cm by 2 cm by 0.1 cm on the left proximal buttock, status unchanged. Review of the Pressure Ulcer Weekly Report, dated 1/7/15, showed the areas assessed as follows: -Stage IV left buttock measured 2.9 cm by 1 cm by 0.9 cm; status blank; -Stage III coccyx measured 3.3 cm by 1.2 cm by 0.1 cm; status blank; -Stage III right buttock measured 5.2 cm by 6 cm by 0.1 cm; status blank; -Stage II left proximal buttock measured 2.5 cm by 2 cm by 0.1 cm; status blank. During an interview on 2/4/15 at 3:00 P.M., the DON said the resident's skin is assessed during showers using the bath sheets. She said staff should document any skin issues on the bath sheet. Staff turn in the bath sheets to her every month and then they are discarded. The DON said the resident is seen by the wound clinic for pressure ulcers, however the wound clinic would not be in this week. The DON said the staff may also document skin assessments on the back of the Medication Administration Record [REDACTED] Review of the resident's bath sheet, dated 1/14/15, showed a bed bath was provided and staff did not note any skin problems, rashes, bruises, ulcers, skin tears, or excessively dry skin. Review of the TAR, dated 1/01/15 through 1/31/15, showed two entries as follows: - 1/13/15, treatment in progress to buttock and coccyx; - 1/20/15, treatment in progress to buttock and coccyx; Neither entry provided a description of the resident's pressure ulcers or measurements. Observation on 2/4/15 at showed the following pressure ulcers and measurements: - Stage IV to the left buttock measured approximately 1.7 cm by 1.2 cm; - Stage III left proximal buttock measured 3 cm by 2.5 cm; - Coccyx measured 1.6 cm by 1 cm. During an interview on 2/4/15 at 9:30 A.M., the resident said the day shift staff rarely turn and reposition him/her, but evening shift does reposition him/her. The resident said evening staff use pillows to reposition in bed as he/she cannot reposition him/herself. During an interview on 2/5/15 at 2:40 P.M., the ADON said staff turn the resident to prevent breakdown. The ADON said the resident had an air mattress and on 12/22/14, the air mattress was not holding air and had sunk in the middle to where you could feel the metal on the bed. The ADON said he ordered another air mattress which did not work so they are using an overlay instead of an air mattress, and it seems to work better for the resident and his/her condition. During an interview on 2/5/15 at 3:00 P.M., the social service designee said a physical therapy company is going to come to the facility to measure the resident for a new wheelchair and pressure relieving devices.

Based on observation, interview and record review, the facility failed to provide ordered wound care, maintain proper wound care technique, and assess and obtain new treatments for wounds for four out of 14 sampled residents (Resident #13, #6, #12, and #11). The census was 83. 1. Review of Resident #13's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/30/12, showed: -No memory or cognitive impairment; -Independent with all care; -Intravenous (IV, through the vein) antibiotics; -Foot infection. Review of the nurses notes, dated 5/8/12 at 12:05 P.M., showed staff made an appointment with the wound clinic for 5/17/12 at 1:00 P.M. Review of the nurse's notes, dated 5/17/12, showed no information about the resident leaving for a wound clinic appointment. Review of the physician's orders [REDACTED]. -Readmission from the hospital with a [DIAGNOSES REDACTED]. -[MEDICATION NAME] 0.1% (an antibiotic) to left great toe and dry dressing daily; -[MEDICATION NAME] 750 milligrams (mg) (an antibiotic) IV daily through a peripherally inserted central catheter line (PICC, a long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access); -No orders to flush or care for the PICC line. -Wound care consult. During an interview on 5/22/12 at 10:00 A.M., the resident said he/she came to the nursing home for IV treatment of [REDACTED]. He/She recently went back to the hospital and returned on 5/7/12. He/She was supposed to have a daily dressing change to the areas on the left foot, but on three occasions, he/she had to change the dressing because staff did not. He/She used the supplies, including the [MEDICATION NAME] ointment the hospital provided at discharge. He/She said there was supposed to be a wound clinic appointment but that had not happened yet and he/she could not find out why. He/She was uncertain who his/her physician was, because his/her IV bags had one name and he/she saw an infectious disease physician, and another physician's name was on his/her record. The staff also used the tube of [MEDICATION NAME] he/she brought from the hospital. He/She was worried because it was almost empty and staff did not seem to know how to get more. Observation on 5/22/12 at 10:20 A.M., showed a plastic bag from the hospital that contained alcohol wipes, tape, gauze dressings, wound cleanser and a tube of [MEDICATION NAME] with less than 1/8 of the tube left, stored on the floor under the chair in the resident's room. During an interview and observation on 5/22/12 at 12:50 P.M., Licensed Practical Nurse (LPN) J said the facility used [MEDICATION NAME] ointment on the resident's foot. He/She then searched the treatment cart and produced two tubes of [MEDICATION NAME] ointment from different drawers in the cart. The tubes did not have the resident's name on them and there was evidence that a pharmacy label was removed from the tubes. LPN J said those were the tubes he/she used for the dressing changes. During an interview on 5/22/12 at 1:42 P.M., the Director of Nurses (DON) said she found out from the pharmacy that staff faxed over an order on 5/7/12, for the [MEDICATION NAME] ointment, but the pharmacy failed to send any for the resident. The pharmacy would send the medication for the resident. During an interview on 5/23/12 at 11:45 A.M., Unit Manager, Registered Nurse (RN) O said he/she was not aware of the wound clinic appointment. He/she looked at the appointment book during the interview and saw cancelled written on the appointment sheet. He/she did not recognize the handwriting and there was no explanation on the sheet to say why the appointment was cancelled. He/she said the facility realized on 5/20/12, the resident needed to see a wound person. They use a company that comes to the facility on Mondays. The company was already gone on 5/20/12, when they realized the resident was supposed to have been seen. The resident would see the wound company on Tuesday 5/29/12, due to the holiday on Monday, 5/28/12. This information was not in the record and he/she could not say for sure if the physician knew the resident did not see the wound clinic. Observation on 5/24/12 at 9:28 A.M., showed the following: -LPN J washed his/her hands, took a pair of scissors out of his/her waist pack (the same scissors the surveyor saw used on another resident's dressing change just prior to Resident #13's dressing change. The LPN did not clean the scissors between the residents) and placed them along with the supplies needed for the dressing change on a clean towel on an over-bed table including a large packet of 4 by 4 inch gauze pads. -LPN J donned gloves and cut the soiled dressing off the resident's left foot; -LPN J cleaned the top of the left great toe and a small, less than 1 centimeter (cm) circular scab like area on the base of the great toe with wound cleanser and gauze. -LPN J reached into the pack of gauze for more pads to wipe the areas dry and then one more time to obtain 4 by 4's to put the [MEDICATION NAME] (a new tube labeled for the resident) on and use as a dressing; -Still wearing the same gloves worn to cut the soiled dressing off, LPN J applied the new dressing and wrapped the resident's foot with a gauze wrap. -LPN J put the scissors back in his/her pack, without cleaning them; -He/She removed the soiled gloves, washed his/her hands and put the packet of gauze pads back into the treatment cart. During an interview on 5/24/12 at 9:36 A.M., LPN J confirmed he/she did not clean the scissors he/she used between the dressing changes of the two residents. The scissors were his/her own and were not supplied by the facility. During an interview on 5/25/12 at 9:28 A.M., the DON said she expected the nurses to document in the notes when residents go to appointments or if they were cancelled. The nurse cancelling an appointment or making one should also communicate with the unit manager to ensure the orders were followed regarding appointments. 