Every finding on record at Rehab of Kansas City South

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #2) was free from abuse when on 6/3/26 Resident #1 hit Resident #2 causing a bloody lip out of 13 sampled residents. The facility census was 87 residents.On 6/12/26, the Administrator was notified of past non-compliance which occurred on 6/3/26. Immediate interventions were put into place for both Resident #1 and Resident #2. All staff received education prior to working their next shift. The deficiency was corrected on 6/4/26. Review of the facility's policy titled Abuse Prevention and Prohibition Program dated 10/24/22 showed:-Each resident had the right to be from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.-The policy provided did not define physical abuse or resident-to-resident altercations. 1.Review of Resident #1's admission Record showed he/she was admitted to the facility with a diagnosis of Crohn's disease (intestinal disorder) of both small and large intestine with unspecified complications. Resident #1 did not have any Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) in IQIES completed by the facility or at the prior facility from which the resident had transferred. Review of Resident #2's admission Record showed he/she admitted to the facility with a diagnosis of acute infarction of spinal cord (a stroke in the spinal cord). Review of Resident #2's comprehensive admission MDS dated [DATE] showed:-The resident was cognitively intact.-The resident did not exhibit any behavioral symptoms within the seven day look back period. Review of an Incident Report dated 6/3/26 showed:-The incident occurred on 6/3/26.-The incident involved Resident #1 and Resident #2.-Description of the altercation:--At approximately 6:30 P.M. Resident #2 was outside of Resident #1's doorway.--Resident #1 asked Resident #2 if he/she could move down the hall because Resident #2 was being too loud and he/she was trying to sleep.--Resident #2 then responded to Resident #1 by calling him/her a racial slur.--Resident #2 also stated, if you don't want to hear it then close the door.--Resident #2 was also rolling his/her wheelchair towards Resident #1.--Resident #1 then hit Resident #2.-A skin assessment was completed on both Resident #1 and Resident #2, and it was noted that Resident #2 had an abrasion on his/her bottom lip.-In conclusion, the facility determined that abuse occurred because Resident #1 had intentionally caused harm to Resident #2. Review of Resident #1 and Resident #2's Progress Note dated 6/3/26 showed:-Resident #2 was outside Resident #1's doorway when Resident #1 asked Resident #2 to go down the hall because Resident #2 was too loud and Resident #1 was trying to sleep Review Resident #2's Weekly Skin Check dated 6/3/26 at 7:16 P.M. showed the resident had a small abrasion to the inner bottom lip. Review of Resident #2's care plan dated 6/4/26 showed:-The resident had manipulative behaviors towards his/her peers including:--Argumentative towards peers.--Loud behaviors.--Provoking peers.--The resident had an altercation with another resident on 6/3/26.-The resident had a psychosocial well-being problem related to ineffective coping with peers which included making racial slurs towards others. Review of Resident #1's care plan dated 6/4/26 showed the resident had a psychosocial well-being problem related to an altercation with another peer on 6/3/26. Review of Resident #2's witness statement dated 6/3/26 showed:-He/She was speaking with another resident.-Resident #1 was disturbed by the fact that he/she was able to hear the conversation.-Resident #1 came out and started yelling at Resident #2.-Resident #2 told Resident #1 that if he/she didn't like the conversation, then Resident #1 could shut his/her door.-Resident #1 then got mad and stated that he/she was going to fuck me up.-Resident #2 then responded by saying Okay, I am not afraid of you.-That was when Resident #1 started hitting Resident #2 in the face. During an interview on 6/12/26 at 10:35 A.M. Resident #2 said:-He/She was having a conversation in the hallway.-Resident #1 was upset because the conversation woke him/her up.-Resident #1 then hit him/her in the face twice.-He/She had a bloody lip from the incident. Review of Resident #1's witness statement dated 6/3/26 showed:-He/She had been asleep when he/she woke up to someone loud outside of his/her doorway.-He/She got up and nicely asked Resident #2 to move away from his/her door or to keep it down.-Resident #2 responded by stating, I'm not talking to you.-Resident #2 then got even louder.-He/She asked Resident #2 again to move, and Resident #2 refused.-He/She put his/her hand up trying to scare Resident #2 away.-Resident #2 responded by grabbing his/her arm.-That was when he/she smacked Resident #2 twice in the mouth.-Resident #2 then hit him/her in the arm and chest in defense. During an interview on 6/12/26 at 10:56 A.M. Resident #1 said:-He/She was asleep, and Resident #2 was in the hallway by his/her doorway.-Resident #2 was talking loudly and it woke him/her up.-He/She nicely asked Resident #2 to lower his/her voice or move away from the doorway.-Resident #2 then responded by saying I'm not talking to you, you don't tell me what to do.-Resident #2 also called him/her a racial slur.-He/She then put up his/her hand, but Resident #2 grabbed it.-He/She then smacked Resident #2 in the jaw. Review of an undated witness statement completed by the MDS Coordinator showed:-Resident #2 was outside Resident #1's doorway when Resident #1 asked Resident #2 if he/she could go down the hall because Resident #2 was being too loud.-Resident #2 responded to Resident #1 by calling Resident #1 a racial slur.-Resident #2 also stated, if you don't want to hear it, then close the door.-Resident #2 then rolled his/her wheelchair towards Resident #1 getting into Resident #1's space.-Resident #1 responded by hitting Resident #2. During an interview on 6/12/26 at 12:40 P.M. the MDS Coordinator said:-Resident #2 was talking loudly in front of Resident #1's room.-Resident #1 asked Resident #2 to get away from his/her room.-Resident #2 then rolled his/her wheelchair towards Resident #1 and called him/her a racial slur.-Resident #1 responded to Resident #2 by hitting Resident #2 near his/her jaw. During an interview on 6/12/26 at 9:30 A.M. the Administrator said:-He/She had completed the investigation related to Resident #1 and Resident #2.-He/She determined that abuse had occurred. -Resident #1 admitted to Intentional hitting Resident #2. During an interview on 6/12/26 at 1:40 P.M. Licensed Practical Nurse (LPN) B said:-Physical abuse occurred when someone laid hands on a resident.-A resident-to-resident altercation may not be physical abuse depending on the situation.-If a resident intentionally hits slaps or hits a resident then it would be considered as physical abuse. During an interview on 6/12/26 at 1:49 P.M. LPN A said:-Physical abuse occurred when someone laid hands on another person.-Physical abuse included hitting and slapping.-He/She would consider the incident between Resident #1 and Resident #2 as physical abuse. During an interview on 6/12/26 at 2:20 P.M. the Director of Nursing (DON) said:-On 6/3/26 Resident #2 was talking and being loud.-Resident #1 told Resident #1 to be quiet.-An exchange of words had occurred, and Resident #2 got into Resident #1's face.-Resident #2 called Resident #1 a racial slur and Resident #1 responded to this by slapping Resident #2 in the face.-An injury occurred during the altercation.-Resident #2 had an open area to the inside of his/her lower lip.3033246

Based on interview and record review, the facility failed to provide an appropriate discharge when transferring one sampled resident (Resident #2) out of 7 sampled residents, to a new facility. The resident was not allowed to return to the facility as requested during the appeal process. The facility census was 95 residents.Review of the facility's Transfer and Discharge policy, dated June 2020, showed:-The purpose of the policy was to ensure residents were transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe and appropriate discharge planning and necessary information to the continue care provider.-The facility may transfer or discharge a resident for the following reasons:--It was necessary for the resident's welfare and needs could not be met at the facility.--The resident's health improved sufficiently so they no longer need facility services.--The health and safety of individuals in the facility was endangered by the resident's presence.--Failure to pay or to have services paid for by Medicare or Medicaid.The facility may not transfer or discharge a resident while the appeal of the notice of transfer/discharge was pending.-The notice for discharge will be provided to the resident in advance.-The notice should be provided 30 days prior to the proposed date of transfer/discharge.-Prior to transfer/discharge, Social Services Staff or designee provided the resident or responsible party with reasonable notice that the resident was going to the be transferred or discharge.-The facility may use Notice of Transfer/Discharge or another comparable form to provide the resident and his/her personal representative with advance notice of the transfer or discharge. The notice will include the following information:--Reason for transfer/discharge.--Effective date of transfer/discharge.--Name and complete address and telephone number to which the resident was being transferred.--A statement that the resident had the right to appeal the action to the state with contact information. 1. Review of Resident #2's undated face sheet showed:-The resident was originally admitted to the facility on [DATE].-The resident was diagnosed with paraplegia (the loss of movement and sensation in the lower half of the body, including both legs, usually caused by a spinal cord injury or disease), cognitive communication deficit (a difficulty with communication, such as speaking, listening, reading, or writing) and major depressive disorder (a mental health condition characterized by a persistent, overwhelming low mood, and intense sadness). Review of the resident's quarterly Minimum Data Set (MDS- a health status screening and assessment tool used for all residents of long-term care nursing facilities) dated 1/14/26, showed the resident was cognitively intact. Review of the resident's 30-Day Notice of Involuntary Discharge, dated 1/15/26, showed:-The date of 2/7/26 indicated as being 30 days from the date of the letter.-The letter was dated 1/15/26.-The current facility name was not on the form and the reason for discharge was for failure to pay for, or to pay under Medicare or Medicaid, for services rendered.-Allowable outstanding charges totaled $17,809.40. Review of the resident's care plan (a written document that outlined a resident's care, detailing their specific health needs, goals and interventions), updated 2/9/26, showed the resident opted to stay at the facility. During an interview on 3/24/26 at 11:09 A.M., the Administrator said:-A 30-day notice of intent to discharge was given to the resident.-The notice was dated 1/15/26 and said that 2/7/26 was last day.-The 2/7/26 date was in error and should have been 2/17/26.-The Intent to Discharge was given to the resident, letting him/her know they will be discharging, and they have started looking for a new facility.-The resident was being discharged due to a large unpaid balance.-There was a care plan meeting scheduled for 1/15/26 and the family member cancelled it, which the resident agreed to. -On 1/15/26 the family member was notified via text of notice of intent to discharge.-On 1/15/26 the family responded to the text message to go ahead and send the resident to the other facility.-The family member asked where the resident would be transferred, and he/she was notified by the Administrator of the new facility.-The family member was the resident's Durable Power of Attorney (a legal document that allows a person to appoint a trusted person to manage your financial, legal, or medical affairs).-The DPOA was not enacted (the resident was not incapacitated) as the resident was able to make his/her own decisions.-At first the resident wanted to leave.-The day before the resident was scheduled to leave, he/she said his/her family member told him/her not to leave-The next morning, the resident decided he/she was ok with the transfer and asked to have his/her family member meet him/her at the new facility.-It was the Administrator's understanding that the decision to transfer was up to the resident. -On 2/12/26 at 10:00 A.M. the resident willingly boarded the facility vehicle and was transported with his/her items, paperwork and medications to the new facility.-The family member arrived on site while the resident was in the van and stopped it.-The resident made no indication that he/she wanted off the van and proceeded to the new facility.-He/She talked to the family member and stated he/she needed to stay at the current facility where his/her people were. -On 2/12/26, after the resident left, he/she opened his/her email and saw that on 2/11/26 a letter from the family member was sent via email at 3:35 P.M., which notified the administrator of an Appeal (a formal legal challenge of the transfer).-The resident had already left the facility by the time he/she read the email. During an interview on 3/24/26 at 3:09 P.M., the Ombudsman said:-The resident's family member contacted the Ombudsman Office and notified the office of the Appeal. -On 2/11/26 the facility did provide a copy of the 30-Day Discharge which was sent to the resident via email.-There was an email chain between him/her and the facility Social Service Director (SSD).-On 2/11/26 he/she received an email from the facility's SSD which had the 30-day notice to discharge attached.-That notice did not have an address of where the resident was going.-The Appeal hearing was scheduled for 4/2/26 at 2:00 P.M., and the resident should have been allowed to return to the facility during the Appeal process. During an interview on 3/24/26 at 3:43 P.M., the resident said:-The facility put him/her in a wheelchair, wheeled him/her on to the van and took him/her to the new facility.-He/She was aware his/her family member appealed the decision.-He/She would like to continue with the appeal process.-He/She would like to go back to the facility where he/she had friends. 2747386

Based on observation, interview and record review, the facility failed to maintain the toilets securely in place in the 100 and 300 Hall Spa Rooms, 200 Hall Spa Room toilet was blocked with equipment, 400 Hall Spa Room was inaccessible and the toilet in room [ROOM NUMBER] was inoperable. From 6/15/25 to 6/16/25 Resident #3 was unable to utilize his/her toilet and when using the 100 Hall Spa Room toilet it moved causing him/her to become unbalanced and fearful of using the toilet. Resident #3 then attempted to utilize the 300 Hall Spa Room toilet to find it was not secured. This practice potentially affected all residents who utilized the spa bathroom toilets. The facility census was 89 residents. 1. During an interview on 6/17/25 at 1:56 P.M. the Administrator said: -He/She was informed on 6/15/25 at approximately 4:00 P.M. about a toilet being clogged. -He/She contacted a plumber to fix the toilet. -The plumber was unable to get the toilet fixed and returned the next day. -The plumber was able to unclog the toilet on 6/16/25. During an interview on 6/17/25 at 1:59 P.M. the Maintenance Director said: -There had been no concerns about the shower/spa rooms or work orders for any of them. -There was a concern about a clogged toilet on 6/15/25 which was resolved on 6/16/25. -The resident had access to spa room toilets during the repair of his/her clogged toilet. Observation on 6/18/25 at 1:38 P.M. showed: -The 100 Hall spa (shower) room toilet was not bolted in place. -The toilet was moved easily 90 degrees. Review of Resident #3's admission Record showed the resident was admitted on /22/25 with diagnoses including hemiplegia and hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain), following a cerebral infarction (stroke) affecting the right dominant side and asthma. During an interview on 6/18/25 at 1:39 P.M. Resident #3 said -He/She was unable to use his/her bathroom [ROOM NUMBER]/15/25 through 6/16/25. -When attempting to use the bathroom in the 100 Hall spa room, the toilet moved causing him/her to become unsteady and fearful of falling and/or injury. -He/She said there were other toilets that were not bolted down as well. Observation on 6/24/25 at 4:09 P.M. showed: -Spa room on 300 Hall, the toilet was not bolted down and moved 90 degrees. -Unable to access 400 Hall Spa room. -200 Hall Spa room filled with equipment, that blocked access to the toilet. During an interview on 6/24/25 at 4:10 P.M. the Assistant Director of Nursing (ADON) said: -He/She was not aware of the toilets not being bolted down in the 100 and 300 Hall spa rooms. -He/She was not able to access the 400 Hall Spa room and was not sure why the door would not open. -He/She was shocked he/she was able to move the toilet 90 degrees with no resistance. -He/She confirmed the toilets were not safe for use. During an interview on 6/24/25 at 4:35 P.M. the Maintenance Director said: -He/She has not received any concerns related to the toilets other than the clogged toilet. -He/She has not been informed of any safety concerns related to any toilets in the facility. -He/She said the 400 Hall Spa room door should open. -The 200 Hall Spa room was used to store extra equipment. -He/She denied knowledge of the 100 and 300 Hall Spa room toilets not being bolted down. -He/She said all toilets should be secured. -He/She will bolt the toilets down immediately. MO00254912

Based on observation, interview and record review, the facility failed to ensure odors were not pervasive on the 300 Hall. The facility census was 89 residents. Review of the facility Resident Rights Policy dated 8/2020 showed: -All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. 1. During an interview on 6/16/25 at 3:18 P.M. Family Member A said: -He/She visited in the facility approximately five times over the last three months. -During the visits there was the presence of strong body odor smell of feces and urine. -The facility is unclean. -He/She was so overwhelmed with the smell he/she was unable to pay attention to anything else. -He/She was unable to stay and visit with his/her family member due to the smell. During an interview on 6/17/25 at 2:15 P.M. the Housekeeping Supervisor said: -If there are odors in the facility, it is not because of housekeeping, it is usually due to resident's medical conditions. -A resident on the 300 hall often has strong odors. -If he/she smell odors he/she will clean and deodorize the area. -Housekeeping staff can get more deodorizers if needed. Observation on 6/17/25 at 2:30 P.M. showed a strong odor around resident room [ROOM NUMBER]-308 and extended throughout the hallway to the activity room at the end of the hall. Observation on 6/18/25 at 1:41 P.M. showed the Regional Registered Nurse Consultant acknowledged the extremely strong odor throughout the 300 Hall. MO00255924