2. Review of Resident #6's MDS, dated [DATE], showed: -No memory or cognitive problems; -Minimal to no assistance needed for transfers, ambulation in a wheelchair, dressing and grooming; -Foot infection, surgical wounds. Review of the April and May 2012 POS, showed the following: -[DIAGNOSES REDACTED]. -an order written [REDACTED]. -an order written [REDACTED]. Observation on 5/24/12 at 8:12 A.M., showed: -LPN J washed his/her hands and donned a pair of gloves; -He/She then placed the necessary supplies for the dressing changes on a towel on an over-bed table, including a pair of scissors from his/her waist pack and a package of gauze 4 by 4 inch pads from the treatment cart; -The LPN started to cut the soiled dressing off the right foot dated 5/22/12, stopped went to the treatment cart to obtain red bag. He/She then removed the soiled gloves, washed his/her hands, donned a new pair of gloves and continued to cut the dressing off the right foot. -LPN J cleansed the areas on the right foot with normal saline and reached into the gauze pack several times to obtain new pads to cleanse and dry the foot; -He/She cut the tops off several packets of TAO with the scissors used to remove the soiled dressing. -LPN J applied the dressing and wrapped the foot with a kling wrap. He/She used the scissors to cut the roll of kling. Then, still wearing the soiled gloves, obtained a strip of tape from a large box of precut tape, reached into his/her waist pack, got a pen out and labeled the tape; -After labeling the tape and securing the dressing, LPN J removed the soiled gloves and washed his/her hands; -LPN J donned new gloves and cut the soiled dressing dated 5/21/12 off the left foot; -The dressing had a quarter sized, red stain on the outside and on the gauze next to the great toe amputation site, but there was no evidence of actual bleeding; -LPN J obtained gauze from the large pack at least four times during the dressing change and used the same scissors to cut open packets of TAO and the non-stick pads; -The amputation site was clean and had a less than 1 centimeter (cm) scabbed area where the toe should have been. -After applying the dressing, still wearing the same gloves, LPN J adjusted the resident's covers and pillow, placed the large pack of gauze pads in the cart before he/she removed the gloves and washed his/her hands. During an interview on 5/24/12 at 8:20 A.M., LPN J said the dressing he/she removed from the right foot was the one he/she applied on 5/22/12. The dressing to the left foot was supposed to be changed daily. Review of the treatment administration record (TAR), showed staff initialed they completed the treatment to the left foot on 5/23/12. During an interview on 5/25/12 at 9:28 A.M., the DON said each treatment cart had scissors. The staff should clean the scissors between each use. The staff should not wear the same gloves during the dressing change. The gloves should be removed and staff should cleanse their hands after removing the soiled dressing. Treatments should be completed as ordered. 3. Review of Resident #12's quarterly MDS, dated [DATE], showed the following: -Required extensive assistance for dressing, hygiene, and bathing; -Incontinent of bowel and bladder. Review of the resident's care plan, updated 3/8/12, showed the facility identified the resident's dependence on staff for all daily care, incontinence of bowel and bladder, and history of skin breakdown. The approaches included for staff to perform weekly skin checks with documentation, report problems to physician as needed, observe skin for changes/abnormalities during care, report findings to nurse as needed. The goal was for the resident to have no skin breakdown through the next review. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -Skin assessment weekly. -No current orders for treatment to the resident's toes. Review of the TAR, dated May 2012, showed the following: -Skin assessment, check and record weekly on Fridays: -5/11/12, DuoDerm (wound treatment) to right buttock intact. Protective barrier cream after each incontinent episode. No other skin issues notes. -No current treatment for [REDACTED]. Observation on 5/23/12 at 12:33 P.M., showed a scabbed area on the resident's middle toe on the left foot and a pinpoint area on the fifth toe. During an interview on 5/23/12 at 12:35 P.M., RN A said the staff applied triple antibiotic ointment to the toe and left it open to air. Review of the TAR, dated May 2012, showed the following: -Skin assessment, check and record weekly on Fridays: -5/25/12, DuoDerm to right buttocks, changed as needed. No other open areas noted. -No current treatment for [REDACTED]. During an interview on 5/25/12 at 11:25 A.M., RN K said he/she saw the scab on the resident's toe before, and he/she had not put anything on it. It should be on the skin assessment. Toes should be included as part of the skin assessment. The night nurse did the skin assessment. Review of the wound assessment record, dated 5/25/12, showed a 1 cm by 1.3 cm superficial area on the resident's left third toe. The nurse (RN K) documented the area as dry and scabbed with no signs/symptoms of infection. 4. Review of Resident #11's care plan, dated 12/9/11, showed the following: -Weekly skin checks with documentation; -Observe skin daily during daily care, notify nurse of any changes; -Treatment per physician orders; -Notify physician as needed of any change in condition. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -12/19/11, cleanse area on right hip with wound cleanser or normal saline, apply [MEDICATION NAME] (an opaque dressing used to create a moist wound healing environment while protecting from contamination) dressing change every three days and as needed; -2/22/12, skin assessment check and record weekly. Review of the resident's TAR, dated 2/1/12 through 2/29/12, showed no order for weekly skin checks transferred and no wound documentation. Review of the resident's MDS, dated [DATE], showed: -Required extensive one person assistance with hygiene, toileting, and bathing; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -At risk for pressure ulcers. Review of the TAR, dated 3/1/12 through 3/31/12, showed the skin assessments initialed on 3/12/12 and 3/19/12, but no notes present. No documentation of the condition of the resident's right hip. Review of the TAR, dated 4/1/12 through 4/30/12, showed the skin assessment documented 4/19/12, with a notation, dated 4/19/12 "treatment continues to right hip. No new open areas or bruising noted." Review of the TAR, dated 5/1/12 through 5/31/12, showed no documentation of the weekly skin checks performed, no notation on the back of the TAR, or a description of the treated area on the right hip. Observation on 5/22/12, showed: -8:00 A.M., the resident sat outside the TV room by the nurse's station. He/she scratched the back of his/her neck several times. -8:28 A.M., the resident sat by the nurse's station and scratched the back of his/her neck. -9:00 A.M., the resident sat in an activity. He/she repeatedly scratched the back of his/her neck. -10:35 A.M., the resident sat on side of bed. He/she had a pencil eraser sized scab on the right shin, a skin tear on the left forearm, 20 small scabs on the left forearm, over 32 scabbed areas on the left upper arm and a reddened abrasion at base of skull. -12:35 P.M. showed the right hip had a reddened area without any opening. Observation on 5/23/12, showed: -11:00 A.M., he/she sat in dining room and scratched the back of his/her neck. -12:30 P.M., resident sat up in bed, scratched arms and back of neck. Area at base of skull approximately 5 cm by 4 centimeters cm, reddened, dry and crusty. Several scabbed areas noted. During an interview on 5/23/12 at 3:45 P.M., LPN B said the resident did not have any open areas except for the left arm. He/she did not notice the resident scratched much and he/she did not know of any treatment orders. He/she did not know how long there had been open areas. During an interview on 5/24/12 at 11:13 A.M., CNA C stated the resident had scratched for a long time. When he/she worked on the resident's assignment, he/she put lotion on the resident when he/she got the resident up or gave him/her a shower. He/she was not assigned to the resident very often and he/she did not know how long the skin was open. Review of the resident's POS, showed staff obtained an order for [REDACTED]. Observation and interview on 5/25/12 at 8:30 A.M., showed the resident's base of the skull with a 5 cm by 8 cm red and crusty area with several small scabbed areas noted. Scabbed areas on left arm increased in size and number. The resident complained his/her neck and arms itched, and said lotion did not help it.

Based on observation, interview and record review, the facility failed to obtain medications, including narcotic pain medications, for a new admission who experienced severe pain, change dressings to skin tears as ordered, document descriptions of skin tears and report laboratory results to the physician timely, for four of 13 sampled residents. (Resident #32, #33, #34 and #6) The census was 82. This deficiency remains uncorrected. For previous examples see the statement of deficiencies at Event ID#BL6O11 dated 5/25/12. 1. Review of Resident #32's history and physical summary from the hospital, dated 7/17/12, showed: -Date of birth 8/7/71. -Admission to emergency department on 5/19/12, for three days of nausea, vomiting and diarrhea. The resident said it happened every two weeks and denied any contact with sick people. The resident reported gastroparesis ([DIAGNOSES REDACTED] of the stomach in which food does not transport through the digestive tract appropriately) and had been on [MEDICATION NAME] and [MEDICATION NAME] (anti-nausea drugs) without any improvement. He/she stopped taking his/her insulin since he/she was not eating or drinking, became fatigued and came to the emergency department. He/she had a [MEDICAL CONDITION] bladder (lack of bladder control due to a brain or nerve condition) and performed straight catheterizations (inserting a tube into the bladder to drain urine). -In the emergency department, the resident had polyuria (excessive passage of urine often found in residents when their diabetes is in poor control) after running out of insulin with blood glucose in the 600's (normal range 60-100); -Much pain, started after a cervical injury; -[DIAGNOSES REDACTED]. -allergies [REDACTED]. -Vital signs: pulse 108 (normal 60 to 80), blood pressure 166/89 (normal 120/80), respirations 18 (normal range 12 to 20), temperature 96.5 degrees Fahrenheit (F) (normal 98.6 degrees F), pain 10 out of 10 (pain measurement scale with 0 as no pain, 4 to 6 moderate pain and 7 to 10 severe pain), 69 inches tall and weighed 108.7 pounds. -A weight loss of 50 pounds within the last year. Review of the resident's admission nurse's note, written by LPN B, dated 7/17/12 at 1:00 P.M., showed an assessment from head to toe completed and charted in the appropriate area. Discharge orders (from the hospital) verified with the physician and the physician told of new admission and history. Discharge orders, new orders and new medications faxed to the pharmacy and the physician's office. Resident oriented to facility, asked if he/she had any pain, he/she rated pain a 7 on a scale of 1 to 10, to his/her back, neck and left leg. Nurse assured the resident once his/her pain medications were brought to facility from the pharmacy, he/she could get some, approximate time when he/she could get them was that night or the next day. He/she wrote the resident complied and had no problems with that. Admission completed. No further nurse's notes until 7/18/12 at 6:00 A.M. Review of the resident's nurse's note for the night shift written by LPN FF, dated 7/18/12 at 6:00 A.M., showed the resident remained on observation for new admission. The resident complained of pain, but refused as needed (PRN) Tylenol (used to treat mild to moderate pain) because he/she said it would not work. LPN FF wrote he/she called the pharmacy twice in regards to the pain medication and the pharmacy said that they would call the physician by 9:00 A.M. and would then send the pain medication. LPN FF wrote he/she would pass on in report to day shift, to follow up with pain medication delivery. No vital signs documented. Review of the resident's physician order [REDACTED]. -[MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]-a narcotic pain medication to treat moderate to severe pain) tablet, 5/325 by mouth every 6 hours as needed; -[MEDICATION NAME] (a narcotic pain medication to treat moderate to severe pain) 30 milligrams (mg) SA (extended action) one tablet by mouth every 12 hours for pain (8 A.M. and 8 P.M.); -[MEDICATION NAME] 5% (a pain patch used to relieve nerve pain), apply to affected area once a day (leave on for 12 hours, remove and destroy, off for 12 hours, repeat); -[MEDICATION NAME] (a medication used to lower blood pressure) 10 mg tablet, take one half tablet by mouth once a day to lower blood pressure. (Do not take if systolic blood pressure (the upper number of the blood pressure) is less than 100.); -Menthol/M-[MEDICATION NAME] 10-15% topical cream (menthol/aspirin combination pain medication), apply liberally to affected area four times a day. External use only; -[MEDICATION NAME] ([MEDICATION NAME]-an anti-nausea medication) 10 mg tablet. Take one half tablet by mouth three times a day with meals for gastroparesis (6 A.M., 11 A.M. and 4 P.M.); -[MEDICATION NAME] 20 mg ([MEDICATION NAME]-a medication for GERD) EC capsule. Take two capsules by mouth twice a day, 30 minutes before meals (6 A.M. and 4 P.M.); -[MEDICATION NAME] HCL 8 mg ([MEDICATION NAME]-an antinausea medication) tablet. Take one tablet by mouth before meals for nausea associated with gastroparesis (6 A.M., 11 A.M. and 4 P.M.); -Polyethylene [MEDICATION NAME] ([MEDICATION NAME]-a powder laxative) 3350, measure one cap and mix in eight ounces of water as needed; -[MEDICATION NAME] ([MEDICATION NAME]-an antidepressant) 40 mg tablet. Take one half tablet by mouth every morning; -[MEDICATION NAME] 300 mg capsule (a medicine used to treat neuropathic pain) three pills three times a day (8 A.M., 4 P.M. and 8 P.M.); -Blood sugar checks four times a day (6 A.M., 11 A.M., 4 P.M. and bedtime); -[MEDICATION NAME] (fast acting) sliding scale insulin; -Insulin [MEDICATION NAME] ([MEDICATION NAME]-long acting insulin) 15 units at bedtime. Review of the pain screening form completed by facility staff and dated 7/17/12, showed the resident at a level of 5 (5 or greater indicated a comprehensive pain assessment was needed). The resident had moderate daily pain. Review of the mini-mental exam completed by facility staff dated 7/17/12, showed he/she was at normal level. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. or bedtime on 7/17/12. Staff did not administer the resident's [MEDICATION NAME] at bedtime. At 6:00 A.M., the resident's blood sugar registered 185 and staff administered 3 units of [MEDICATION NAME] sliding scale insulin. Observation and interview on 7/18/12 at 8:40 A.M., showed the resident lay in bed on his/her stomach. The resident said he/she was in a lot of pain and had been throwing up. He/she had not received any medications, including pain medications. A plate of food sat at his/her bedside. The resident said he/she was not going to eat. The resident said he/she had pain yesterday when admitted . It was at a level of a 7. Review of the resident's nurse's note written by the Director of Nurses (DON) dated 7/18/12 at 11:00 A.M., showed she notified the physician of the resident's medications not being delivered from the pharmacy the night before and would be sent STAT (immediately) on 7/18/12. No new orders received, medications would be resumed per schedule. Observation and interview on 7/18/12 at 12:55 P.M., showed the resident lay in bed. He/she said he/she couldn't sit up because he/she throws up. He/she had not received any medications at all and was in a lot of pain. His/her pain level was at an 8 and said it was both muscular and joint pain in his/her back and legs. During an interview on 7/18/12 at 1:20 P.M., the DON said the facility had an emergency medication supply that had antibiotics and injectables, but no pain medications. During an interview on 7/18/12 at 1:50 P.M., the resident's primary care physician said the facility usually calls his office to get medication orders. The facility should then fax the orders to the pharmacy. He thought six hours was an appropriate time period to have orders verified and sent to the pharmacy. The night before when the facility hadn't received the resident's medications, the nurse on duty should have called the pharmacy, given the allergy information over the phone and requested immediate delivery of the medications. If necessary, the nurse should have called the pharmacy again to follow up. He had received an informational text message on 7/17/12 at 2:20 P.M., from his office that the resident had been admitted and another physician in the group had confirmed the resident's orders. He was not aware of the resident's pain level, he planned to meet with the resident for the first time that day. When the pharmacy received orders for narcotic pain medications, they would call or text the physician to call the pharmacy. The physician would then give a verbal order for the medications to be filled and that provided a three day emergency supply of pain medications until the doctor could get the pharmacy a written prescription. The pharmacy called the physician earlier that morning (7/18) to procure a verbal order for emergency pain medications and he signed the orders the pharmacy faxed to his office earlier that morning. He did not remember speaking with the DON at 11:00 A.M., that morning about the medications not being in or what to give the resident when it did come in. He then scrolled through his phone records and said the only record from the facility was a call at 9:30 A.M., about an x-ray for a different resident. When the medications were delivered, the facility should call the physician and find out what he wanted the resident to have at that time, instead of administering medications without consultation. He did not know when the medications had arrived and had not been able to review the resident's chart and determine what to administer. During an interview on 7/18/12 at 2:30 P.M., the DON said she was not aware the night before that the resident had not received his/her medications. The nurse was still in the facility at 1:00 A.M. or 1:30 A.M., working on the admission. She did not expect staff to call her at home to inform her of the lack of medications. He/she said no non-pharmacological pain relief measures had been attempted with the resident the night before. She saw the resident in the hall at 5:30 A.M., with his/her walker. The resident said he/she would like a whirlpool bath and the DON got someone to help the resident with it. During an interview on 7/19/12 at 10:30 A.M., a customer service agent for the facility's pharmacy said the first logged communication the pharmacy received concerning the resident's medication was a fax with new orders at 12:47 A.M. on 7/18/12. No allergies [REDACTED]. All of the medications, except for the narcotics, were signed for at the facility at 12:07 P.M. on 7/18/12, according to the computer record. Observation on 7/18/12 at 2:10 P.M., showed the resident lay in bed and said he/she received two pills for his/her stomach. He/she was still in a lot of pain and had not received any pain medication. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., showed certified medication technician (CMT) KK had only administered [MEDICATION NAME] and [MEDICATION NAME] to the resident. During an interview on 7/18/12 at 2:37 P.M., the DON said the resident's narcotic pain medication had arrived and she sent the nurse directly to the resident's room to administer it. The CMT originally gave the two medications, but was instructed to give others that were once a day and/or were due and adjust the times for the day. She did not know the CMT only gave two of the resident's medications. During an telephone interview on 7/19/12 at 3:30 P.M., the administrator said the facility did not have a new admission policy and procedure. 2. Review of Resident #33's July 2012 POS, showed the following: -Hospice care; -[DIAGNOSES REDACTED]. -No treatment order for a skin tear to the left forearm until 7/11/12, when staff obtained an order for [REDACTED]. Review of the nurse's notes, showed the following: -No information about a skin tear to the left forearm prior to 7/6/12, by facility or hospice staff; -7/6/12, no time noted, note by hospice, Op-site (a clear adhesive dressing) to left forearm skin tear. The note did not contain a description of the area, or information how the skin tear occurred. -7/9/12, no time noted, note by hospice, dressing to left forearm intact. The note did not contain a description of the area. -7/11/12 at 7:50 A.M., note by hospice, Op-site replaced over skin tears times two, to left forearm; -7/11/12 at 2:00 P.M., the resident pulled [MEDICATION NAME] (a clear adhesive dressing, similar to Op-site) off, put on by hospice that morning, making a skin tear. The note did not contain a description of the area. -No description of the skin tear as of 7/18/12. Observation during incontinence care on 7/18/12 at 7:31 A.M., showed an adhesive gauze dressing on the resident's left forearm dated 7/16/12. Observation and interview on 7/18/12 at 8:05 A.M., showed Nurse U removed the dressing dated 7/16/12, from the resident's left forearm. The