Based on interview and record review, the failed to ensure an allegation of possible misappropriation of resident's funds was investigated timely when on 5/23/25 Resident #2's family reported a $300 charge from the resident's CashApp on his/her phone out of 12 sampled residents. The facility census was 89 residents. Review of the facility Abuse and Prohibition Program policy dated 10/24/22 showed: -The purpose was to ensure the facility established, operationalized, and maintained 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, and crime in accordance with federal and state requirements. -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. -The facility has a zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. -Staff must not permit anyone to engage in 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. -Facility staff are mandatory reporters. -Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. -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 strict non-retaliation policy for good faith reporting in compliance with the Elder Justice Act and any other state specific laws. -Failure to report suspected or known abuse may result in legal action against the individual(s) withholding such information. -In order to facilitate reporting, ensure confidentiality, and promote order at the facility, the administrator, or his/her 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. -All mandated reporters 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 financial abuse, physical abuse, neglect, abandonment, isolation, abduction, or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering. -The facility will report allegations including misappropriation of resident property. --Immediately, but no later than two hours after forming the suspicion, if the alleged violation involves abuse or results in serious bodily injury to state survey agency, adult protective services, law enforcement, and the ombudsman. --No later than 24 hours after forming the suspicion, if the alleged violation does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and 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 copy of the investigative report within five days of the incident. -Failure to file a report within the required time frames may result in disciplinary action, up to and including termination. -If multiple staff become aware of the same incident, facility staff may choose to submit individual reports or submit a joint report containing each staff member's name and information about the suspected abuse from each staff person. -The facility will post a notice that informs facility staff of their reporting obligation and the right to file a complaint with the Department of Public Health if they feel that they facility has retaliated against them for making the report. -Anyone who fails to report within mandated timeframe's will be subject to a civil money penalty of not more than $200,000 and the covered individual who failed to report may be excluded from participation in any Federal health care program. 1. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including legal blindness, muscle weakness and cognitive communication deficit. During an interview on 5/15/25 at 6:11 P.M. the Hospital Social Worker said: -There were concerns about a $300 charge from the resident's CashApp that was traced back to a nurse in the facility. -He/She was under the understanding law enforcement had been contacted related to the missing money. During an interview on 6/18/25 at 1:46 P.M. the Social Worker said: -He/She had the resident's phone when the family came to retrieved the phone. -The charge nurse had reported to him/her there was another resident going to Resident #2's room asking about the phone repeatedly. -The nurse took the phone and locked it up in the medication cart. -When he/she came into the facility the nurse brought him/her the phone. -The resident's spouse came for the phone. -The phone was dead and was charged in the facility. -When the family looked on the phone and the CashApp was reinstalled and reviewed by the family. -There was an allegation at that time of a transaction the family did not recognize. -The son of the resident stated him/her to find out who did it and to get law enforcement involved. -He/She did interview the nurse and the resident's spouse. -The spouse did not want to file a grievance. -He/She did suggest the spouse dispute the charges. -He/She brought up the allegations the following day in the morning meeting with department heads. -He/She did not contact law enforcement or participate in investigation. -He/She understood the phone was locked up by the nurse two days prior the being turned over to him/her. -He/She did not report the allegations to Department of Health and Senior Services or law enforcement. -He/She was told to complete a grievance about the phone. -He/She completed a grievance on 6/18/25 and gave it to the Administrator. -He/She was a mandated reporter and felt this was a reportable incident. -He/She did not report as the Administrator was aware and usually did the reporting in the facility. During an interview on 6/18/25 at 2:20 P.M. the Human Resource (HR) person said: -He/She was coming upstairs and noticed the family was upset as they came out of the Social Services office and recalled the allegation of misappropriation being discussed in morning meeting. -He/She was a mandated reporter and felt this was a reportable incident. -He/She did not report the allegation as the interim Administrator was aware and usually did the reporting in the facility. During an interview on 6/18/25 at 2:25 P.M. the Business Office Manager (BOM) said: -He/She did recall the allegations being brought up in morning meeting. -He/She was not aware if there was an investigation. -He/She was a mandated reporter and felt this was a reportable incident. -He/She did not report the allegation as the interim Administrator was aware and usually did the reporting in the facility. During an interview on 6/18/25 at 2:37 P.M. the Interim Administrator said: -He/She was filling in for the Administrator who was on medical leave through late April. -The Social Worker mentioned the allegations about the resident's money being taken through a CashApp. -He/She told the Social Worker to see if the family could bring proof of the money transaction. -There was no further information brought to him/her. -He/She asked the son to prove the transaction occurred. -He/She said the Administrator was responsible to investigate allegations of abuse and/or neglect. -He/She did not conduct an investigation because the family would not return his/her calls and no other information was brought to him/her. -He/She did not document his/her attempts to contact the family or the initial allegations. During an interview on 6/24/25 at 11:07 A.M. the Administrator said: -He/She has been in contact with the resident's spouse and has offered to replace the money. -He/She requested the screen shot of the transaction to continue his/her investigation. -He/She asked the Assistant Director of Nursing (ADON) to contact the spouse to obtain information. -The spouse has not provided any information from the resident's phone. -Allegations of misappropriation should be investigated and reported. MO00254321

Based on interview and record review, the facility failed to prevent physical abuse for two sampled residents (Resident #3 and #4) out of nine sampled residents. The facility census was 94 residents. On 5/7/25, the Administrator was notified of the past non-compliance which occurred on 4/25/25. Facility staff were educated on the root-cause of the abuse and keeping the back patio doorway/area clear. Interventions were put into place to mitigate future occurrences. The deficiency was corrected on 4/26/25. Review of the facility's policy titled Abuse Prevention and Prohibition Program dated August 2020 showed each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Review of the facility's policy titled Reporting Abuse showed: -Abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Physical abuse meant assault, battery, assault with a deadly weapon or force likely to produce great bodily injury, unreasonable physical constraint or prolonged or continual deprivation of food or water, sexual assault, use of a physical or chemical restraint or psychotropic medication for punishment or for beyond a period of time that was ordered by a licensed physician, or for any purpose not authorized by the physician. 1. Review of Resident #5's admission record showed he/she admitted to the facility 2/7/24 with the following diagnosis of bilateral amputations of his/her legs. Review of Resident #5's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/21/25 showed: -The resident had moderately impaired cognition. -The resident exhibited verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) one to three times within the seven days look back period. Review of Resident #4's Pre-admission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of source of payment) dated 9/15/23 showed: -The resident had a diagnosis of Schizophrenia. (a disorder that affects a person's ability to think, feel, and behave clearly). -The resident had an Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -The resident had a Traumatic Brain Injury (TBI- brain dysfunction caused by an outside source). -The resident had minimal behavioral symptoms related to being withdrawn or depressed. Review of Resident #4's admission record showed he/she re-admitted to the facility 1/16/24 with the following diagnoses: -Paraplegia (the inability to voluntarily move the lower parts of the body). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Schizophrenia . Review of Resident #4's quarterly dated 2/03/25 showed the resident was cognitively intact. Review of video footage of the altercation dated 4/25/25 at 8:21 A.M. showed: -The footage had no sound. -The video footage was two minutes and eight seconds long. -Both residents can be seen outside on the patio. -Resident #4 wheeled up close to the back entrance door of the facility smoking a cigarette. -Resident #5 could be seen in the back area away from the door. -Approximately 20 seconds into the video, Resident #5 could be seen starting to propel his/her wheelchair towards the same door that Resident #4 was in proximity of. -Resident #5 continued towards the door and then became within arms distance of Resident #4 and appeared words were exchanged. -After possible words exchanged Resident #5 pushed Resident #4 out of the way to continue to try to get into the building. -That action caused Resident #4 to become visibly upset and Resident #4 wheeled his/her wheelchair back towards Resident #5. -Resident #5 responded to this by reaching out and grabbing Resident #4's sleeve. -Resident #5 continued to hold Resident #4's sleeve and started to shake Resident #4's arm around. -Resident #4 and Resident #5 also appeared to be exchanging words with each other. -Certified Medication Technician (CMT) A and Activity Assistant A could then be seen exiting the facility to respond to the incident. -At that same time Resident #5 continued to hold Resident #4's sleeve and punched Resident #4 twice in the face. -CMT A then separated the residents. -Resident #4 and Resident #5 continued to communicate with each other even though they had been physically separated. -CMT A then pulled Resident #4's wheelchair back, so Resident #5 could enter the building. -As Resident #5 entered the building he/she could be seen visibly upset by the altercation. -The video footage concluded once Resident #5 entered the building. Review of the facility Investigation Summary for the altercation dated 4/25/25 showed: -Resident #4 and Resident #5 were involved in an altercation. -Both residents had been outside in the back patio area. -Resident #5 had been attempting to get back into the facility and Resident #4 was blocking Resident #5's path. -Both residents became agitated and were bumping wheelchairs against each other. -Both residents were flinging their arms at each other. During an interview on 5/5/25 at 10:45 A.M. Resident #4 said: -He/She had been hit in the head and neck during the altercation. -He/She felt safe at the facility and was not afraid of Resident #5. -He/She had been outside in the smoking area. -Resident #5 hit him/her because he/she had been in the way and he/she needed to go back inside to use the bathroom. During an interview on 5/5/25 at 10:50 A.M. Resident #5 said: -Resident #4 had thrown a cigarette on him/her. -Resident #4 was not supposed to be smoking by the door. During an interview on 5/7/25 at 12:05 P.M. Resident #4 said he/she felt like he/she had not deserved to be hit. Review of a witness statement dated 4/25/25 completed by Activity Assistant A showed: -Resident #4 had been sitting in his/her wheelchair in the walkway area. -Resident #5 had been trying to get through. -Resident #4 continued to smoke his/her cigarette. -Resident #4 and Resident #5 began to argue and were bumping into each other. During an interview on 5/7/25 at 1:06 P.M. Activity Assistant A said: -He/She had been standing by the door to the back patio area. -Resident #4 and Resident #5 started bickering with each other about Resident #4 being in Resident #5's way. -He/She had seen Resident #5 punch Resident #4. During an interview on 5/7/25 at 4:12 P.M. the Assistant Director of Nursing (ADON) said: -He/She was aware that Resident #4 and Resident #5 had been in an altercation but had not seen the video footage. -He/She was unsure of what happened during Resident #4's and Resident #5's altercation. -The staff had been educated after the altercation about keeping the back patio doorway and area clear to prevent further issues. -That intervention seemed to be effective since being put in place. -Staff were responsible for intervening and attempting to re-direct residents when exhibiting verbal behaviors. -If a resident hits another resident it counted as physical abuse. During an interview on 5/7/25 at 4:55 P.M. the Director of Nursing (DON) and Regional Corporate Nurse A said: -Abuse had occurred during the altercation. -The abuse occurred when Resident #5 punched Resident #4. 2. Review of Resident #2's Pre-admission Screening and Resident Review dated 1/7/25 showed: -The resident had Schizophrenia. -The resident had Schizoaffective Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania or depression). -The resident had an Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -The resident had Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. -The resident had Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). -The resident had difficulty in adapting to change. Review of Resident #2's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of Resident #3's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of the facility's Investigation Summary dated 5/8/25 showed: -On 5/3/25 Resident #2 and Resident #3 were involved in an altercation with each other. -Resident #3 was sitting in the dining room in his/her wheelchair when Resident #2 approached Resident #3 and stated the resident owed him/her 20.00. -Resident #3 denied owing Resident #2 anything. -This caused Resident #2 to become agitated and allegedly pushed Resident #3 to the ground. -Staff then entered the dining room and noted that Resident #3 was on the ground. -Resident #2 and Resident #3 were separated at that time and told to stay away from each other. -Resident #3 then called the police and the police came to the facility to file a report. -Resident #2 and Resident #3 were also placed on 1:1 monitoring. -Skin assessments were completed for Resident #2 and Resident #3. -Resident #3 had noted injuries to his/her nose and left knee. During an interview on 5/5/25 at approximately 9:30 A.M. Resident #2 said: -He/She thought that Resident #3 was going to hit him/her with his/her cane and was defending himself/herself by deflecting the cane from hitting him/her which caused him/her fall to the ground. -The altercation had occurred in the dining room. -The altercation had started as an argument about money. During an interview on 5/5/25 at 11:50 A.M. Resident #3 said: -Resident #2 had owed him/her money. -He/She went into the dining room to confront Resident #2 about the money. -He/She had been trying to walk away from the incident with his/her cane when Resident #2 had swiped his/her legs from underneath him/her which caused him/her to fall on a table then to the floor. -He/She thought Resident #2 was going to hit him/her. During an interview on 5/7/25 at 4:12 P.M. the ADON said: -Resident #2 mostly exhibited verbal behaviors. -Resident #3 was not known for exhibiting any behaviors. -He/She was unsure of what happened in the altercation between Resident #2 and Resident #3. -He/She knew that the altercation occurred in the dining room and that there had been an argument. During an interview on 5/7/25 at 4:55 P.M. the DON and Regional Nurse Consultant A said: -Resident #2 liked to be noisy with other staff and residents. -Resident #2 should have behavioral monitoring in place prior to 5/7/25. -He/She was unsure why behavioral monitoring was not in place for Resident #2 prior to 5/7/25 and it was possible the incident could have been avoided. MO00253302 & MO00253688