dressing contained a moderated amount of yellow tan drainage. Nurse U commented the wound looked infected and he/she would not use an adhesive dressing, but would wrap the area with gauze to protect the skin from further damage. The charge nurse, LPN J on duty 7/17/12, should have changed the resident's dressing. During an interview on 7/18/12 at 9:00 A.M., the DON said the hospice staff should tell the charge nurses if they find an open area and apply a dressing. The hospice worker thought she obtained an order on 7/6/12, for the Op-site and made a note in the chart about the description of the area, but obviously did not. 3. Review of Resident #34's July 2012 POS, showed the following: -[DIAGNOSES REDACTED]. -An order dated 7/3/12, to cleanse the left arm with normal saline or wound cleanser, apply Santyl (an ointment that removes dead tissue and heals good tissue) with Vaseline gauze (a gauze impregnated with Vaseline to keep the area moist) and a dry dressing every day and as needed until healed. Review of the nurse's notes, dated 7/2/12 at 4:00 P.M., showed the Mobile Wound Solution (MWS) company (an outside agency specializing in wound care) saw the resident and obtained an order for [REDACTED]. Review of the MWS documentation dated 7/16/12, showed the area on the resident's left arm measured 0.4 centimeters (cm) by 1.2 cm by 0.1 cm deep. Observation on 7/18/12 at 7:17 A.M., showed Nurse O removed a dressing dated 7/16/12, from the resident's left arm and completed the dressing change as ordered. During an interview on 7/18/12 at 7:25 A.M., Nurse O said the dressing should have been changed on 7/17/12, by LPN J. LPN J did not initial the treatment record that he/she completed the dressing change. During an interview on 7/18/12 at 1:35 P.M., the DON said LPN J should have changed the dressing as ordered. The nurses were monitoring the dressing changes and they were completed as ordered up to yesterday. They do not know what caused the wound to the resident's left arm. The MWS staff came in and did full body audits and found the open area on the resident's arm. 4. Review of Resident #6's July 2012 POS, showed the following: -[DIAGNOSES REDACTED]. -An order dated 6/25/12, to cleanse the right great toe with wound cleanser or normal saline, apply [MEDICATION NAME] (an antibiotic) ointment and cover with a dry dressing twice a day; -An order dated 7/11/12, to obtain a culture of the toe; -An order dated 7/16/12 at 8:45 P.M., to administer [MEDICATION NAME] (an antibiotic) 1.5 grams, intramuscular (IM, injection into the muscle) every six hours, no stop date; -Surgery scheduled 7/20/12, for toe amputation. Review of the laboratory results, showed staff obtained the culture on 7/11/12 and the results were available on 7/14/12, but were not printed in the facility until 7/16/12. Staff paged the physician at 7:15 P.M. on 7/16/12, reported the results at 8:45 P.M. and received orders for the [MEDICATION NAME]. Review of the MAR, showed the resident did not receive any doses of the [MEDICATION NAME] on 7/17/12. He/She received the first dose at 12:00 A.M., on 7/18/12. During an interview on 7/18/12 at 11:00 A.M., the DON said the facility received the laboratory results via a printer which was set to auto print the results Monday through Friday. They did not receive printed results during the weekend. The laboratory should call if there were any critical labs generated on the weekend. According to the resident's physician the organism in the resident's toe was colonized (the bacteria is present, but not causing a disease) and the only real treatment was amputation. The facility has not received laboratory test results on the weekends for awhile. She did not know why there was a delay to administer the antibiotic.

Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1) who was at risk for elopement. The facility identified nine residents as at risk for elopement. Of those nine, five residents were sampled. On the morning of [DATE], Resident #1 eloped from the facility, undetected by facility staff. The resident was not found until [DATE]. The resident was found in a creek located approximately one mile from the facility. He/she had expired. The census was 80. 1. Review of Resident #1's facility face sheet, showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medical record, showed there was no social service initial assessment completed. Review of activity notes, dated [DATE], showed the resident walked the building. Review of social service notes, dated [DATE], showed social services met with the resident in the hallway, and asked the resident if all was well. The resident said yes. The resident appeared to be adjusting well to his/her new environment. Review of the resident's Elopement/Flight Risk Assessment, dated [DATE], showed the following: -Behaviors that might predispose him/her to leaving the facility; -Exiting behaviors or attempts to leave any facility; -Wandered aimlessly; -Past history of flight risk from another facility. Review of the nurse's notes, dated [DATE] at 7:00 P.M., showed the resident was alert, talkative and confused. The resident was ambulating on the halls and attempted to elope out of exit doors. Staff redirected him/her to bible study. Review of the resident's care plan, dated [DATE], showed the following: -Problem: Alert to self with intermittent confusion, ambulated independently around the facility. Wandered daily and at risk for wandering into unauthorized or unsupervised areas placing him/her at risk for harm. Resident attempted to leave facility. -Goal: Will not leave the facility unattended through next review. -Approaches: -Remove resident from exit doors, redirect resident as needed; -Check whereabouts per facility procedure; -Offer a diversion/distraction as needed; -Redirect to room, activity room or TV room, etc. as needed; -Rounds every two hours and as needed to assess needs, incontinence, positioning, comfort and safety; -Check exit alarms per protocol; -Monitor whereabouts frequently; -Alert staff to wandering behaviors; -Approach in a calm, accepting manner; -Picture in elopement risk book. Further review of nurses notes, showed the following: -[DATE] for the 7:00 A.M. through 3:00 P.M. shift, resident ambulatory. Confusion noted, needed redirection at times. -[DATE] at 7:00 P.M., alert and talkative. Ambulating on halls. Very confused. Sleeping a great deal on shift. Redirected to room, numerous times. -[DATE] for the 7:00 A.M. through 3:00 P.M. shift (late entry), the resident was ambulatory, alert with some confusion noted. Needed redirection at times. -[DATE] at 7:00 P.M., ambulating on hallways. Alert and talkative and confused. -[DATE] at 6:00 A.M., up in hallway one time during the night. Redirected back to bed. -[DATE] at 6:00 A.M., up in hallway early part of night. Easily redirected to his/her room. -[DATE] at 5:00 A.M., resident up this shift. Was encouraged to go to room to rest. Resident was non-compliant. Further review of activity notes, dated [DATE], showed the resident walked the building. Review of the Interdisciplinary Care Plan Conference Record, dated [DATE], showed the resident wandered about the facility daily. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Disorganized thinking; -Wandered daily; -Independent with most activities of daily living. Review of the physician's progress note, dated [DATE], showed the resident's [DIAGNOSES REDACTED]. Review of the Elopement/Flight Risk Assessment, dated [DATE], showed the following: -Behaviors that might predispose him/her to leaving the facility; -Exiting behaviors or attempts to leave any facility; -Verbally expressed the desire to go home, leave or packed belongings to go home or stayed near exit doors; -Wandered aimlessly; -History of exit seeking; -History of exiting other facility. Further review of the nurse's notes, dated [DATE] at 1:15 P.M., showed the nurse was notified by staff that the 200 hall exit door alarmed. The resident exited the door, but remained in eye sight of staff. The resident was redirected easily in the building by staff. The resident said he/she was looking for his/her keys, and wasn't going anywhere. The resident was assisted to the TV room on the West wing. The resident sat in a recliner and said this was where he/she was going. Further review of the resident's care plan, updated on [DATE], showed the facility added an intervention, offer resident a snack when exit-seeking. During an interview on [DATE] at 8:45 A.M., the Director of Nurses (DON) said most of the time, the resident had been looking for food when he/she wandered and staff gave him/her a snack after the incident on [DATE]. The resident had been fine after that. Further review of the nurse's note, dated [DATE] at 8:10 A.M., showed the resident had last been seen in the West resident lounge at 7:30 A.M. At 8:00 A.M., staff could not locate the resident for breakfast. A house wide search was completed and the resident was not found inside the facility. Grounds were searched. The family and the police were notified. At 9:00 A.M., the police were at the facility and filed a report. The police returned at 9:50 A.M., and requested another facility search. During an interview on [DATE] at 8:10 A.M., Certified Nurse Aide (CNA) D said he/she arrived at the facility on [DATE] at 6:50 A.M. CNA D said he/she saw the resident seated in the lounge and asked the resident if he/she had been to breakfast. The resident said no. CNA D told him/her to go to breakfast. CNA D went to the dining room and did not see the resident when he/she came back down the hall at approximately 7:15 or 7:20 A.M. CNA D said he/she did not hear any alarms go off. The resident loved to hang out by the 400 Hall exit door and look out the window. CNA D said the resident had gone out the door sometime during the summer and staff brought him/her back inside. During an interview on [DATE] at 10:20 A.M., Certified Medication Technician (CMT) E said he/she observed the resident in a recliner in the lounge at 7:30 A.M., when he/she passed by with the medication cart. CMT E said he/she did not hear door alarms that morning. The resident sometimes went to the doors and looked out the window. During an interview on [DATE] at 8:45 A.M., the administrator said they did not know how the resident got out of the facility. There was a 30 minute window where he/she had not been seen by anyone and none of the door alarms sounded. The resident had been in the Elopement Risk Book, but had not been on 15 minute checks after he/she got out of the building on [DATE]. During an interview on [DATE] at 9:15 A.M., Maintenance employee F said the exit doors were checked monthly with the fire drill. Observation on [DATE] at 10:05 A.M., showed all eight of the facility's exit doors alarmed and released with the push bar in 15 seconds. After the doors closed, there was a five second delay before the doors relocked. During an interview on [DATE] at 10:15 A.M., CNA A stated the resident often went to the doors and had to be redirected. During an interview on [DATE] at 10:25 A.M., CNA B said the resident wandered all over the building and pushed on the doors until the alarms sounded. He/she stated this behavior occurred every day. CNA B said the call lights sounded a lot like the exit door alarms. When staff were in the resident rooms with the water running, they were not able to hear the alarms. During an interview on [DATE] at 10:50 A.M., CNA C stated the resident wandered the facility and pushed on doors every now and then. CNA C said the call light and the exit door alarms sounded the same. During an interview on [DATE] at 10:34 A.M., the social worker said the resident sometimes wandered into a room, but was easily redirected. She had not seen the resident attempt to get out of the exit doors. During an interview on [DATE] at 10:37 A.M., the activity director said the resident came to activities, but would not stay. The resident liked to walk. He/she would get cookies and something to drink, but when the resident wanted to walk, he/she walked. During an interview on [DATE] at 10:15 A.M., the resident's physician said the resident had dementia and some exit-seeking behaviors. He was not notified by the facility about the resident's elopement and was very disappointed that no one called him. The physician was perplexed about how the resident could have gotten out of the facility because one had to be cognitively functional to get out. The resident must have sneaked out, but it was hard to see that happening. During an interview on [DATE] at 8:19 A.M., the resident's adult child said when he/she and the resident's spouse placed the resident at the facility, staff were made aware of the fact that the resident had been physically able and had walked out of a facility before. The resident's security had been the main reason for placement at the facility. Other facilities had denied the resident's admission because of his/her elopement attempts. The administrator and other staff were told the resident wandered and had reassured them the resident would be safe. They had not been notified by the facility of instances when the resident had gotten out of the facility or had tried to get out of the doors. The resident had been missing before 7:30 A.M., because he/she received a call from the facility at 7:27 A.M., saying they could not locate the resident. Review of wunderground.com for ,[DATE] through ,[DATE], showed the temperature ranged from 48 degrees Fahrenheit (F) to 83 degrees F. Conditions included clouds, overcast and light rain. Review of the police report, dated [DATE], showed a missing person's report was made to the police department at 8:44 A.M. from the DON. The report showed the resident was last seen on [DATE] at 7:30 A.M. sitting in the lounge by the nurses station. When the resident did not show up for breakfast at 8:00 A.M., staff began looking for him/her. The resident wore an orange shirt, grey sweatpants and black shoes. The report noted it was an extremely windy day. The police notified the adult child who advised them the resident had dementia and a history of walking away from a nursing facility. The adult child told the police they moved the resident to the facility in April, because it was supposed to be a more secure facility. On [DATE], while searching for the resident, a detective observed the resident in a creek with most of his/her body submerged in water. The resident had expired. During an interview on [DATE] at 8:53 A.M., the administrator at the medical examiner's office said the resident had been found partially submerged in a creek. The preliminary results of the autopsy showed the resident drowned. Review of the facility's policy, entitled "Elopement/Flight Risk Management", dated [DATE], included the following: -Purpose: The purpose of this policy is to establish guidelines ensuring that each resident is assessed to determine if they are at risk for elopement or flight and to ensure that they receive appropriate and individualized interventions that reduces this risk if it exists. -Policy Statement: It is the policy of this facility that each resident will be assessed for potentially adverse behaviors that place them at risk for elopement. Risk assessments will be completed at time of admission, 14 days after admission and reviewed for changes quarterly and/or with any significant change in condition. This policy is not intended to dictate specific elopement. It is expected that individualized interventions be implemented when possible to minimize the risk of elopement/flight. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J." Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility added Immediate Door Alarms that must be turned off with a key, inserviced all staff on responding to door alarms, inserviced staff about exit seeking behaviors, began inservicing on diversional activities for exit seeking behaviors and changed the tone of the call light system to assist staff with identifying the door alarms. The facility will assess all residents for elopement risk and update the care plans of those identified as at risk with individualized interventions. 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 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 Class I violation(s). MO 776

Based on observation, interview and record review, the facility failed to notify one of three sampled residents' physicians of a change of condition. The facility failed to notify one resident's physician of extensive bruising (Resident #1). The facility failed to assess, document, and follow physician orders [REDACTED].#2). The census was 79. 1. Review of Resident #1's face sheet, showed the following: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's POS, dated 6/1/11 through 6/30/11, showed the following: -An order, dated 9/2/10, for aspirin (blood thinner) 81 mgs (milligrams) one tablet by mouth once a day; -An order, dated 9/2/10, for [MEDICATION NAME] (extends a resident's bleeding time) 100 mg one tablet by mouth once a day; -An order, no date, for [MEDICATION NAME] (blood thinner) a total of 7 mgs by mouth once a day during the evenings. Review of the resident's care plan, dated 6/8/11, showed the following: -Problem: at risk for bruising due to the effects of [MEDICATION NAME] therapy; -Goal: the interventions will reduce the possibility of the resident getting bruises; -Approaches: report all signs of any bruising to nurse immediately and monitor sight for changes. Review of the resident's MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Required extensive assistance from the staff for bed mobility, transfers, dressing and toilet use; -Required total assistance from the staff for personal hygiene and bathing; -Balance during transferring was not steady moving from sit to stand position and on and off toilet; -Always incontinent of bowel and bladder. Additional review of the resident's POS, dated 6/1/11 through 6/30/11, showed the following: -An order, dated 6/16/11, for [MEDICATION NAME] (blood thinner) a total of 9.5 mgs by mouth once a day during the evenings. Review of the resident's nurses' notes, showed the following: -6/21/11, no time documented, bruises noted to the knee and wrist when the resident lay on the bed rails. Bruise also noted to the chest area (no sizes, diameters or descriptions documented). The resident's physician was notified. -6/22/11, no time documented, bruise to the left chest wall area (no size, diameter or description documented). The bruises of the knee, wrist and the chest wall was reported to the physician. -6/23/11, there was no documentation regarding the appearance or condition of the bruise from all three shifts. -6/24/11, no time documented, bruising remains (no size, diameter or description documented). -6/25/11, there was no documentation regarding the appearance or condition of the bruise from all three shifts. -6/26/11 at 8:00 P.M., Certified Nurse Assistant (CNA) C informed Nurse D of the purplish bruise on the resident's breast which reached around to his/her breast. During an interview on 7/28/11 at 9:13 A.M., CNA C said the following: -On 6/26/11, he/she assisted the resident to the shower room and when he/she took the resident's gown off, he/she noticed a large bruise covered the front of the resident's chest wall and extended around the resident's back. -The bruise on the chest wall looked very bad and CNA C went to tell Nurse D. CNA C said the bruise looked like it had increased in size. -Nurse D told CNA C "it was always like that". During an interview on 7/28/11 at 3:30 P.M., Nurse D said on 6/26/11, he/she remembered CNA C informed him/her about the bruise on the chest, but did not go into the resident's room and look at the bruise or call the physician because he/she thought the bruise always looked like that. Further review of the resident's nurses' notes, showed the following: -6/27/11, there was no documentation regarding the appearance or condition of the bruise on the chest from all three shifts. -6/28/11, no time documented, the resident was seen by the physician and an x-ray of the ribs were ordered. There was no documentation regarding the appearance or condition of the bruise from all three shifts. -6/29/11 and 6/30/11, the resident's x-ray results still pending. There was no documentation regarding the appearance or condition of the bruise on the chest from all three shifts. Review of the resident's nurses' notes, dated 7/1/11, showed the following: -5:20 A.M., noticeable bruising from mid-back to the front of the resident's chest, yellow and purple in color. There was no documentation the resident's physician was called. -8:00 A.M., a call placed to the x-ray company for the results of the rib x-rays. -9:00 A.M., a call placed to the physician concerning the x-ray results and a new area noted mid-sternal and now the left arm. -11:00 A.M., the physician returned the facility's call and informed the facility to send the resident to the emergency room for evaluation. -No time documented, call placed to the hospital and the resident was admitted to the hospital for a [DIAGNOSES REDACTED]. Review of the resident's x-ray results, dated 6/28/11, showed a non-displaced [MEDICAL CONDITION] 10th rib. During an interview on 7/29/11 at 3:30 P.M., RN A said the physician must be called on a change in the resident's condition. During an interview on 8/3/11 at 10:00 A.M., the administrator said it is the facility's policy if the resident had a change in condition to call to the physician. During an interview on 8/3/11 at 12:15 P.M., the physician said the following: -The facility should have called him on 6/26/11 at 8:00 P.M., when the CNA reported to the nurse and noticed the bruise extended from the breast and around the resident's back. He would have obtained a [MEDICATION NAME] (a lab test that measured a person's bleeding time), evaluated the resident, and sent him/her out to the hospital. -He came in to see the resident on 6/28/11 and ordered an x-ray of the ribs. The facility did not call with the results until 7/1/11. -A call on 6/28/11 from the facility would have made a difference. The resident would have went to the hospital on [DATE] instead on 7/1/11. The facility did not follow their policy for notifying the physician of a change of condition. Review of the facility's policy entitled, "Notification: Changes in Condition", dated 9/1/07, showed the following: -Policy statement: It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental, or psychosocial status. 