Based on observation, interview, and record review, the facility failed to ensure three sampled dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidney were not functioning properly) residents (Resident #23, Resident #32, and Resident #33) and one supplemental resident who had a feeding tube (a medical device that delivers liquid nutrition directly to the stomach through a surgically created opening in the abdominal wall), (Resident #42) were on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) out of 18 sampled residents and one supplement resident, failed to adequately educate the staff about EBP, and failed to have EBP or isolation signs on the door and isolation carts (a container that contained Person Protective Equipment (PPE - clothing and other equipment designed to protect the wearer from the risk of injury of infection) at the resident's rooms or in the hallway. The facility census was 92 residents. Review of the facility's policy, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multi-Drug Resistant Organisms (MDROS) dated July 12, 2022 showed: -EBP may be indicated for residents with any of the following: -Wounds or indwelling medical devices. -Infections. -Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE and hand hygiene supplies at the point of care. 1. Observation on 2/19/25 at 9:30 A.M. of 300 and 400 hallways did not show: -Any signs on the following residents' doors (Resident #23, Resident #32, Resident #33 or Resident #42), which showed the staff was to use EBP when doing cares with the residents on those hallways. -Any isolation equipment at any of the residents' rooms or in the hallway. Observation on 2/19/25 at 1:30 P.M. of 300 and 400 hallways did not show: -Any signs on the following residents' doors (Resident #23, Resident #32, Resident #33 or Resident #42), which showed the staff was to use EBP when doing cares with the residents on those hallways. -Any isolation equipment at any of the residents' rooms or in the hallway. Observation on 2/20/25 at 9:15 A.M. of 300 and 400 hallways did not show: -Any signs on the following residents' doors (Resident #23, Resident #32, Resident #33 or Resident #42), which showed the staff was to use EBP when doing cares with the residents on those hallways. -Any isolation equipment at any of the residents' rooms or in the hallway. 2. Review of Resident #23's face sheet showed the resident was admitted to the facility on [DATE] with the following diagnosis: -End Stage Renal Disease (ESRD - the last stage of Kidney disease). -He/She resided on the 300 hallway. Review of the resident's care plan dated 1/7/25 showed: -Did not show the resident was to have been on EBP. -He/She required the assistance of one staff for personal hygiene. -He/She received dialysis Monday, Wednesday, and Friday. -Staff was to assess the dialysis shunt every shift and notify the physician of abnormalities or absence of thrill (the vibration when touching the dialysis shunt indicating a good blood flow) or bruit (a whooshing sound heard with a stethoscope over the dialysis shunt). Review of the resident's February 2025 Physician's Order Sheet (POS) showed the following order: -Dialysis treatment Tuesday, Thursday, and Saturday, dated 2/5/24. -EBP when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting every shift for EBP, dated 2/14/25. -Assess dialysis right arm shunt site(a surgical connection between an artery and a vein in the arm or wrist to perform dialysis) every shift for signs and symptoms of infection, bleeding, pulsation or aneurysm (blood clot) every shift, dated 1/22/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/11/25 showed: -He/She was moderately cognitively impaired. -He/She was on dialysis Observation and interview on 2/19/25 at 2:00 P.M. showed: -Two Certified Nursing Assistants (CNA)s said they were going to change the resident's brief. -Observed the two CNAs as they entered the resident's room and closed the curtain around the resident to change the resident's brief without wearing a gown. -There was no sign on the resident's door indicating EBP precautions were to have been used with the resident. -There was no isolation cart with PPE in the hallway or in the resident's room. During an interview on 2/19/25 at 2:30 P.M. the resident said: -When the staff performed cares such as changing his/her brief or assessing his/her dialysis shunt, they wore gloves but no gown. -He/She had not seen a sign on his/her door about EBP or an isolation cart outside the room. 3. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Periorbital cellulitis (infection of the skin surrounding the eye). -ESRD. -Other bacterial infections. -He/She resided on the 400 hallway. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was occasionally incontinent of urine. -He/She was frequently incontinent of stool. -He/She was on dialysis. -Wound infections was not checked. Review of the resident's care plan dated 1/13/25 showed: -He/She needed the assistance of one staff member for bathing. -He/She had a genital infection. -Staff was to maintain universal precautions when providing resident care. -He/She received renal dialysis. -Staff was to auscultate Bruit and palpate Thrill to shunt every shift and notify physician of abnormalities or absence, dated 5/7/24. -Staff was to change dressing daily at access site as ordered, dated 5/7/24. -Did not show the resident was to have been on EBP. Review of the resident's February 2025 POS showed the following orders: -Assess dialysis shunt site (right chest) every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm, dated 12/9/24. -Dialysis on Monday, Wednesday, and Fridays, dated 12/9/24. -EBP when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting, dated 2/14/25. -Apply Vaseline or Aquaphor (an ointment that enhances skin healing) four times a day on eyelid until follow up appointment at the eye clinic, dated 2/27/24. -Cleanse legs with soap and water pat dry. Apply Calcium Alginate (a natural absorbent biodegradable substance used in wound dressings)to right lower leg. Cover with ABD (abdominal pads - used do help keep wounds dry) pads. Wrap and secure with kerlix (bandage rolls which provide absorbency). Dressing to have been changed twice a day for Osteomyelitis (a bone infection) dated 2/20/25. -Miconazole 7 Vaginal (used to treat vaginal infections) Cream 2% insert one application vaginally every 12 hours for Candida (a yeast infection), dated 12/7/24. -Nystatin (a powder used to treat yeast infections) External Powder 100000 unit/gram to apply to bilateral pannus folds (an abnormal extra layer of skin on the abdomen) topically every six hours as needed for skin condition, dated 12/7/24. -There was no order for the resident to have been on EBP. During an observation and interview with the resident on 2/20/25 at 9:10 A.M.: -He/She said: --The staff had not been using EBP (gown or gloves) when checking his/her dialysis site. --The staff did wear gloves but not a gown when they applied a cream to his/her genital area. --The staff did not wear a gown when they put an ointment on his/her eye. --The staff did not wear a gown or gloves when they bathed him/her. --He/She had the toes on both feet surgically removed in the fall of last year. --He/She was not able to see if the surgical sites had healed. --He/She said there was no sign on his/her door nor any isolation cart. --He/She had open areas on his/her legs that weeped from cellulitis (skin infection). --He/She had a surgical site on left eye was open to air (where they had surgically removed extra skin). --He/She had a dialysis access was a PICC (a Peripherally inserted central catheter, a thin flexible tube inserted into a vein and threaded into a large vein in the heart) line on the right side of his/her chest. -There was no sign outside of his/her door indicating staff was to wear PPE. -There was no isolation cart at the door of the resident's room. -Observation showed the resident had a surgical site under his/her left eye. -Observation showed the resident had a PICC line on the right side of his/her chest. -Observation showed the resident had several open areas on his/her legs that were weeping. -Observation showed an open area on both of the resident's feet from old surgery where his/her toes had been amputated. During an interview on 2/21/25 at 10:30 A.M. Licensed Practical Nurse (LPN) A said: -He/She knew the resident had a PICC line in her chest and they did dialysis through that line. -They check the site for redness or warmth or drainage every shift and is on the Treatment Administration Record (TAR). -He/She did not know what EBP was. -They just started to put signs on the doors saying to See Nurse and putting isolation containers on the doors since survey started. 4. Review of Resident #42's quarterly MDS dated [DATE] showed: -He/She was moderately cognitively impaired. -He/She had a feeding tube. -He/She resided on the 300 hallway. Review of the resident's February 2025 POS while on site showed the following orders: -Aquaphor (ointment used to apply to dry skin) to have been applied four times a day on the resident's left eyelid. -Staff was to follow EBP, dated 2/14/25. -Staff was to assess dialysis shunt site (PICC) right upper chest daily. Observation of tube feeding administration on 2/24/25 at 9:00 A.M. with LPN A showed: -The nurse entered the room set up supplies and started to flush the resident's feeding tube with water. -The nurse was stopped and asked twice if he/she had forgotten anything and he/she responded no. -The nurse was wearing gloves but not an isolation gown. -There was a sign on the resident's door that said See Nurse. -There was an isolation container with gowns and gloves hanging on the door to the resident's room. During an interview on 2/24/25 at 9:25 A.M. LPN A said: -They had just started using the isolation carts after survey started. -The ADON had talked about EBP a couple of weeks ago but he/she forgot what they were supposed to have done. -He/She did not know why a resident would have been on EBP. 5. Review of Resident #32's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Acute kidney failure. -He/She resided on the 300 hallway. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was on dialysis. Review of the resident's February 2025 POS showed the following orders: -Dialysis on Monday, Wednesday, and Friday. -EBP when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting every shift, dated 2/14/25. -Upon return from dialysis palpate right arm shunt for thrill and bruit. Repeat twice within eight hours post dialysis. Check bruit and thrill every shift routinely. -May apply Barrier cream as needed to redness or excoriation (skin that has been scraped away which resulted in scratches or wounds) after incontinent episodes every morning and night for skin breakdown dated 11/30/23. Review of the resident's care plan dated 2/5/25 showed: -He/She needed the assistance of one staff member for bathing/showering and dressing. -He/She received dialysis three times a week. -Staff was to auscultate the Bruit and palpate Thrill to right arm shunt every shift. -The care plan did not include using EBP with the resident. During an interview on 2/20/25 at 1:59 P.M. the resident said: -He/She goes out to dialysis. -He/She declined allow wound care/dialysis shunt cares to be observed. -The staff did not always check his/her dialysis shunt like they were supposed to. -When they checked his/her dialysis shunt they did not wear a gown or gloves. -When they checked his/her heel they did not wear gloves or a gown, he/she frequently had open heel sores. -Staff had just put up a sign on his/her door which said to see Nurse. -Staff had just put a isolation station at his/her door today. -He/She had not received education from the nursing staff about why there was a sign on his/her door or why staff was wearing PPE. 6. During an interview on 2/24/25 at 1:30 P.M. LPN/Infection Preventionist (IP) said: -EBP had started in the building on 2/14/25. -He/She had provided education with the staff about EBP by doing 1:1 education. -There had not been signs which showed the staff or visitors were to see the nurse on the third or fourth hallways. -The nurse would have told the staff or visitors to wear EBP if doing cares with the residents. -The staff should have been told in report that EBP was needed on which residents and why. -There should have been an order for EBP from the physician. -It should have been in a resident's care plan that EBP was needed by the MDS Nurse. -If a resident had open areas on their skin, had a foley, a PICC line, dialysis shunt, or a feeding tube, they should have had EBP. -He/She did not put the isolation containers or signs on the door of the third and fourth hall until the second day of survey. -He/She was responsible for ensuring that staff were educated on EBP, that there were signs on the residents door for those who needed EBP, there were isolation containers at the residents door, and should have done spot checks to ensure staff was following EBP protocol. -There were many residents at the facility that were on EBP. During an interview on 2/26/25 at 9:37 A.M. LPN B said: -They had education provided by the ADON about two weeks ago but he/she could not recall what the education included. He/She did not know what PPE should be included for EBP or when to use EBP. -They just started to put signs on the resident's doors which said See Nurse, and have isolation containers on some of the residents doors on Tuesday after the survey started. -They were to wear gloves and gowns when working with a resident who had a foley (tube that goes into the bladder to drain urine), peg tube, open wound, dialysis shunt, or PICC line. During an interview on 2/26/25 at 10:25 A.M. Certified Medication Technician CMT B said: -There might have been education about a month ago that the ADON provided 1:1 with the staff about EBP, but he/she could not recall what the education included. He/She did not know what PPE should be included for EBP or when to use EBP. -They had just put out the signs and isolation carts after survey started. -He/She did not know why a resident would have been on EBP. During an interview on 2/26/25 at 12:10 P.M. the Director of Nursing (DON) said: -If staff were to use EBP on a resident there should have been a sign on the door stating staff was to wear PPE when working with the resident. -An isolation container with PPE was to have been available at the resident's doorway. -EBP was not put in place until after the start of survey. -Education about EBP had been provided by the IP maybe 2/14/25. -No education had been provided to the residents or family about EBP. -Any resident who had a foley, PICC line, Dialysis shunt, feeding tube, or an open wound should have been on EBP. -

Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside unattended for three sampled residents (Residents #53, #57, and #23), out of 19 sampled residents, failed to ensure medication carts were maintained and locked when unattended by staff, failed to maintain cleanliness in the medication room, and failed to maintain the medication refrigerator temperatures within recommended ranges. The facility census was 92 residents. Review of the facility's policy, Storage of Medications, dated 8/2020 showed: -Medications and biologicals were to have been stored safely, securely, and properly, following manufacturer's recommendations. -The medication supply was accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. -Medication rooms, carts, and medication supplies were to have been locked when they were not attended by persons with authorized access. -Medication storage areas were to have been kept clean, well-lit, and free of clutter and extreme temperatures and humidity. -Medication storage conditions were to have been monitored on a regular basis by the consultant pharmacist and corrective action was to have been taken if problems were identified. -All medications were to have been maintained within the temperature ranges noticed in the United States Pharmacopeia and by the Centers for Disease Control (CDC). -Refrigeration was to have been 36 degrees Fahrenheit (F) to 46 F degrees, with a thermometer to allow temperature monitoring. -The facility should have checked the refrigerator in which vaccines were stored at least two times a day, per CDC guideline. Policy for medication administration was requested and was not provided. Review of The Nursing Drug Handbook 2017 retrieved on 3/6/25 showed: -Insulins: Store unopened insulin lispro (a rapid acting insulin) pens between 36 degrees F to 46 degrees F. Do not freeze. Do not use if frozen. --Insulin Lispro pens included: Admelog and Humalog. -Insulins: Store unopened insulin glargine (a long acting insulin) pens between 36 degrees F to 46 degrees F. Do not freeze. Discard if frozen. --Insulin Glargine pens included: Semglee and Lantus. 1. Observation on 2/24/25 at 7:15 A.M. of the medication pass on the south hallway with Licensed Practical Nurse (LPN) A showed: -He/She went into a resident's room to wash his/her hands. -He/She had left the medication cart facing outward in the hall, unlocked while in the room. -An unidentified resident rolled by the unlocked medication cart in his/her wheelchair. Observation on 2/24/25 at 7:20 A.M. of the medication pass on the south hallway with LPN A showed: -He/She came out to the medication cart to obtain the equipment to check the resident's blood sugar. -He/She left the cart unlocked facing outward in the hall while he/she went into the room to take the resident's blood sugar. -An unidentified resident walked by the outward facing in the hall unlocked cart. Observation on 2/24/25 at 7:48 A.M. of the nurses' medication cart on the south hallway with LPN A showed: -There was a large pink stain in the bottom of the first drawer which contained residents prescribed medications. -There was one round pink pill loose in the bottom of the medication drawer. -There was one half of a round blue pill loose in the bottom of the medication drawer. -In the top drawer with resident's prescribed medication there were the following items: --A used hair clip. --A lighter. --Two sets of car fobs to an unknown person's car. --A pair of used tweezers. Observation and record review on 2/24/25 at 8:13 A.M. of the medication room on the south hallway with LPN A showed: -There was no documentation of the medication refrigerators temperature on the Temperature log for the last two days. -The temperature documented the previous six days was at 32 F degrees or lower. -The Temperature Log said to maintain refrigerator temperature at 36 to 41 degrees F. -In the medication refrigerator there were the following medications: -Three vials of Tuberculin (TB - a sterile liquid used in a skin test to help diagnose tuberculosis -a serious bacterial infection that infects the lungs). -On the TB box it showed to not freeze, and was to have been stored at 36 to 46 F degrees. -Five Semglee unopened insulin pens. -Five unopened Admelog solostar insulin pens. -Four unopened Humalog insulin pens. -Four unopened Lantus insulin pens. -There was one round tan pill on the floor. -The only sink in the medication room was dirty with rust. -There was no paper towels so staff could wash and dry their hands. During an interview on 2/24/25 8:15 A.M., LPN A said: -The medication carts should always have been locked if you were not in front of it using it. -There should not have been a pink stain in the drawer it was probably from an old medication that had spilled. -There should not have been any loose pills in the drawers or on the floor. -There should not have been any personal items in the medication cart. -Whoever had used the medication cart should have ensured it was cleaned at the end of their shift. -Dietary was in charge of checking the refrigerator temperatures. -The temperature of the medication refrigerator should have been checked daily by the night nurse. -The temperature of the medication refrigerator should not have been below freezing, 32 F degrees. -Pharmacy should have been notified that the medications had been stored at a temperature less than freezing to see what they recommended and that had not been done as far as he/she knew. -If the temperature was out of range maintenance should have been notified and that had not been done. -Housekeeping should have ensured the sink in the medication room was clean and that there were paper towels so nursing staff could wash their hands, they had been out of paper towels several days. -He/She did not think that the sink had been cleaned for a while. 2. Observation on 2/24/25 at 8:50 A.M. of the Certified Medication Technician (CMT) cart on the south hallway with CMT A showed: -The following loose pills were found in the drawers of the medication cart: -One white round pill. -One peach colored oblong pill. -One red capsule. -One white oblong pill. During an interview on 2/24/25 at 9:00 A.M. CMT A said: -Whoever was on the medication cart should have kept it clean. -There should not have been any loose pills in the drawers or on the floor. -Twice in the last month he/she had seen pills on the floor. -He/She would tell the nurse then pick up the pills from the floor and throw them away. -The medication carts should have been locked if you were not in front of it as there were some residents who would have tried to take something out of it. -There should not have been any personal items in the medication cart. -The housekeeper should have ensured the medication room sink was cleaned daily and that there were paper towels so you could have dried your hands after washing them. -The Unit Manager should have ensured the medication refrigerator was kept within the temperature range. During an interview on 2/24/25 at 1:30 P.M. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said: -There should not have been any loose pills or other objects in the medication cart with the residents medications. -There should not have been any pills on the floor. -The nurse was responsible for ensuring the temperature of the medication refrigerator was within range and checked every night. -If it was not within the range 36 to 46 degrees maintenance should have been notified. -The medication cart should not have been unlocked if he/she was not using it. -The nurse was responsible for ensuring the temperature of the medication refrigerator was within range and checked every night. -If it was not within the range 36 to 46 degrees maintenance should have been notified. -The medication cart should not have been unlocked if he/she was not using it. During an interview on 2/26/25 at 12:10 P.M. the Director of Nursing (DON) said: -There should not have been any medication found on the floor. -There should not have been any loose pills in the medication carts. -There should not have been any personal items in with the residents' medications. -The medication cart should have been cleaned after each shift by the staff member who used it. -The medication cart should have been locked if staff was not directly in front of it. -The nursing staff was responsible for ensuring the medication room was clean and that they had supplies such as the paper towels in it. -The nursing staff should have checked the medication refrigerator at least daily to ensure the temperature was within range and that none of the medications had been frozen. -The Charge Nurse was responsible for ensuring the medication refrigerator was checked to ensure it was within range and not below 32 degrees F. -If the medication refrigerator was out of range the DON should have been notified, he/she had not been told it had been out of range. -He/She could have readjusted the temperature and rechecked to ensure it was within range. -If medication such as insulin had been frozen it should have been thrown away and new insulin ordered from the pharmacy. 3. Observation on 2/26/25 at 9:45 A.M., north nursing station medication cart showed: -Left unlocked facing outwards toward the hallway and unattended by staff. -One resident observed to roll by in his/her wheelchair past the medication cart while unlocked. 4. Review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain). -Heart failure (a condition in which the heart does not pump blood as well as it should). -Hemiplegia and Hemiparesis following cerebral infarction affecting right non-dominate side (a condition that causes weakness or paralysis (loss of muscle function) on on side of the body after blood flow to the brain was reduced. -Dysphagia (a difficulty swallowing foods or liquids). -Altered mental status (a change in a person's level of consciousness, awareness, and cognitive function). -Muscle weakness. Review of the resident's care plan dated 1/7/25 showed: -He/She was able to feed self once the meal tray was set up. -There was nothing about the resident able to self administrate their own medications. Review of the resident's entry Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/21/25 showed: -He/She was moderately cognitively impaired. -He/She was impaired on one side. -He/She needed set up assistance to eat. Review of the February 2025 Physician's Order Sheet showed the following orders: -Crush oral medications or open capsules and mix all medications together for administration with medium of resident's choice, dated 12/4/24. -There was order to leave medications at bedside. Observation on 02/19/25 at 9:53 A.M. showed: -He/She was not in the room. -There was a pill cup toppled over on the resident's bedside tray table. -There were two white oblong pills and one round blue pill under the resident's bed. -The roommate was severely cognitively impaired. Observation on 2/21/25 at 12:28 P.M. showed: -The resident was not in the room. -There was a cup with four pills in it sitting on the resident's bedside tray table. -One tan oblong pill, one dark brown capsule, one round white pill, one round blue pill. During an interview on 2/24/25 at 8:13 A.M. LPN A said: -The resident was most likely at dialysis. -There should not have been any medications left at bedside. -None of the resident's had a physician's order stated that medications could have been left at bedside. -Nurses were responsible to ensure the residents took their medications and that the medication was not left at the bedside. -Staff was to watch to make sure the residents took the medication and did not choke. -The facility had provided education on ensuring residents took their medications and staff did not just leave the medications at bedside. -This resident did not have an order to leave any medications at bedside. -His/Her medications were to have been crushed and put in applesauce or pudding. 46890 5. Review of Resident #57's quarterly MDS dated [DATE] showed the resident was cognitively intact. Observation and interview on 2/19/25 at 9:46 A.M., showed: -The resident was sitting on side of his/her bed. No facility staff present. -Showed he/she had a medication cup with pills inside not dated or marked on top of his/her dresser. -He/She said that it was his/her morning medication and staff had always left at his/her bedside before he/she took it. 6. Review of Resident #53's quarterly MDS dated [DATE] showed the resident was cognitively intact. Observation and interview on 2/25/25 at 10:10 A.M., showed: -The resident was in his/her bed asleep. His/Her breakfast tray on over the bed table with medication cup of pills on tray not marked or dated. No staff present. -He/She had woke up and said that it was his/her morning medication and had fallen back to sleep before taking. -He/She said that staff often left his/her medication on the meal tray. 7. During an interview on 2/24/25 at 8:00 A.M. CMT A said: -None of the residents had an order to leave medications at their bedside. -There would have had to had a physician's order to leave the medication at bedside. -He/She had seen pills left at the bedside from the previous shift twice this month. -He/She had told the nurse and then threw the pills away. -The Charge Nurse was responsible for ensuring medication were not left at bedside. -You need to watch the residents swallow the pills to ensure they don't choke. -He/She had seen other residents roam into other resident's rooms so you needed to ensure pills were not left at bedside because a different resident might have taken them. During an interview on 2/24/25 at 1:30 P.M. with the ADON said: -There should not have been any pills left at bedside or on the floor. -Staff needed to watch to ensure the residents took their medications. During an interview on 2/26/25 at 9:39 A.M., Certified Nursing Assistant (CNA) A said medication should not be left at resident bedside and if he/she saw them he/she would have thrown them in the trash and told the nurse. During an interview on 2/26/25 at 9:46 A.M., CMT A said medication should not be left at the bedside. He/She would take to the nurse if found. During an interview on 2/26/25 at 10:07 A.M., LPN A said: -Medication should not be left at bedside unless there is a physician order. -He/She would be responsible make sure staff are not leaving medication unattended. -Medication administration competencies are done yearly During an interview 2/26/25 at 12:10 P.M., the DON said: -He/She would expect medication not to be left at resident bedside if no physician orders. -He/She would be responsible for medication administration training and audits are completed. -Staff was to have watched the residents take their medications. -There should never have been any pills left at bedside or spilled on the floor.