2. Review of Resident #2's hospital consultation note, dated 3/18/11, showed the following: -An admission date of [DATE] with marked obesity and severe [MEDICAL CONDITION] (persistent local tissue swelling with localized fluid retention) of the lower extremities with a venostatis ulcer (wounds that are thought to occur due to improper functioning of venous valves) over the right lateral leg. -A fungal infection over the right leg. Review of the resident's face sheet, showed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's history and physical, dated 4/5/11, showed [MEDICAL CONDITION] (inflammation of the tissue beneath the skin) of the legs with [MEDICAL CONDITION] of the lower extremities. Review of the resident's annual MDS, dated [DATE], showed the following: -No short and long term memory problems; -Independent with bed mobility, transfers, dressing, eating and personal hygiene; -Balance not steady from a sit to stand position, walking, on and off toilet and transfer from bed to chair; -The resident used a wheelchair and a walker; -Continent of bowel and bladder. Review of the resident's care plan, dated 6/13/11, showed the following: -Problem: At risk for skin breakdown due to a [DIAGNOSES REDACTED]. -Goal: [MEDICAL CONDITION] will continue to show healing through the next review. -Approach/Interventions: treatment as ordered (see POS and TAR), monitor and record response to treatments, observe skin daily and notify the nurse of any changes to the skin. Review of the resident's physician order [REDACTED]. Review of the facility's weekly wound status report, dated 6/14/11, showed no descriptions, measurements or documentation of the resident's stasis ulcers Review of the resident's treatment administration record (TAR), dated 6/1/11 through 6/30/11, showed the following: -6/16/11 on the 11:00 P.M.-7:00 A.M. shift, no documented wound treatment done. -6/18/11 on the 7:00 A.M.-3:00 P.M. shift, no documented wound treatment done. -6/20/11 on the 7:00 A.M.-3:00 P.M., no documented wound treatment done. -6/23/11 on the 11:00 P.M.-7:00 A.M., no documented wound treatment done. During an interview on 7/15/11 at 12:50 P.M., RN A said the last documented wound report was the week of 6/14/11. Review of the resident's nurses' notes, dated 6/23/11, no time documented, showed the resident had episodes of bleeding from the [MEDICAL CONDITION] sack on the back of his/her thigh with an extreme foul odor. The resident was sent to the emergency room . Review of the emergency room notes, dated 6/23/11, showed the following: -The resident weighed over 700 pounds, and was sent from the facility with a ruptured [MEDICAL CONDITION] sack that had a foul smell with multiple sacks, necrotic (dead skin tissue) in appearance. -The resident's skin was hard and leathery with blood and pus present. -[MEDICAL CONDITION] noted on the right leg with [MEDICAL CONDITION] and nodules noted. -The resident's leg was swollen with drainage and seepage, wounds and [DIAGNOSES REDACTED] (redness) diffused over the right leg. Review of the hospital face sheet, dated 6/23/11, showed the resident was admitted to the hospital with [REDACTED]. Review of the hospital consultation note, dated 6/23/11, showed a gigantic [MEDICAL CONDITION] with hyperkeratotic (thick) skin. The wound is posterior of the right thigh with tunneling and foul smelling drainage and yellowish crust. During an interview on 7/8/11 at 8:35 A.M., FM E said the following: -The resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] of the legs and the physician ordered dressing changes twice a day. -On 6/23/11, the resident scraped his/her leg on the side of his/her bed and the odor was like a "sewer". Review of the hospital discharge instruction, dated 7/1/11, showed the following: -Wound Care: Cleanse the lower legs with normal saline and use a 4 x 4 dressing to dry, then apply [MEDICATION NAME] cream (used to reduce redness, swelling and itching) to the right lower leg daily. -Wound Care: Cleanse the posterior thigh with normal saline and apply a layer of calcium alginate (uses calcium in exchange for sodium to pull excess fluid from the wound) to both thigh wounds. Change the layer daily and as needed. Review of the nurses' note, dated 7/1/11, no time documented, showed the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. Review of the resident's POS, dated 7/1/11 through 7/31/11, showed the following: -7/1/11, cleanse the lower legs with normal saline and use a 4 x 4 dressing to dry, then apply [MEDICATION NAME] cream (used to reduce redness, swelling and itching) to the right lower leg daily. Review of the resident's TAR, dated 7/1/11 through 7/31/11, showed the following: -7/5/11, 7/6/11 and 7/11/11, showed no documented wound treatment done on the right lower leg, measurements of the wound, or a description of the wound and its progress. -There was no documentation of the reason for the treatment not being done on the right lower leg. Review of the nurses' notes from 7/5/11 through 7/11/11, showed no documented reason why the treatment was not done on the right lower leg. Review of the resident's POS, dated 7/1/11 through 7/31/11, showed the following: -7/1/11, cleanse the posterior thigh with normal saline and apply a layer of calcium alginate (uses calcium in exchange for sodium to pull excess fluid from the wound) to both thigh wounds. Change the layer daily and as needed. Review of the resident's TAR, dated 7/1/11 through 7/31/11, showed the following: -7/1/11 through 7/6/11, 7/11/11, 7/13/11 and 7/14/11, showed no documented wound treatment done, measurements of the wound, or a description of the wound and its progress. -There was no documentation of the reason for the treatment not being done on both thigh wounds. Review of the nurses' notes from 7/5/11 through 7/14/11, showed no documented reason why the treatment was not done on both thigh wounds. Review of the facility's wound report, showed the facility could not produce a report from 6/14/11 through 7/15/11. Observation on 7/15/11 at 10:00 A.M., showed the resident in a large gown, sitting on his/her bed with an exposed groin area. The skin on his/her thighs and lower legs were thick, dark and leathery with black nodules (lumps), up and down the resident's large legs and purulent (containing pus) drainage running down the resident's legs from the nodules. A foul smell was noted upon entering the resident's room. The resident was sent to the hospital for a temperature of 103 degrees Fahrenheit (normal range, 98.6 degrees to 99 degrees Fahrenheit). Review of the hospital admission report, dated 7/15/11, showed [DIAGNOSES REDACTED]. During an interview on 7/15/11 at 12:50 P.M., RN A said the following: -He/she expected the nursing staff to document and follow the physician orders [REDACTED]. -Documentation of the dressing changes should be on the resident's TAR. -If there was a blank space on the TAR for the dressing change, the reason why it was not done should be placed on the back of the TAR and the physician should be notified. The staff did not follow this procedure. -Measurements of the wound, a description of the wound and its progress should be on the wound report. -The last wound report documented was the week of 6/14/11. Nurse A could not find any reports or documentation of the resident's wounds, and of the measurements or descriptions of the wounds for the weeks of 7/1/11, 7/8/11, and 7/15/11. Review of the resident's nurses' notes, showed the following: -7/1/11 through 7/14/11, showed no documented wound treatments done, measurements of the wounds, a description of the wounds or its progress or why the treatments were not done. MO 382 MO 392 MO 497