Based on observation, interview and record review, the facility failed to post staffing information that consistently included the facility name, daily census, and the actual hours worked per shift for each of the three categories of nursing employees: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) directly responsible for resident care. The facility census was 92 residents. Review of the facility's Nurse Staffing Posting Policy, revised June 2020 showed: -The facility would post the staffing on a daily basis and would have included: --Facility name. --The current date. --The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: ---RN's. ---LPN's. ---CNA's. --Resident Census -The facility would post the nursing data specified above, on a daily basis at the beginning of each shift. -Data must be posted in a clear and readable format and in a prominent place accessible to residents and visitors. 1. Observations on 2/19/25 at 11:15 A.M., 2/20/25 at 9:30 A.M., and 2/21/25 at 9:50 A.M., showed the posted staffing sheet did not show the total number worked for RN's, LPN's, or CNA's. During an interview on 2/24/25 at 1:16 P.M., Staffing Coordinator said: -He/She filled out the form the facility used for staffing. -The form did not have a space for actual hours worked for all staff by job title. -If the form had that spot he/she would have filled it in. -He/She did not know that he/she needed total hours worked per job title. During an interview on 2/26/25 at 11:05 A.M., the Administrator said: -He/She the Staffing Coordinator filled out and posted the form. -The Staffing Coordinator was responsible for filling out the staffing form. -He/She was unaware that the form needed total hours worked per job title. During an interview on 2/26/25 at 12:11 P.M., the (Director of Nursing) DON said: -He/She did not fill out the daily staffing form. -He/She did not verify that this was done. -It was his/her expectation that the staffing would be posted daily with the required information. -He/She did not realize the facility had been using the wrong form without all the required information.

Based on observation, interview, and record review, the facility failed to ensure documentation related to attending the dialysis (a procedure that filters the blood when the kidneys were no longer able to do so) unit and coming back from the dialysis unit was completely filled out and accurate for four sampled dialysis residents, (Residents #10, #23, #32, and #33), and failed to document assessments in the computer in a consistent manner for two sampled resident, (Resident# 23, Resident #32) out of 19 sampled residents. The facility census was 92 residents. Review of the facility Dialysis Care policy dated June 2022 showed: -The facility was 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 for all non-dialysis needs off the residents including during the time period when the resident was receiving dialysis. -The facility maintained a contract with a dialysis service provider which addresses communications between the facility and the provider. -The facility would provide a method of communication between the dialysis provider and the facility. -Nursing staff would communicate pertinent information in writing to the Dialysis staff which might include medication changes, recent changes in condition and the resident's tolerance of dialysis. -The dialysis provider would communicate in writing to the facility the resident's current vital signs (temperature, heart rate, breathing rate, and blood pressure), pre and post dialysis weight and any problems encountered while the resident was at the dialysis provider. -The nursing staff would keep the resident's attending physician, the resident and the resident's family informed of any change in the resident's condition. -(The Facility) would inspect the shunt site (a surgical connection of an artery and a vein for dialysis) area for color, warmth, redness, tenderness, pain, edema, drainage, and bruit (the whooshing sound) one per shift. -(The Facility) would check for a bruit (a pulsation felt of blood flowing through the ateriovenous anastmomosis (shunt site). -Place your fingertip slightly over the vein and feel for the thrill. -Place the stethoscope over the vein and listen for the buzz or bruit. -Document the findings in the medical record. -The dialysis provider and the resident's attending practitioner (medical professional including physicians and nurse practitioner with advanced education and licensed to diagnose and treat health conditions) must be notified of a canceled or postponed dialysis treatment and responses to the change in treatment must be documented in the resident's medical record. -If dialysis was canceled or postponed, the nursing staff and dialysis provider should provide or obtain ongoing monitoring and medical management for changes such as fluid gain, respiratory issues, reviews of relevant lab results, and any other complications until dialysis can be rescheduled based on resident assessment, stability and need. -Nursing staff were to use the Nurses Dialysis Communication Record or comparable form to convey information to the dialysis provider. -All documentation concerning dialysis services and care of the dialysis resident would be maintained in the resident's medical record. Review of the facility Dialysis and Nursing Home Handoff Communication Tool, undated showed: -A section for Information to be completed by nursing home and sent with the resident for each dialysis treatment. -A section to be completed by dialysis and returned with the resident for each dialysis treatment that included pre-dialysis weight, post-dialysis weight, problems during dialysis, amount of fluid removed, post dialysis vitals, labs drawn yes/no, copy of lab results attached yes/no, updated physician (MD) orders attached yes/no. did dietitian make recommendations, did social worker make recommendations, food/fluid consumed during dialysis, percentage meal consumed, fluids consumed, medications given during dialysis - anemia (low red blood cell count) medications, other medications, vascular access (where the dialysis machine connects to the bloodstream during dialysis treatments) condition, dialysis nurse's signature and date. 1. Review of Resident # 10's electronic medical record on 2/19/25 through 2/26/25 showed: -He/She was admitted to the facility on [DATE]. -He/She had a physician's order for dialysis on Tuesday, Thursday and Saturday. -There were a total of four Dialysis and Nursing Home Handoff Communication Tools dated 1/30/24, 2/4/25, 2/8/25 and 2/11/25. Review of the resident's Dialysis and Nursing Home Handoff Communication Tool dated 1/30/25, 2/4/25 showed: -The section to be completed by dialysis had only the resident's pre-dialysis weight and a post-dialysis weight, pulse and blood pressure. -No additional information was documented by the dialysis staff and/or facility staff. Record review of the residents Dialysis and Nursing Home Handoff Communication Tool dated 2/11/25 showed: -The section to be completed by dialysis had only the resident's pre-dialysis but not the resident's post-dialysis weight, temperature, respiratory rate and blood pressure and the area for problems showed he/she was taken off dialysis early. -No additional information was documented by the dialysis staff and/or facility staff. Review of the resident's Nursing Progress Notes dated 1/1/25 through 2/26/25 showed: -No documentation of facility licensed nurse follow-up with dialysis regarding any missing dialysis communication forms. -No documentation of facility licensed nurse follow-up with dialysis regarding any missing information on the resident's 1/30/25 2/5/25, and 2/11/25 dialysis communication forms. During an interview on 2/25/25 at 3:55 P.M. the Director of Nursing (DON) said: -The resident had been going to dialysis three times a week, there should be more dialysis communication forms than the three in his/her EMR. -There might be more dialysis communication forms waiting to be uploaded to the resident's EMR. -He/She would check with medical records to see if there were additional dialysis communication forms not in the resident's medical record and would bring any dialysis communication forms found in medical records to the surveyor. -Note: At the time of the survey exit on 3/5/25 no additional dialysis communication forms for the resident were provided to the survey team. 39469 2. Review of Resident #23's face sheet showed he/she was readmitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD - a permanent condition in which the kidneys are no longer able to function), dated 6/26/24. Review of the resident's care plan dated 1/7/25 showed: -He/She received dialysis on Monday, Wednesday, and Friday. -Staff was to auscultate Bruit and palpate Thrill to fistula/shunt every shift. Notify physician of abnormalities or absence, dated 7/11/24. -Staff was to monitor site as ordered. Review of the Entry Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/21/25 showed: -He/She was moderately cognitively impaired. -He/She had ESRD. Review of the January 2025, Dialysis Communication Tool received by the facility on 2/21/25 at 8:37 A.M. showed: -No documentation before 1/17/25 was in the resident's chart. -The Communication Tool dated 1/17/25 showed: -The Pre dialysis weight was 81.1. -The Post dialysis weight was 81.1. -462 milliliters of fluid was removed. -No fluid was added. -There was no other Dialysis Communication Tools for January (missing 12). --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's January Nurses' Administration Record showed: -Staff was to assess the resident's dialysis right arm shunt site every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm dated 1/21/25. -Out of 30 opportunities the staff documented: -(n) 27 times. -(no/-) twice. -NA once. -None of the above were in the chart code (approved abbreviations to have been used by the nursing staff in documentation). Review of the resident's February 2025 Physician's Order Sheet (POS) showed the following orders: -Assess the resident's dialysis device graft/fistula in right arm. Monitor for bruit/thrill every shift related to ESRD, dated 1/22/25. -Assess dialysis right arm shunt site every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm every shift, dated 1/22/25. -Dialysis treatment on Tuesday, Thursday, and Saturday. Review of the February Nurses' Administration Record showed: -Staff was to assess the resident's dialysis right arm shunt site every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm dated 1/21/25. -Out of 61 opportunities the staff documented: -(n) 50 times. -(m) twice. -NA six times. -(no/-) three times. -None of the above were in the chart code. Review of the February 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 8:37 A.M. showed: -No documentation for the following days; 2/3, 2/5, 2/14, and 2/19. -Documentation on 2/17 was not completed by dialysis unit. -There was no documentation the dialysis unit had been contacted to retrieve the information. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. During an interview on 2/21/25 at 1:30 P.M. the DON said: -There was no Communication Tool from the Dialysis unit before 1/17/25 for this resident. -They must have done something different at the dialysis unit for the weight to have been the same before and after treatment. -He/She would not have expected the facility staff to have question the weight being the same before and after treatment. -Documentation from the dialysis unit did not show the resident had any extra treatments. -He/She would have expected there to have been a Communication Tool to have came back with the resident after every treatment and that it was completely filled out. -The Communication Tool should have been downloaded into the resident's chart every week. -He/She would have expected nursing staff to have ensured the Communication Tool came back with the resident and if that was not done staff should have called the dialysis unit to have them fax the document, this has not been done. 3. Review of Resident #32's face sheet showed he/she had been admitted to the facility on [DATE] with a diagnosis of Acute Kidney Failure. Review of the resident's January 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 8:37 A.M. showed: -There were two Dialysis Communication Tools dated 1/1/25 by the facility. -(A) showed the date on the facility's section was 1/1/25. -The date on the dialysis section was 12/30/24. -(B) showed the date on the facility's section was 1/1/25. -The date on the dialysis section was 1/1/25. -Documentation on 1/8/25 did not show a code status (a person's predetermined medical instructions regarding the use of life-saving measures in the event they stop breathing) on the facility's section. -Documentation on 1/10/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -Documentation on 1/13/25 did not show a code status on the facility's section. -Documentation on 1/13/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -Documentation on 1/15/25 did not show a code status on the facility's section. -Documentation on 1/15/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. --The pre dialysis weight was documented by the dialysis unit as 119/68. --The post dialysis weight was documented by the dialysis unit as 119/68. -Documentation on 1/17/25 did not show a code status on the facility's section. -Documentation on 1/17/25 was on a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -There was no documentation on 1/20/25. -Documentation on 1/27/25 was not completed by the facility or the dialysis unit. -There was no Dialysis Communication tool on 1/29/25. -There was no Dialysis Communication tool on 1/31/25. --NOTE: The facility did not have documentation from 1/1/25 -1/27/25 at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's January 2025 Nurses' Administration Record showed: -Upon return from dialysis palpate the resident's right arm shunt for thrill and listen for the bruit. Repeat twice within eight hours post dialysis. -If either was absent notify the physician and document findings. -Check the bruit and thrill every shift routinely, every Monday, Wednesday, and Friday. -Document Y for audible bruit and thrill. -Document N if there were no audible sound and notify the physician immediately, dated 4/10/24. -Out of 93 opportunities (three times 31 days) there was no Y or N they were marked with an X. -X was not in the chart code. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She had ESRD. -He/She was on dialysis. Review of the resident's February 2025 Nurses' Administration Record showed: -Upon return from dialysis palpate the resident's right arm shunt for thrill and listen for the bruit. Repeat twice within eight hours post dialysis. -If either was absent notify the physician and document findings. -Check the bruit and thrill every shift routinely, every Monday, Wednesday, and Friday. -Document Y for audible bruit and thrill. -Document N if there were no audible sound and notify the physician immediately, dated 4/10/24. -Out of 70 opportunities (three times 31 days) 43 times they were marked with an X. -X was not in the chart code. -N was marked 23 times, there was no documentation the physician was notified. -There were four Vs. Review of the resident's February 2025 POS showed the following orders: -Dialysis on Monday, Wednesday, and Fridays, dated 7/1/24. -Upon return from dialysis palpate right arm shunt for thrill and listen for the bruit. Repeat twice within eight hours post dialysis. -If either was absent notify the physician and document findings. -Check the bruit and thrill every shift routinely, every Monday, Wednesday, and Friday. -Document Y for audible bruit and thrill. -Document N if there were no audible sound and notify the physician immediately, dated 4/10/24. Review of the resident's care plan dated 2/5/25 showed: -He/She was to receive dialysis three times a week on Monday, Wednesday, and Friday. -Staff was to Auscultate the Bruit and palpate the Thrill to the right arm shunt every shift. -Staff was to notify the physician of abnormalities or absence. -Monitor the dialysis site as ordered. -Monitor vital signs before and after Dialysis. Review of the resident's February 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 8:37 A.M. showed: -There was no Dialysis Communication Tool on 2/3/25. -Documentation on 2/5/25 was blank (not completed by the dialysis unit). -Documentation on 2/7/25 was blank (not completed by the dialysis unit). -There was no Dialysis Communication tool on 2/10/25. -Documentation on 2/12/25 was blank (not completed by the dialysis unit). -Documentation on 2/14/25 did not include vital signs taken by the facility. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. 4. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of ESRD. Review of the resident's care plan dated 1/13/25 showed: -He/She had a behavior problem and would refuse to go to dialysis. -He/She received dialysis. Review of the quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She had ESRD. -He/She was on dialysis. Review of the resident's January 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 9:37 AM. showed: -There was no documentation showing that the resident went to dialysis or refused to go to dialysis from 1/2/25 to 1/15/25, missing five dates. -Documentation on 1/17/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -There was no documentation showing that the resident went to dialysis or refused to go to dialysis from 1/18/25 to 1/31/25, missing six dates. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's February 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 9:37 A.M. showed: -On 2/5/25 there was no documentation showing that the resident went to dialysis or refused to go to dialysis. -On 2/12/25 there was no code status on the facility's part of the Dialysis Communication Tool. -There was no post dialysis weight documented by the dialysis unit. -There was no documentation showing that the resident went to dialysis or refused to go to dialysis on 2/14/25 or 2/17/25. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's February 2025 POS showed a physician order for Dialysis three times a week on Monday, Wednesday, and Friday, dated 12/9/24. During an interview on 2/19/25 at 11:15 A.M. the resident said: -He/She has a Peripherally Inserted Central Catheter (PICC a long think flexible tube inserted into a person vein in the arm) line on his/her chest. -Staff did not look at the PICC site when he/she would return from dialysis. -The resident some times refuses dialysis. -The staff was supposed to have sent a sheet with his/her vitals on it to the dialysis unit and he/she was supposed to have brought the sheet back from the dialysis unit with the dialysis information on it. He/She would give the dialysis staff the notebook when he/she went to dialysis, but he/she did not look in the notebook. -He/She did not look in the notebook, so he/she may have taken an empty notebook back and forth. During an interview on 2/21/25 at 10:30 A. M .,Licensed Practical Nurse (LPN) A said: -The resident had a PICC line in her chest and they did dialysis through that line. -This resident was his/her own person and often refused to go to dialysis. -If the resident refused, they were to document on his/her medical record as well as the Dialysis Communication Record that the resident had refused. -He/She ensured the resident's refusal had been documented but did not think other staff did. -On the Dialysis Communication Record should have been completely filled out with the vital signs, code status and the other information on the sheet. -The dialysis unit was to completely and accurately complete their part of the Dialysis Communication Record. -The dialysis unit should have ensured the resident's pre and post weights as well as vital signs and any difficulties. -There should have been a Dialysis Communication Sheet filled out completely by the facility and the dialysis unit that was accurate every time the resident went to dialysis. -If a Dialysis Communication Sheet did not come back from the dialysis unit the receiving nurse should have called the dialysis unit to have it faxed back to the facility. -That did not always happen. -The receiving nurse should have seen that the resident's weight was the same before and after dialysis there might have been a reason but there was no not stating why the weight was the same. -The nursing staff should have documented the dialysis site assessment the same way and it was not being done. -He/She could not tell what the documentation concerning the dialysis site meant. -He/She said maybe they need some education. -The DON was ultimately responsible for ensure documentation was done correctly and accurately every time. -The resident had a dialysis notebook that he/she was to take to dialysis and had them fill out, bring it back and upload the information weekly. -They have called the dialysis center to notify them the notes have not been coming back with the residents and they were still not sending the notebook with documentation back as they should. 5. During an interview on 2/24/25 at 1:30 P.M. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said: -The receiving nurse should have looked at the dialysis notes from the dialysis unit to ensure that they were completely filled out and were accurate. -He/She could not think of a reason that the pre and post dialysis weights would have been the same. -If the dialysis unit did not send a note back or it was incomplete the nurse should have called the dialysis unit back to retrieve the note. -If a resident refused to go to dialysis then it should have been documented in the Nurses' Notes. -The assessment of the dialysis site on the Nurses' Administration record should have been recorded as Y (yes there was an infection or bleeding at the site) or N (no bleeding or infection) the staff has not been doing that. -The DON was ultimately responsible for ensuring there was complete and accurate documentation that went to the dialysis unit and came back from the dialysis unit every time. During an interview on 2/26/25 at 9:37 A.M. LPN C said: -There are several residents that go out to dialysis. -If a resident declined to go out to dialysis it should have been charted in the Nurses' Notes. -The resident should have received education and the physician should have been notified. -The note from the facility should have included vital signs and code status. -The note when it came back from dialysis should have been viewed by the receiving nurse to ensure it was filled out completely and correctly. -The note should have included pre and post weights and vital signs as well as anything unusual. -The dialysis unit did not always send the note back. -The receiving nurse would have then contacted the dialysis unit to retrieve the documentation. -It has been a struggle to get the note from the dialysis unit. -The weights should never have been the same as they take fluid off of the resident. -The dialysis shunt should always have been assessed to ensure there was not bleeding or infection. -The documentation would have been on the progress notes not the nurses' notes. -The thrill should have been document as (+) if it was felt. -If the thrill was not felt then it should have been documented as (-). -The staff was documenting the assessments many different ways and was not able to understand their documentation. -The DON was ultimately responsible for ensuring staff was documenting correctly and documentation came back from the dialysis unit every time a resident went to dialysis. During an interview on 2/26/25 at 12:10 P.M. the DON said: -The facility should have had written communication with the dialysis unit. -There was a sheet that was started at the facility then went to the dialysis unit in a binder with the resident. -The sheet should have been filled out by both the facility and the dialysis unit then it would have been sent to Medical Records to have been downloaded into the resident's medical record. -The sheet should have included vital signs and weights before and after dialysis. -The facility licensed nurse on duty at the time of the resident return from dialysis assesses the resident's vital signs and dialysis access and reviews the resident's dialysis communication form and if there is missing information, the licensed nurse should then contact the dialysis center and obtain the missing information and should confirm any information regarding the resident's pre and post-dialysis weights as needed. -The DON should have been notified if a resident did not have three completed sheets from dialysis every week. This has not been done. -If a resident refused to go to dialysis then it should have been document in their chart. -The sheet the facility filled out should have included a code status. -If the resident's weight was the same pre and post dialysis he/she would have expected the nurse to have called the dialysis unit to find out why. -They have had a lot of issues with the dialysis unit sending the sheets back with the resident. -Staff should have documented the shunt assessment in the same way not three or four different ways. They should have all charted the same way. -He/She was ultimately responsible for ensuring staff was documenting the same way. -He/She had not audited the dialysis notebooks or assessments.

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment such as tubing, nebulizer (a machine that converts liquid medication into a fine mist that could be inhaled through a mouthpiece or mask) and Bilevel Positive Airway Pressure machine (BiPAP- a non-invasive ventilator that helps patients breathe by providing two different air pressure levels for inhaling and exhaling) were stored in a clean plastic bag when not in use for two sampled resident's (Resident #55 and #57) and failed to have a physician's order for two sampled residents to use a nebulizer and/or BiPAP (Resident #55 and #57) out of 18 sampled residents. The facility census was 92 residents. Review of the facility's policy, BiPAP Support, revised 5/2015 showed: -A physician's order is required to initiate BiPAP support and should include BiPAP settings as prescribed. -All BiPAP equipment should be cleaned and stored per general cleaning storage guidelines. Review of the facility's policy, Oxygen Administration, dated 6/2020 showed: -A physician's order was required to initiate oxygen therapy. -All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen would be changed weekly and when visibly soiled. -Oxygen items would have been 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 #55's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). -Obstructive Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Review of the resident' care plan dated 1/27/25 showed: -He/She had COPD. -Staff was to administer oxygen as ordered if ordered, dated 8/28/23. -Staff was to give aerosol (treatment) as ordered, dated 8/28/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 2/3/25 showed: -He/She was cognitively intact. -He/She had COPD. -Respiratory treatment was not checked. Review of the resident's February 2025 Physician's Order Sheet (POS) did not show an order for a nebulizer treatment. Observation on 2/19/25 at 12:27 P.M. showed a nebulizer mouthpiece was sitting on the resident's night stand not in a bag. There was no bag to store the nebulizer mouthpiece in. Observation on 2/20/25 at 9:27 A.M. showed a nebulizer mouthpiece was sitting on the resident's night stand not in a bag. There was no bag to store the nebulizer mouthpiece in. Observation on 2/21/25 at 11:30 A.M. showed a nebulizer mouthpiece was hanging off the side of the resident's night stand not in a bag. There was no bag to store the nebulizer mouthpiece in. 4. Observation and interview on 2/26/25 11:46 A.M. with Licensed Practical Nurse (LPN) A showed: -The nebulizer was on the resident's nightstand and the mouthpiece was not in a bag. -The LPN A said he/she could not find an order for the nebulizer but the resident had COPD. -The nebulizer must have been the roommates. -The LPN A removed the nebulizer from the resident's room. During an interview on 2/24/25 at 1:30 P.M. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said: -A nebulizer pipe (mouthpiece) or oxygen equipment should have been in a bag with the date written on it showing when it was changed. -The nebulizer pipe (mouthpiece) should have been cleaned daily and then air dried then put into a bag to keep it clean. -There should have been an physician's order for any type of oxygen. -The nurse was responsible to ensure oxygen equipment was kept in a bag when not in use. During an interview on 2/26/25 at 9:37 A.M. LPN B said: -When oxygen equipment such as the nebulizer was not in use it should have been in a bag to ensure it was kept clean. -There should have been a date on the bag or the tubing indicating when it was changed, it should have been changed weekly. -The nebulizer pipe (mouthpiece) and tubing should not have been hanging off the side of the resident's nightstand. -Nursing was responsible to ensure the oxygen equipment was changed out weekly, kept in a bag with the date it had been changed written on it. During an interview on 2/26/25 at 12:10 P.M. the Director of Nursing (DON) said: -There should have been an order for a resident to have oxygen or oxygen equipment. -The resident did not have an order for the nebulizer. -The oxygen equipment should have been hanging off of the nightstand. -Nursing was responsible to ensure the oxygen equipment was kept in a sanitary condition. -The oxygen equipment when not in use should have been kept in a bag with the date it had been changed written on it. During an interview on 2/26/25 at 1:30 the resident said: -The staff did not put the nebulizer mouthpiece in a bag when not in use, there was no bag in the room. -Someone had stolen his/her nebulizer in the last hour or so. -The nebulizer was his/her personal machine. -He/She still used it. -The nursing staff provided the medication for the nebulizer machine. -He/She had a treatment the day before. -He/She did not know how they got the medication for the nebulizer if they did not have a physician's order for it. 46890 2. Review of Resident #57's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Abnormalities of breathing. -Heart failure. Review of the resident's Electronic POS dated 2/2025 showed he/she had no orders for BiPAP. During an observation and interview on 2/19/25 at 9:46 A.M., showed: -The resident had a BiPAP at least a couple of weeks. -The resident had not seen staff clean or cover the mask. -The mask was observed in the resident's top dresser drawer uncovered. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was not using BiPAP. Review of the resident's care plan on 2/25/25 showed: -His/Her care plan was last reviewed/revised on 12/19/24. --Note: The care plan had not addressed BiPAP. Review of the resident's Electronic Medical Record on 2/25/25 showed he/she had a physician consult sheet dated 1/15/25 that showed new BiPAP and pressure setting ordered by his/her physician. During an interview on 2/26/25 at 9:39 A.M., Certified Nursing Assistant (CNA) A said: -Resident masks should be placed in a plastic bag when not in use. -Charge nurses are responsible for resident BiPAP machines. -If a resident has a BiPAP it should be in his/her care plan that is located at the nursing station. -He/She was not aware that Resident #57 had a BiPAP. During an interview on 2/26/25 at 9:46 A.M., Certified Medication Technician (CMT) A said: -He/She has worked at the facility for three years. -Masked should be covered when not in use. -The charge nurse is responsible for the resident BiPAP machines. -BiPAP's should have orders. -The Unit Managers are responsible for updating resident care plans. During an interview on 2/26/25 at 10:07 A.M., LPN A said: -Residents who have BiPAP's should have physician orders for settings and care for the machine. -The charge nurses are responsible obtaining BiPAP orders. -The MDS nurse is responsible to update the resident care plans. -He/She is updated in daily nursing report of any resident changes. -He/She was not aware that Resident #57 had a BiPAP. During an interview on 2/26/25 at 10:12 A.M., the MDS nurse said: -He/She had worked at the facility for five years. -He/She was responsible for the resident care plans. -He/She reviews new orders and updates the care plans. -He/She was not aware that Resident #57 had a new order for BiPAP. -Physician consults are reviewed during morning meetings for any new orders. During an interview 2/26/25 at 12:10 P.M., the DON said: -He/She would expect there would be orders including care if the BiPAP. -All new orders are reviewed in morning meetings and care plans updated. -He/She is responsible that orders are written and the care plans are updated. -He/She was not aware that Resident #57 did not have BiPAP orders written related to a physician consult from 1/2025.

Based on interview and record review, the facility failed to ensure written notification to the resident and/or family prior to transfer from the facility for one sampled resident (Resident #10) out of 18 sampled residents. The facility census was 92 residents. Review of the facility Transfer and Discharge policy dated June 2020 showed: -Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. 1. Review of Resident #10's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/8/24 showed the resident was moderately cognitively impaired. Review of the resident's Change of Condition progress note dated 12/20/24 showed: -He/She was leaning to his/her right side, his/her mouth also was sliding to his/her right side, he/she was unable to sit upright even after being repositioned and his/her pulse was 105 beats per minute. -His/Her physician was notified, and an order was received to send him/her to the emergency room for evaluation and treatment. -He/She left the facility at 10:30 A.M. in route to hospital emergency room. -There was no mention of written notification to the resident or the resident's family prior to the resident's transfer to hospital. Review of the resident's entire Electronic Medical Record (EMR) showed no written notification to the resident or the resident's family regarding his/her transfer to hospital on [DATE]. Review of the resident's Change in Condition progress note dated 12/23/24 showed during a telephone call, a facility licensed nurse informed the resident's family member that the resident had gone to an emergency room and was then admitted to the hospital. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) Dated 1/16/25 showed he/she was cognitively intact. During an interview on 2/20/25 the resident said: -He/She had been admitted to hospital a couple of times in the past couple of months. -He/She could not remember if the facility had given him/her written notification of the reason for his/her hospitalization and the name and address of the hospital. During an interview on 2/26/25 at 12:01 P.M. the facility social worker said: -He/She did not provide written notice to the resident or family when a resident was transferred to hospital. -That would be a licensed nurse responsibility since he/she was usually not in the facility when a resident was transferred to hospital. During an interview on 2/26/25 at 12:17 P.M. Licensed Practical Nurse (LPN) B said: -He/She had worked at the facility for over one year. -He/She had never given a resident or a resident's family a written transfer notification with information about the reason for and location of the resident's transfer prior to sending the resident to a hospital. During an interview on 2/26/25 at 12:15 P.M. the Director of Nursing (DON) said: -The licensed nurse on duty at the time of the resident's transfer was responsible for providing written notification regarding the resident's transfer, including the reason for the transfer and the location of the transfer. -He/She was responsible for monitoring to ensure transfer/discharge notices were given to residents/residents' family prior to a resident's transfer or discharge.

Based on observation, interview, and record review, the facility failed to accommodate three out of three sampled residents' (Residents # 1, #2, #3) preferences related to showering. The facility census was 91 residents. Review of the facility's Resident Rights - Accommodation of Needs policy, revised 8/2020 showed: -Residents' individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. -In order to accommodate residents' individual needs and preferences facility staff attitude and behavior are directed toward assisting the residents in maintaining independence, dignity, and well-being to the extent possible according to resident wishes. 1. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 10/22/24, showed the resident was: -Cognitively intact. -Dependent (helper does all effort) on staff for toileting hygiene, bathing/showering, and shower/tub transfers. -Incontinent of bowel. -Diagnosed with paraplegia (loss of movement of both legs and generally the lower trunk). Review of the resident's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) care plan, revised 10/24/24 did not show any of the resident's bathing/showering needs or preferences. Review of the resident's shower sheets dated 12/2024 showed: -On 12/4/24, 12/11/24, 12/17/24, and 12/19/24 he/she received showers. -On 12/22/24 he/she refused a shower. The form did not document why the resident refused. During an interview on 12/26/24 at 11:20 A.M. Certified Medication Technician (CMT) A said: -The resident took showers whenever they were offered. -The resident would speak up if he/she had to go too long without a shower. -As far as he/she knew the resident was getting them. Observation on 12/26/24 at 11:35 A.M. showed the resident had what looked like crumbs and a few dots of stains on the lap area of his/her pants. During an interview on 12/26/24 at 11:35 A.M. the resident said: -There were times he/she had gone a couple of weeks before getting a shower. -He/She hadn't had a shower during the week of Christmas and would have liked to have had one because he/she wanted to feel clean, especially if visitors came. -A weekly shower wasn't enough to keep him/her feeling clean. He/She needed one at least every few days. During an interview on 12/26/24 at 12:42 P.M. Certified Nurse Assistant (CNA) A said the resident did not refuse showers when they were offered. During an interview on 12/26/24 at 2:14 P.M. Licensed Practical Nurse (LPN) A said: -The resident often needed a shower. Anytime they gave residents showers the resident was on the list for one. -He/She was always dropping something on himself/herself. -The resident got a shower at least once a week. 2. Review of Resident #2's quarterly MDS dated [DATE] showed the resident was: -Severely cognitively impaired. -Dependent upon staff for toileting hygiene, bathing/showering, and tub/shower transfers. -Always incontinent of bowel and bladder. -Diagnosed with Hemiplegia/hemiparesis (paralysis/weakness affecting one side of the body). Review of the resident's ADL care plan, revised 10/16/24, showed the resident was dependent on one staff for bathing/showering twice weekly and as needed. A sponge bath would be offered when a full bath or shower cannot be tolerated. Review of the resident's shower sheets dated 12/2024 showed: -On 12/6/24 he/she refused a shower. There was no documentation as to why. -On 12/20/24 and 12/16/4 he/she had a shower. -On 12/20/24 he/she refused a shower. There was no documentation as to why. During an interview on 12/26/24 at 12:00 P.M. the resident said he/she: -Didn't always get to have showers every week. -Wanted more showers than what he/she was getting because he/she felt dirty and thought others could smell him/her. -Would like to get at least a couple of showers a week. 3. Review of Resident #3's quarterly MDS, dated [DATE] showed the resident was: -Cognitively intact. -Dependent on staff for toileting hygiene, bathing/showering, and tub/shower transfers. -Always incontinent of bowel and bladder. -Diagnosed with multiple sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability) and had upper and lower extremity impairments on both sides of his/her body. Review of the resident's ADL care plan, revised 12/5/24, showed the resident required assistance of two staff for bathing/showering as necessary. It did not mention the resident's bathing/showering preferences related to frequency or time of day. Review of the resident's shower sheets dated 12/2024 showed he/she had showers on 12/2/24, 12/9/24, 12/14/24, and 12/18/24. Observation on 12/26/24 at 12:25 P.M. showed the resident had a body odor. During an interview on 12/26/24 at 12:25 P.M. the resident said: -He/She wasn't getting showers as often as he/she wanted. Sometimes it was only once every two weeks. -He/She had always liked to shower daily, but in the facility setting that probably wasn't possible. -At the very minimum he/she would like to shower at least two or three times a week. -He/She didn't feel clean which affected his/her mood. He/She felt better when he/she was clean. -He/She didn't have any set days of the week for showering and didn't think there was a shower schedule. -He/She was often told there weren't enough staff to shower him/her. -Today he/she asked one of the CNAs for a shower and was told to wait until Saturday (two more days) because staff were too busy. During an interview on 12/26/24 at 12:42 P.M. CNA A said the resident did not refuse showers when they were offered. During an interview on 12/26/24 at 2:14 P.M. LPN A said: -The resident never mentioned to him/her that he/she wanted a shower. -There were four CNAs assigned to the halls on his/her side of the building so a CNA should have been available to give the resident a shower if he/she asked for one. He/she had not heard the resident had refused any shower. 4. During an interview on 12/26/24 at 12:42 P.M. CNA A said: -Residents had scheduled shower days. Lately the nurse just told the CNAs when a resident needed a shower. They hadn't been going by the shower schedule. -Resident showers were documented on shower sheets. During an interview on 12/26/24 at 2:14 P.M. LPN A said: -He/She determined if a resident needed a shower by looking at them. -There was a bathing schedule, and all residents were scheduled to receive two showers a week, but the nurse just determined by looking at residents who actually needed one. -They didn't necessarily get two showers a week since the shower aide had been working as a CNA. During an interview on 12/26/24 at 4:45 P.M. the Acting Director of Nursing (DON)/Regional Nurse Manager said: -Residents should be offered a shower on their scheduled shower days. -If a resident refused a regular bath or shower staff should offer a sponge bath. If they refuse that staff should get the nurse involved to see why the resident was refusing. -If there are four CNAs working on one side of the building staff should shower everyone who is scheduled to get a shower. They can give extra showers as they have time or see if the next shift can get the resident showered. MO00246401

Based on interview, and record review, the facility failed to properly secure one sampled resident (Resident #3) during transport in the facility van out of three sampled residents. The facility census was 91 residents. Review of the facility's Safe Transportation Unloading Procedure, undated, showed: -Always make sure the resident is secure with wheelchair locks engaged and tie down hooks secured to frame of wheelchair. -If transporting multiple residents, ensure other resident wheelchair(s) are fully secured (wheel locks engaged and tie down straps on wheels) until ready for unloading. -If for any reason you must step away from the resident reapply the wheel locks, hook straps and make sure the resident is fully secured. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Multiple Sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability). -Left knee contracture (a shortening of muscles and soft tissue often leading to deformity and rigidity). -Abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 11/14/24 showed the resident: -Was cognitively intact. -Had upper extremity impairments on both sides and lower extremity impairments on both sides. -Was dependent (helper does all the effort) for dressing, transfers, showers, toileting, and repositioning. -Used a motorized wheelchair. Review of the resident's Fall Risk care plan, dated 11/27/24 showed a goal for the resident to be free of falls and injuries. Review of the resident's internal Fall Report, dated 12/12/24 showed: -On 12/12/24 At 3:30 P.M. the resident reported he/she fell inside the van and hit his/her head when returning from an appointment. -Transportation Driver (TD) A's written statement showed he/she was bringing the resident and another resident back to the facility when he/she made a turn onto another street and the resident's chair tilted over and the resident said he/she hit his/her head. He/She didn't fall out of his/her seat. -Transportation Escort (TE) A's written statement showed the van turned a corner. The resident's chair was leaned back and he/she tilted over and said he/she hit his/her head. The resident never hit the floor. He/She and TD A tilted the chair back over and the resident rolled back into the facility. -There were no new interventions or plans mentioned in the Fall Report for preventing a similar future accident from happening. During an interview on 12/26/24 at 1:38 P.M. TD A said: -He/She was the driver to take residents to medical appointments. -Before he/she headed home he/she asked TE A if Resident #3 was strapped up and TE A said he/she strapped in Resident #3's wheelchair. -He/She was heading back to the facility from resident medical appointments when he/she made a turn and Resident #3's wheelchair tilted towards the van window. -He/She stopped the vehicle and the resident said he/she hit the right side of his/her head on the window during the turn. At the time the resident said his/her head hurt a little bit, but later told him/her he/she was OK. -The resident had a motorized wheelchair and the back of the wheelchair was found reclined instead of all the way up when they stopped. Another resident was in a manual wheelchair to Resident #3's right and the other resident's wheelchair stopped Resident #3 from falling to the van floor. Resident #3's wheelchair was leaning on the other resident's wheelchair when he/she stopped. Resident #3 didn't hit the other resident, just his/her wheelchair. -TE A strapped Resident #3 in on the day of the accident. He/She had shown TE A how to strap in wheelchairs using four straps per wheelchair, attaching them just under the resident's seat. -On the day of the accident they were transporting two residents. TE A had difficulty getting Resident #3 and the other passenger in because TE A's motorized wheelchair was so large. All the motorized wheelchairs tended to be larger than the manual wheelchairs. -He/She didn't know if TE A used all four straps, but TE A said he/she did. -When he/she stopped the van after Resident #3 tilted to his/her right he/she saw that the two straps on the left side of Resident #3's wheelchair were not attached. He/She had never known wheelchair straps to come off and out of the floor slot before. Either TE A didn't have the straps on securely or they weren't on right. -He/She thought Resident #3 was just so scrunched up with the other resident in the van TE A couldn't put the straps on like he/she normally did. -As the driver he/she was responsible for ensuring all wheelchairs were strapped down appropriately. He/She should have double checked the wheelchairs were strapped in correctly. During an interview on 12/26/24 at 3:30 P.M. Resident #3 said: -He/She was not strapped in correctly. They put straps on one side, but not the other so he/she was only half-way buckled in. -He/She tipped over while the van was in motion and the right side of his/her head hit the window hard. It really hurt at the time. -He/She called an ambulance when they got back to the facility and went to the hospital to have it checked out. He/She wanted to make sure he/she was alright. During an interview on 12/26/24 at 3:50 P.M. TE A said: -Resident #3 and another resident were in the back of the van. -He/She attached three straps onto Resident #3's wheelchair. He/She was supposed to put anywhere from two to four straps on the wheelchair. -The previous Transportation Driver, who was no longer working at the facility, had shown him/her how to attach the straps to the wheelchairs. -When he/she got the residents in the van the back of Resident #3's wheelchair was positioned upright. -On the way back from the medical appointments he/she heard a little scream. -The driver pulled over immediately. -They found Resident #3's wheelchair tipped over onto the back section of another resident's wheelchair and the back of Resident #3's wheelchair was reclined. Neither resident was hurt. -The front left strap that had been attached to Resident #3's wheelchair came up off the van floor. -Once before one of the wheelchair straps came up out of the van floor when they were transporting a different resident. That resident wasn't hurt either. -He/She wasn't aware of any protocol he/she needed to follow to prevent a similar accident from happening again. -It was fine to use anywhere from two to four straps to secure wheelchairs in the van. During an interview on 12/26/24 at 4:10 P.M. the MDS Coordinator said: -The resident used an outside transportation company as well as the facility van for appointments. -The driver should make sure the resident's wheelchair was locked and he/she was strapped down correctly before transporting. During an interview on 12/26/24 at 4:25 P.M. the Maintenance Director said: -He/She supervised the Transportation Driver. -He/She was told the resident tipped in his/her wheelchair during transport. -Without having seen it, he/she didn't know if the resident was strapped in correctly. -He/She had never been told straps had come up off the van floor. -He/She hadn't spoken to or provided education to TD A or TE A since the resident's accident. -The driver was always supposed to use four straps to secure each wheelchair. -After TD A was hired, he/she trained TD A to always use four straps to attach the front and back of each side of the wheelchair, and to ensure straps were securely latched. -Drivers were supposed to make sure straps were attached correctly. -TE A is the escort. He/She didn't train TE A because the driver was supposed to always secure the wheelchairs. During an interview on 12/26/24 at 4:33 P.M. the Administrator said: -Residents other than Resident #3 also have power (motorized) wheelchairs. -He/She re-educated the driver the day of the accident on making sure all strap latches were secure. He/She also told TD A and TE A to make sure all wheelchairs were in remained in an upright position. -The Maintenance Director was responsible for educating drivers on latching the straps to the wheelchairs. -He/She held the driver responsible for ensuring wheelchairs were secure.

Based on observation, interview and record review, the facility failed to ensure adequate staffing for residents needing a mechanical lift for transfers so they could get out of bed as desired for six sampled residents (Residents #4, #5, #12, #13, #16, #17) out of 23 sampled residents. Additionally, staff reported shifts weren't covered as reflected by the Daily Staffing Sheets and Time Card Records. The facility census was 89 residents. Review of the facility's Nursing Department Staffing, Scheduling and Postings policy, dated 10/22/24 showed: -The facility will employ sufficient nursing staff on a 24-hour basis to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. -In staffing an adequate number of nursing personnel, scheduling will be done as needed to meet resident needs and will account for the resident population census, diagnoses, and acuity (measures care need based on severity of resident illness or condition. Resident acuity can determine the staffing level required to provide services to residents). Review of the Facility Assessment Tool, dated 12/29/23 showed: -The facility would provide resources necessary to meet the various resident medical condition and psychiatric/behavioral health needs. Specialized treatments and cares included intravenous (IV) medications, oxygen therapy, ostomy, and hospice care. -Over half of the population required assistance of one to two staff or were totally dependent upon staff for dressing bathing, transfers, and toileting. -The facility's staffing plan included: --A full-time Director of Nursing (DON) daily. --An Assistant Director of Nursing (ADON)/Infection Preventionist. --A Treatment/Wound nurse. --A Minimal Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Nurse. --Two Registered Nurses or Licensed Practical/Vocational Nurses per each shift. --Two Medication Technicians (CMT) on the Day and Evening shifts. --At least four Certified Nurse Assistants (CNAs) on each shift. Review of the facility's list of residents requiring Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) cares showed: -Nineteen current residents required two-staff transfer assistance for full-body mechanical lifts. Twelve of the residents who required a mechanical lift were on the north side of the building and seven were on the south side. -Twenty-six residents required one-staff transfer assistance. Nine of the residents were on the north side and seventeen were on the south side. -One resident on the north side and one on the south side required the help of one to two staff for transfers. -One resident on the south side required the help of two staff (without a mechanical lift). -One additional resident on the north side sometimes required help with transfers. -Twenty-one residents required total cares for toileting, including twelve residents on the north side and nine on the south side. -One resident on the north side and two residents on the south side had to be fed their meals. Review of the facility Census Sheet for 10/16/24 showed forty-one residents were on the north side of the building and forty-eight residents were on the south side. 1. Review of the facility Staffing Sheet for 10/3/24 showed: -On the north side of the building on the night shift one nurse and three CNAs were originally scheduled to work, but the three CNAs called in. CMT A was scheduled to fill in as the CNA. -On the south side one nurse and two CNAs were scheduled on the night shift. One of the two CNAs worked a partial shift from 10:37 P.M. to 3:13 A.M. Review of the facility Staffing Sheet for 10/5/24 showed: -On the night shift on the north side one nurse and one CNA worked the full shift. One CNA called in and a third CNA left at 10:00 P.M. -On the night shift on the south side a nurse and one CNA worked. A second CNA called in. Review of the facility Time Card Report for 10/5/24 showed the CNA on the north side shown on the Staffing Sheet left at 10:00 P.M. clocked in at 3:10 P.M. and out at 10:00 P.M. and clocked back in at 10:30 P.M. and out at 4:00 A.M. the following morning. Review of the facility Staffing Sheets for 10/10/24 showed: -On the night shift one nurse and three CNAs were scheduled for the north side of the building. One of the CNAs had been moved from the south side to the north side. One of the three CNAs working on the night shift left at 5:30 A.M. -On the south side one nurse and one CNA were shown as working the night shift. One CNA was shown to have walked out at 11:15 P.M. and one did not show up for work. Review of the facility Time Care Record for 10/10/24 showed: -One CNA on the north side clocked in at 9:51 P.M. and out at 6:59 A.M. the following morning. One CNA clocked in at 3:41 P.M. and out at 5:06 A.M. and one CNA clocked in at 9:06 P.M. and out at 5:38 A.M. -The CNA on the south side clocked in at 10:20 P.M. and out at 7:00 A.M. the following morning. Review of the facility staffing sheet for 10/11/24 showed: -One nurse, one CMT and two CNAs worked the day shift on the north side. A third CNA called in. -On the south side a nurse, a CMT and four CNAs were shown as scheduled and working on the day shift. Review of the facility Time Card Report for 10/11/24 showed: -One CNA shown scheduled on the north side worked 6:43 A.M. to 10:14 A.M. The other scheduled CNA did not work. -One CNA shown scheduled on the south side worked 6:59 A.M. to 2:30 P.M. One CNA worked 7:00 A.M. to 12:33 P.M. One worked 7:49 A.M. to 3:34 P.M. and the fourth CNA shown on the schedule did not work. Review of the facility Staffing Sheets for the day shift on 10/12/24 showed: -A nurse, one CMT, and three aides (one was CMT A who worked the shift as a CNA) were scheduled for the day shift on the north side (100 and 200 Halls). -A nurse, a CMT, and four CNAs were scheduled on the south side (300 and 400 Halls). One CNA on the south side was being oriented as a new employee. Review of the facility Time Card Report for 10/12/24 showed: -On the north side of the building one of the CNAs shown on the 10/12/24 staffing schedule worked 6:43 A.M. to 10:14 A.M. instead of the full eight-hour shift. Another CNA worked 8:50 A.M. until 2:20 P.M. CMT A, worked 7:49 A.M. to 3:34 P.M. -On the south side of the building one CNA worked 6:59 A.M. to 2:30 P.M., one worked 7:00 A.M. to 12:33 P.M., one worked 7:29 A.M. to 12:00 P.M. and 2:41 P.M. to 10:01 P.M., and the CNA in orientation worked 7:02 A.M. to 2:30 P.M. Review of the facility Staffing Sheets for the day shift on 10/13/24 showed: -A nurse, a CMT, and CMT A, who was scheduled as a CNA, was on the schedule for the north side. Two other CNAs called in and one did not call or show up. -A nurse, a CMT, and four CNAs, one of which was being oriented, were scheduled on the south side of the building. Review of the facility Time Card Report for 10/13/24 showed: -CMT A clocked in at 8:25 A.M. and out at 2:20 P.M. -One CNA scheduled to work the south side worked 7:28 A.M. to 2:45 P.M. One CNA worked 7:39 A.M. to 2:31 P.M. The CNA in orientation worked 7:15 A.M. to 2:31 P.M. One CNA shown as working on the south side did not clock in. 2. Review of Resident #4's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -It was very important he/she do things with a group of other people and go outside to get fresh air. -Had upper and lower extremity impairments on both sides. -Was totally dependent on staff for transferring from one surface to another (such as from the bed to a wheelchair), dressing, bathing, incontinence cares, and rolling from side to side. Review of the resident's Comprehensive Care Plan, dated 9/4/24 showed the resident required total assistance of two staff for transfers and repositioning, total assistance of one staff for dressing and incontinence cares, extensive assistance (staff does over 50 percent of the effort) of two staff for bathing, and extensive assistance of one staff for personal hygiene. Review of the resident's grievance for 10/12/24 and 10/13/24 showed: -The resident did not get out of bed the weekend of 10/12/24 and 10/13/24 and did not receive care from staff. -A grievance response dated 10/16/24 showed nursing was to educate staff on getting the resident up timely and providing cares and rounds every two hours. -Attached to the grievance was a statement by CMT A showing he/she was the only aide working the day shift on 10/13/24 on the north side of the building. The resident asked to be gotten up and was a two-person transfer. He/She made sure the resident was clean and dry and the resident didn't ask to get up any more throughout the shift. During an interview on 10/16/24 at 1:30 P.M. the Social Services Designee said: -The resident filed a grievance because nobody on the day shift got him/her up over the weekend of 10/12/24 and 10/13/24. He/She stayed in bed the entire weekend. -The resident liked to sleep in and have breakfast in his/her room and wanted to get up before lunch. During an interview on 10/16/24 CMT B said: -On 10/13/24 CMT A was the only staff working as a CNA on the north side. The south side had three staff working as CNAs. He/She didn't know why one wasn't pulled to help CMT A on the north side. -The resident was not up at any time on the day shift on 10/12/24 and 10/13/24. He/She was in the resident's room multiple times on those dates, but didn't recall if the resident mentioned why he/she wasn't out of bed. He/She normally got out of bed during the day. -CMT A never asked him/her to help get the resident up on 10/13/24. He/She wasn't asked to get anyone up and didn't get anyone up. -On 10/13/24 he/she helped pass trays, helped feed residents in the dining room and answered call lights. During an interview on 10/16/24 at 2:47 P.M. Licensed Practical Nurse (LPN) A said: -There were only two CNAs working the north side on 10/12/24 and one of the two CNAs on the north side left before residents were served lunch. -CMT A, who was working as a CNA, was asked to work on the south side on 10/12/24 because they were short staffed. -On 10/12/24 Resident #4 didn't get out of bed, but normally does get up. Two staff were needed to get the resident up because he/she was transferred with a full body mechanical lift. The CNA never asked him/her (LPN A) to help get the resident out of bed and didn't know if he/she asked the CMT for help. -The resident asked CNA G to get him/her up. At the time CMT B was at lunch and CNA G said he/she would ask CMT B to help get him/her up after CMT A finished his/her break. By the time CMT A finished his/her break at around 1:00 P.M. trays were being passed to the rooms. Room trays were being picked up right before the evening shift started at 2:30 P.M. -He/She didn't realize until 1:00 P.M. the resident hadn't gotten out of bed before lunch. -There needed to be at least three CNAs on the north side during the day shift because there were several residents who had to be transferred with the mechanical lift. Several residents also needed incontinence cares and help getting dressed. During an interview on 10/21/24 at 10:30 A.M. LPN B said: -He/She worked as the nurse on the south end on 10/12/24 and 10/13/24. -He/She wasn't sure about the staffing on the north side of the building on 10/12/24. -On 10/13/24 the south end had two CNAs and a CMT. There was a third CNA who was in orientation and could help with resident cares but couldn't be left alone with residents. -On 10/13/24 CMT A was acting as the CNA on the north side. He/She was the only CNA scheduled for the north side who showed up. -The Weekend Nurse Supervisor was calling the Staffing Coordinator to try to get someone in, but wasn't able to find anyone. He/She thought the CMT from the south side helped CMT A a short while on the north side, but he/she could only do that while working around his/her medication pass times. -Nurses and CMTs can help with cares but must work around their medication passes and the CNA has to tell them they need help. -The north side nurse was responsible for contacting the Staffing Coordinator if his/her side was short staffed. During an interview on 10/21/24 at 12:55 P.M. LPN C said: -He/She worked on the north side of the building on 10/13/24. -CMT A was the only staff working as a CNA. -He/She and CMT B helped CMT A answer call lights and pass meal trays. -He/She didn't help anyone out of bed. No residents asked him/her to assist them out of bed and CMT A didn't ask for help in getting anyone up. -Sometimes only one CNA shows up for a shift. It makes for poor resident care. It takes longer to do everything like getting everyone up, cleaned, and dressed. -There were several residents on the north side that needed two staff for mechanical lift transfers so it makes it very difficult to meet their needs when only one CNA shows up and medications have to be passed. During an interview on 10/21/24 at 2:09 P.M. CMT A said: -On 10/12/24 he/she was on the schedule to work the north side, but ended up working on the south side because he/she was asked to do so. -On 10/13/24 he/she worked by himself/herself on the north side. He/She didn't get anyone up that needed a mechanical lift transfer because he/she was by himself/herself. In the early morning before the day shift started on 10/13/24 the night shift got a few people up, but he/she didn't get anyone up who needed a mechanical lift transfer. They didn't send anyone over from the south side to help him/her. There were two CNAs and a newer CNA who was orienting on the south side on 10/13/24. -The north side nurse and CMT did not offer to help get anyone up. They helped with meal trays. The call lights were going crazy all day and the north side nurse and CMT helped answer lights. They didn't help get anyone up or provide incontinence cares. He/She didn't think they had time to help with that. They looked busy all day. -He/She had to keep all the incontinent residents clean and dry on the north side. -Resident #4 asked to get up on 10/13/24. The resident normally gets up every day. He/She told the resident he/she would try to get someone to help get him/her up, but wasn't able to find anyone to help. By the time he/she finished changing the incontinent residents the shift was over. During an interview on 10/21/24 at 3:58 P.M. the resident said: -On the weekend of 10/12/24 and 10/13/24 the day shift would pass meal trays and leave and not come back until the next shift. He/She didn't get up at all either of the two days and wanted up on both days. -He/She was told there wasn't enough staff to get him/her up. He/She knew the CMT and nurse were working both days on the north side and they could have helped the CNA get him/her up or the CNA could have gotten an aide from the south side to help. -The weekend before (10/5/24 and 10/6/24) he/she got up one of the weekend days but not the other. He/She pushed the call light between breakfast and lunch and told the staff he/she wanted up. They said OK and left the room and never came back the rest of the shift. The evening shift told him/her they didn't want to get him/her up just to have to put him/her back to bed, so he/she never got up that day. -When he/she was up and out of bed staff don't want to change his/her brief because they have to put him/her back to bed to change him/her and then get him/her back up again. He/She needed two staff for every transfer. For that reason, he/she stayed soiled most days. 3. Review of the Resident #5's admission MDS, dated [DATE] showed the resident: -Was cognitively intact. -It was very important he/she do things with a group of people and go outside for fresh air. -Had upper and lower extremity impairments on both sides. -Was totally dependent on staff for transfers, dressing, bathing, incontinence cares, and rolling from side to side. Review of the resident's Comprehensive Care Plan, dated 8/30/24 showed the resident required total assistance of two staff for transfers, repositioning, and bathing and total assistance of one staff for dressing and incontinence cares. During an interview on 10/21/24 at 1:15 P.M. the resident said: -He/She never got out of bed on 10/12/24 or 10/13/24. They told him/her there was not enough staff to get him/her up. That's no fun to stay in bed. He/She stayed in bed all day and didn't get up at all on any shift on 10/12/24 and 10/13/24. -It was the same way the weekend before (10/5/24 and 10/6/24). One of those days he/she didn't get up. -It had been bad for about a month or more. That was his/her only complaint. -If it didn't get better, he/she would have to move, but he/she didn't want to move to another place. During an interview on 10/21/24 at 2:09 P.M. CMT A said: -Resident #5 was in bed when he/she told his/her roommate, Resident #4, he/she wasn't able to find anyone to help get him/her up. -Resident #5 normally gets up every day, on both weekends and weekdays. During an interview on 10/22/24 at 1:07 P.M. LPN A said Resident #5 stayed in bed all day on 10/12/24. It was 1:00 P.M. before he/she realized the resident was still in bed and too late to call the Staffing Coordinator. 4. Review of Resident #12's Comprehensive Care Plan, dated 8/22/24 showed the resident: -Required total assistance of two staff for transfers with a mechanical lift, toileting, and bathing and maximal assistance of one staff for repositioning and dressing. -Preferred to get up between 9:00 A.M. and 9:30 A.M. Review of the resident's Annual MDS, dated [DATE] showed the resident: -Was cognitively intact. -It was very important he/she do things with a group of people and it was somewhat important to go outside for fresh air. -Had upper and lower extremity impairments on both sides. -Was totally dependent on staff for transfers, dressing, bathing, incontinence cares, and needed partial/moderate assistance (staff does less than half the effort) for rolling from side to side. During an interview on 10/21/24 at 12:00 P.M. the resident said: -He/She didn't get out of bed at all Friday, Saturday or Sunday (10/11/24 - 10/13/24). He/She really wanted up on Friday and Sunday. -On Friday he/she put his/her call light on before lunch. They didn't come to his/her room until they brought lunch. They never gave him/her a chance to get up. -He/She had to have the mechanical lift to get up. Nurses, except for the wound nurse, won't help get him/her up. -On 10/13/24 he/she put his/her light on at 11:00 A.M. Someone turned it off at 11:30 A.M. and said he/she would tell the aide. The aide didn't come until 1:30 P.M. to change him/her. The CNA didn't offer to get him/her up after lunch. That was too late anyway because he/she wanted up before lunch. -He/She didn't know if they really tell aides when he/she needs help or if they forget. -There were many days he/she missed getting out of bed because staff don't get him/her up. He/She didn't keep track of the dates. During an interview on 10/21/24 at 2:09 P.M. CMT A said Resident #12 normally gets up during the day, but he/she didn't have help to get the resident up on 10/13/24. During an interview on 10/22/24 at 1:07 P.M. LPN A said Resident #12 stayed in bed all day on 10/12/24. It was 1:00 P.M. before he/she realized the resident was still in bed and too late to call the staffing coordinator for more staff. 5. Review of Resident #13's Annual MDS, dated [DATE] showed it was very important to the resident he/she do things with other people and go outside for fresh air. Review of the resident's Quarterly MDS, dated [DATE] showed the resident: -Was cognitively intact. -Was totally dependent on staff for transfers with a mechanical lift and repositioning and required maximal assistance with bathing and dressing his/her lower extremities. Review of the resident's Comprehensive Care Plan, dated 9/24/24 showed the resident required total assistance of two staff for transfers; total assistance of one staff for incontinence cares, repositioning and dressing; and extensive assistance of one staff for bathing. Review of staffing for 10/21/24 showed an LPN, a CMT, and two CNAs were scheduled on the north side. During interview on 10/21/24 at 12:17 P.M. the resident said: -There were lots of times he/she wanted out of bed and couldn't get up because there weren't enough aides. Today was one of those days. -He/She told an aide around 7:00 A.M. he/she wanted up. They said they would get him/her up but nobody has gotten him/her up. -He/She couldn't stay in the bed all day. He/She had a sore on his/her left foot and his/her backside was broken down. He/She was paralyzed and couldn't move himself/herself. -A lot of times when he/she put the call light on he/she waits over an hour for help. During an interview on 10/21/24 at 2:09 P.M. CMT A said: -Resident #13 got up every day, but he/she didn't have help to get him/her up on 10/13/24. -His/Her shift ended at 2:30 P.M. He/She hadn't had time to get the resident up yet. 6. Review of Resident #16's Annual MDS, dated [DATE] showed it was very important to the resident to do things with other people and go outside for fresh air. Review of the resident's Comprehensive Care Plan, dated 8/6/24 showed the resident required total assistance of two staff for transfers with a full body mechanical lift, bathing, dressing, and repositioning and total assistance with incontinence cares. Occasionally the resident needed extensive assistance to eat if he/she was weak or tired. Review of the resident's Quarterly MDS, dated [DATE] showed the resident: -Was severely cognitively impaired. -Was totally dependent on staff for transfers, repositioning, bathing, dressing and incontinence cares and required maximal assistance for eating. During an interview on 10/21/24 at 2:09 P.M. CMT A said Resident #16 gets up every day, but he/she didn't get up on 10/13/24 because he/she didn't have help to get him/her up. During an interview on 10/22/24 at 1:07 P.M. LPN A said the resident stayed in bed all day on 10/12/24 because they were short staffed. 7. Review of Resident #17's Comprehensive Care Plan, dated 8/5/24 showed the resident required total assistance of two staff for transfers with a full body mechanical lift, bathing, and dressing and was dependent upon one staff for repositioning and incontinence cares. Review of the resident's Annual MDS, dated [DATE] showed the resident: -Was moderately cognitively impaired. -Thought it was very important to do things with other people and go outside for fresh air. -Was totally dependent on staff for transfers, dressing and incontinence cares. During an interview on 10/21/24 at 2:09 P.M. CMT A said Resident #17 didn't get out of bed on 10/13/24 because nobody helped him/her get the resident up. 8. During an interview on 10/21/24 at 1:05 P.M. CMT B said: -It was difficult to get everyone up who wanted up when there was only one CNA on a side. -They might want up in the morning, but it might be later in the day before staff have time to get them up. During an interview on 10/21/24 at 1:09 P.M. CNA B said: -Normally there were two CNAs working on the north side of the building. -He/She wouldn't be able to get everyone up who wanted up if he/she was the only CNA. He/She would need assistance. -If only a nurse and CMT was working with him/her he/she would have to wait for them to finish passing medications for them to help with mechanical lift transfers and there wouldn't be time to get everyone up with all the incontinence cares needed as well. -Two CNAs working the north side was doable, but three CNAs was what was really needed for the day shift. It got very busy with just two staff trying to answer all the lights. -If he/she was the only CNA on a side he/she would have to do what he/she could and tell the charge nurse he/she couldn't do all the cares needed and the charge nurse would need to notify the DON to try to get staff to come in. During an interview on 10/21/24 at 2:35 P.M. CNA C said: -He/She worked on the south side of the building on 10/13/24 with CNA D and CNA E who was in orientation. They didn't have time to help CMT A on the north side because they had to get the south side residents to the dining room and didn't have time to help get north side residents up before lunch. -LPN B, who was the charge nurse on the south side, never asked the south side CNAs to help on the north side. -CMT A came over a few times during the shift and asked for the south side CNAs' help, but they didn't have time to help. It was all they could do to take care of the residents on their own side. -CNAs were supposed to ask their own charge nurse for help. The nurse and CMT on that side would have to help outside of medication pass times. Residents who were transferred by mechanical lifts would have to wait until the CNA could get help. During an interview on 10/21/24 at 2:45 P.M. CNA F said he/she would not be able to provide cares by himself/herself on any shift on either side of the building due to the high numbers of residents who needed help getting up and who need incontinence cares. Note: At this point CNA F looked over the list of residents needing various types of ADL assistance and said it looked accurate to him/her. During an interview on 10/21/24 at 4:15 P.M. LPN C said: -It was the Registered Nurse (RN) Supervisor's duty to get needed staff on the weekends. He/She told the RN Supervisor there was only one aide who showed up on the north side on 10/13/24. -He/She didn't realize so many residents were still in bed on 10/13/24 or he/she would have asked the RN Supervisor for help. During an interview on 10/22/24 at 9:50 A.M. LPN D said: -Multiple CNAs had been clocking in and leaving the building and coming back before the end of the shift to clock out. They would be gone for hours and residents weren't receiving the cares they needed. The DON was made aware of the problem by multiple nurses. -Sometimes the DON or LPN E would call CNAs to bring up the staffing numbers. They put them in for a body count, but CNAs would refuse to help on another side when staff were short. During an interview on 10/22/24 at 1:07 P.M. LPN A said: -On 10/12/24 CNA H arrived to work around 6:45 A.M. and about 10:15 suddenly announced he/she was leaving. He/She couldn't tell the CNA not to go. He/She would have left anyway. -Before lunch he/she was busy giving insulin and administering medications and the CMT was also giving medications. -He/She was supposed to call the Staffing Coordinator if there were not enough staff. That day he/she didn't call because it was 10:15 A.M. before he/she realized the CNA was leaving and staff weren't going to be able to get everyone up. -By 1:00 P.M. he/she realized they hadn't gotten several residents up and by then it was so late he/she didn't call the staffing coordinator for more staff. -He/She never knew who would show up on the weekends. They had more call-ins on the weekend. -Three CNAs were enough to get everyone up and keep them clean and dry. If only two CNAs show up they were constantly working and trying to keep up with the work. During an interview on 10/22/24 at 1:30 P.M. CNA E said: -On 10/13/24 he/she was in orientation due to being new. He/She already had a current CNA certification and knew how to do resident cares. -During orientation he/she was allowed to assist with mechanical lift transfers, get people up and dressed, provide incontinence cares, and do everything any other CNA did. During orientation he/she just had to be with another CNA for all resident cares. -He/She and either of the two aides he/she worked with on 10/13/24 on the south side could have assisted CMT A on the north side had any of them been assigned or told to do so. During an interview on 10/22/24 at 1:45 P.M. CNA J said: -He/She had worked alone the night of 10/5/24 and 10/10/24 on the south side of the building and had done so about three times within the past month. -He/She tried to keep up with the incontinence cares as best he/she could. It helped a lot to have a second person to work with. -Sometimes a second aide will leave early and he/she would be left alone for the remainder of the shift. That happened on 10/3/24 and at other times. -On the south side approximately 10 residents were incontinent of bladder on the 400 hall and six or seven were incontinent on the 300 hall. He/She also had to empty three catheter bags on the 400 hall and two on the 300 hall. -There were five residents in particular who were very difficult for one person to turn from side to side to change and reposition in bed. One was on the 400 Hall and four were on the 300 Hall. They were either very heavy, very stiff, or weak and unable to help much with turning. -The facility expected the night shift to get a few residents from the south side up in the morning. That was very difficult to do when there was only one CNA working the morning hours. He/She couldn't always get them up when working by himself/herself. During an interview on 10/22/24 at 2:20 P.M. CMT A said: -He/She has had to work the night shift alone. That happened on 10/3/24. -It was much easier to keep up with incontinence cares when there were two CNAs. -He/She worked mostly on the day shift and on the north side of the building. -There were too many mechanical lift transfers and incontinence cares to do during the day for two CNAs. -Three CNAs were needed on the north side on the day and evening shifts. Two were needed on the night shift to get all the incontinence cares and repositioning done. During an interview on 10/22/24 at 2:42 P.M. CNA K said: -He/She has had to work alone before. He/She tried to get everyone changed at least once or twice throughout the night when working alone. -When there were two CNAs he/she could check everyone every two hours. -When he/she worked the evening shift the nurse and CMT had to pass medications between 7:00 P.M. and 9:00 P.M. -Most of the residents want to go to bed during that time so they had to wait to be transferred to bed. -When there were at least two CNAs it was better, but they really needed three CNAs per side on the evening shift. It went more smoothly when there were three CNAs. -About three or four weeks ago he/she was the only CNA on the evening shift on the south side after 7:00 P.M. when the other CNA left. They tried to get as many residents to bed as possible before 7:00 P.M., but residents were just finishing supper. -Nobody from the north side helped out after the second CNA left. He/She just did what he/she could. During an interview on 10/22/24 at 3:10 P.M. the RN Supervisor said: -He/She had been newly hired at the facility and didn't know most resident or staff names. -He/She recalled the CNA working by himself/herself on 10/13/24. The LPN on the south end didn't want the south side CNAs going to the north side to help. -He/She texted the DON to get staff to help on the north side and waited quite a while to hear back. They were unable to find a CNA to come in. He/She helped on the north side with meal trays and answering call lights. -Nobody reported to him/her there were residents who didn't have the opportunity to get up the weekends of 10/5/24 to 10/6/24 and 10/12/24 to 10/13/24. -They should report to him/her if they can't get everyone up or can't get all their work done. The charge nurses should be watching to make sure everyone gets up who wants up. -He/She expected the CNAs, CMTs, charges nurses and the shift supervisor to work as a team and pitch in and help with resident cares as needed. -He/She gave both sides of the building his/her number to contact him/her with any emergencies or concerns.<BR/

Based on interview and record review, the facility staff failed to provide ordered pressure ulcer wound dressing changes on a consistent basis for two sampled residents (Resident #5 and #8), and failed to prevent an acquired pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one sampled resident (Resident #2) who was at high risk out of nine sampled residents. The facility census was 86 residents. Review of the facility Wound Management Policy, updated 6/2020 showed: -The purpose of the policy was to provide a system for the treatment and management of residents with wounds including pressure ulcers. -Any resident who had a wound was to have received the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. -Treatment of a pressure injury should include minimizing pressure and/or tension on the wound, maintaining moisture balance while controlling drainage and protecting the surrounding skin to avoid deteriorating wound edges. -A licensed nurse was to perform a skin assessment upon admission, readmission, weekly and as needed for each resident. -The assessment of the wound care needed for pressure injuries was to emphasize, identifying risk factors, treatment, mechanical offloading, pressure reducing devices, reducing skin friction, sheer and moisture, proper nutrition, and evaluating and modifying interventions for residents with existing pressure injuries. -The physician was to have been notified of any new pressure injuries, those wounds that were not responding to treatment, any wounds that worsened, any complaints of pain or decrease in mobility by a resident, signs of infection, and any residents refusing treatment. -Wound documentation was to have occurred at a minimum of weekly until the wound was healed. Documentation was to have included: --Location of the wound. --Length, width, and depth measurements recorded in centimeters (cm's). -Direction and length of any tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin), if applicable. -Appearance of the wound base. --Drainage amount and characteristics including color, consistency and odor. --Appearance of the wound's edges. --Description of the peri-wound (the skin surrounding the wound) or evaluation of the skin adjacent to the wound. --Presence or absence of new hearing at the wound rim. --Presence of pain. -Licensed Nurses were to have documented effectiveness of current treatment in the resident's medical record on a weekly basis. Review of the Facility Assessment Tool dated 11/19/24 showed: -The facility was able to meet the needs of residents with skin ulcers and injuries. -One of the services the facility provided was pressure injury prevention and care, skin care, wound care including pressure injuries. -The facility resources necessary to provide competent care and support for residents included administration, a treatment/wound nurse, food and nutrition services, rehabilitation services, physicians, nurse practitioners, pharmacists, and outside providers as needed. -One of the competencies necessary for nursing staff was specialized care including wound care and dressing changes. -The facility was to develop, implement and maintain an effective training program for all new and existing nursing staff, consistent with their expected roles. 1. Review of Resident #5's Facility admission Record showed the resident was admitted on [DATE] with the following diagnoses: -Osteomyelitis of the spine. -Paraplegia (loss of movement of both legs and generally the lower trunk). Review of the resident's quarterly Minimum Data Set ((MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/25/24 showed he/she: -Was cognitively intact. -Bilateral lower extremities were impaired. -Used a wheelchair. -Was totally dependent on facility staff for- --Dressing, showering/bathing, lower body dressing, and applying footwear. --Sitting to standing and standing to sitting. Sitting to lying and lying to sitting. --Bed to chair and chair to bed transfers. --Tub/shower transfers. --Had two stage IV pressure injuries (most severe stage of pressure ulcer where there is a full thickness tissue loss exposing underlying structures like bone, tendon, or muscle) with one of them present upon admission. --Was at risk for skin breakdown. --Had a wound infection. Review of the resident's Nursing Care Plan dated 10/30/24 showed: -He/she had pressure injuries which he/she was admitted with and became infected. -The wounds were to show signs of healing by the next review date. -The facility staff was to administer medications and complete the wound care treatments per the physician's orders. -The facility staff was to assess, record and monitor the wound healing weekly and report improvements and declines to the physician. -The facility staff was to follow the policies and protocols for the prevention of further skin breakdown. -Weekly treatment documentation was to include the measurement of each wound including length, width depth, type of tissue and drainage present. -The resident had a history of noncompliance with wound care, refusing at times to have the wounds treated and refusing to stay in bed when needed for wound off-loading. -The facility staff was to re-educate the resident on the importance of having the wounds treated per the physician's orders. -The facility staff was to re-educate him/her on the need to off load the areas where the wounds were present which meant spending some time up and other times in the bed. Review of the resident's Physician Order Sheet (POS) dated 11/4/24 showed: -The resident's left lateral foot pressure injury was to have been cleaned with wound cleanser or normal saline, packed with Dakins 0.125% (diluted bleach used to treat wounds and prevent or treat infections) moistened gauze, cover with an ABD (a large, thick wound covering) dressing, wrap with kerlix (rolled gauze used to cover a dressing), secured with and ACE (a stretchy tight bandage) bandage every day and as needed for soiling. Review of the Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 11/5/24 at 10:27 A.M., showed: -The resident's Stage IV sacral wound measured 8.5 cm X 6.8 cm x 1.7 cm with 75% granulation tissue (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) and 25% slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) present. -The wound was malodorous (had odor) with heavy drainage and there was exposed muscle. -At this point, the resident had a Negative Pressure Device (a type of wound care treatment device that pulls fluid and bacteria out of a wound to promote healing) he/she was not appropriately utilizing. -The wound was documented as stable. -The resident's left lateral foot pressure injury measured 3.0 x cm x 3.1 cm x 0.7 cm with 90% granulation and 10% slough present. -There was exposed muscle and bone present, and the wound was documented as worsening. Review of the Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 11/12/24 at 10:57 A.M., showed the resident refused to be assessed or treated. Review of the resident's facility wound note dated 11/12/24 at 9:22 A.M. showed: -Wound Nurse A walked into the facility and the resident was seen sitting outside on the patio in his/her wheelchair. -Wound Nurse A asked the resident if he/she was going to see the provider for wound care that day. -Wound Nurse A also reminded the resident that wound care was every Tuesday stating at 9:24 A.M. to 11:30 A.M. -The resident stated that he/she forgot and asked what he/she needed to do. -Wound Nurse A informed the resident that he/she would need to have the staff return him/her to bed for wound care to occur. -The resident then stated he/she did not want to do that because he/she did not know when he/she would be gotten back up into the chair again. -Wound Nurse A then informed the resident that his/her refusal of wound care would have to be documented to which the resident just shrugged his/her shoulders. -Wound Nurse A then walked into the facility and clocked in for work. Review of the resident's facility wound note dated 11/13/24 at 11:01 A.M., showed: -Wound Nurse A noted the resident was sitting up in his/her wheelchair as the nurse was rounding for wound care. -The resident had begun asking to get up at 8:00 A.M., with anxiousness and frustration. -The staff encouraged the resident to remain in bed until his/her wound care was completed. -The resident refused however since the resident had the right to get up, the resident was gotten up into his/her chair shortly after he/she asked. -Wound Nurse A asked resident if he/she would allow his/her wound care to be completed to which the resident asked if he/she could stay in his/her chair to have the dressing changed. -Wound Nurse A explained to the resident that with the wound on his/her sacrum, it was not possible to have the dressing changed. -The resident then rolled his/her wheelchair away and did not get his/her dressing changed. Review of the resident's Wound Care noted dated 11/13/24 at 6:38 P.M., showed: -The resident was in bed at the time after having been up in his/her wheelchair for more than 11 hours. -The resident had not had any wound care completed since 11/9/24 due to refusal and upon removing the dressing, the wound showed malodorous slough and necrotic (dead) tissue. -The resident agreed to have the dressing changed on his/her sacrum and left foot. -The dressings were changed. -His/her left lower leg showed some signs of swelling from the mid-calf to the toes. -The resident had no fever and was currently receiving intravenous (IV) antibiotics. Review of the resident's Wound Note dated 11/13/24 at 8:00 P.M., showed Wound Nurse A reported the change in the resident's condition to the provider who ordered the resident sent to the hospital for evaluation and treatment. Review of the resident's POS dated 11/18/24 showed the sacral wound was to have been cleaned with wound cleanser of Normal Saline, pat dry, lightly pack with Dakins 0.125% strength without packing too tightly, cover with a foam dressing daily and as needed for soiling. Review of the resident Treatment Administration Record (TAR) dated November 2024 showed: -No would care/dressing change was completed for the resident's left lateral foot pressure injury on 11/1/24, 114/24, 11/6/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, 11/11/24, 11/17/24, 11/18/24, 11/19/24, 11/20/24, 11/22/24, 11/23/24 and 11/24/24. -No wound care/dressing change was not completed for the resident's sacral wound on 11/19/24, 11/22/24, 11/23/24 and 11/24/24. -There was no documentation on why the wound care was not done. Review of the resident's Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 11/21/24 at 10:14 A.M., showed: -The resident's sacral pressure injury measured 9.6 cm x 7.0 cm x 2.0 cm with 80% granulation and 20% slough present. -The wound was malodorous and showed as worsening. -He/she remained non-compliant with wound care and dressing changes. -The resident's left lateral foot pressure injury measured 2.3 cm x 2.5 cm x 0.7 cm with 90% granulation and 10 % slough present. -There was muscle and bone exposed and was documented as improving. Review of the resident's Wound Care note dated 11/28/2411/27/24 at 9:33 A.M., showed: -He/she was up in his/her wheelchair at the time of Wound Nurse A's arrival to complete his/her wound care. -The resident had a handwritten note in his/her room on the wall that instructs the resident on when wound care was to be performed so he/she would remain in bed until the wound dressings were changed. -The resident refused to have his/her dressings changed. Review of the resident's Wound Care note dated 11/28/24 at 9:54 A.M., showed: -The resident was observed by Wound Nurse A up in his/her wheelchair. -Wound Nurse A asked the resident if he/she was going to get his/her dressings changed to which the resident stated he/she thought they had already been changed. -He/she refused to have his/her dressings changed. Review of the resident's Outside Certified Wound Care Provider Physician's Assistant's Progress Noted dated 12/3/24 at 10:36 A.M., showed: -The resident's sacral pressure injury measured 9.6 cm x 7.3 cm x 2.2 cm with 70% granulation and 30% slough. -There was heavy drainage and the wound was malodorous with muscle exposed. -The wound was documented as worsening. -The resident remained non-compliant with wound care and dressing changes. -The resident's left later foot pressure injury measured 2.3 cm x 2.6 cm x 0.8 cm with 90% granulation and 10% slough present. -There was muscle and bone exposed and the wound was listed as worsening. During an interview on 12/4/24 at 2:45 P.M., Wound Nurse A said: -The resident was very non-compliant. -He/she had placed a sign in his/her room reminding him/her not to get up until his/her dressing changes were completed but he/she frequently insists on getting up early in the morning. -He/she has a lot of issues with the nursing staff not doing the resident's dressing changes when he/she is not in the building. -He/she keeps his/her treatment cart unlocked in a locked room and all the nurses have a key to get in so there should be no issue with not having supplies to do the resident's dressing changes. -He/she consults with the outside wound care company if he/she feels it to be necessary. -He/she know that he/she was not good at always documenting the dressing changes or reasoning behind dressing change refusals and he/she planned to work on doing a better job of documentation. During an interview on 12/4/24 at 3:24 P.M., Licensed Practical Nurse (LPN) A said: -The resident was very non-compliant with his/her wound care and dressing changes. -He/she wanted to be up in his/her wheelchair all day, every day which was not good for his/her sacral pressure injury. -The resident had an agreement with Wound Nurse A, to be in his/her bed at the times his/her dressing changes were completed, however, he/she frequently did not abide by that request and would insist on getting up early to go outside and smoke. -When Wound Nurse A was off or on weekends, the nursing staff assigned to the resident was to have completed his/her wound care/dressing changes. -Whomever does the dressing change should have documented in detail if the resident refused to have the dressing changes completed after continuing to encourage the resident and re-educate him/her on the importance of getting the dressing changed, getting into the bed to offload his/her sacrum. During an interview on 12/5/24 at 10:50 A.M., the Outside Certified Wound Care Provider Physician's Assistant said: -He/she had a hard time getting the resident to understand that he/she needed to spend some time in bed and that it would be helpful if he/she stayed in bed on the days of his/her consulting days until the dressing changes were completed. -The resident was very non-compliant, however, he/she also had concerns regarding the lack of wound care when Wound Nurse A was not in the building. -He/she frequently came into the facility and found the resident's dressings that were outdated, saturated with drainage or soiled. -He/she had even come in when Wound Nurse A was on vacation to find the same dressing on that he/she had placed on the wound the week prior. -The resident's initial treatment plan was a negative pressure device, however, he/she would remove it, the staff would not keep it charged, and rarely was another dressing placed on the resident's sacral wound. During an interview on 12/5/24 at 11:22 A.M., the Director of Rehabilitation said: -He/she had worked with the resident to get a good off-loading device for his/her wheelchair, but the resident still spent too much time up and not off-loading the sacrum. -He/she saw a real problem with the resident's dressings not getting changed per the physician orders. During an interview on 12/5/24 at 3:00 P.M., the resident said: -He/she thought he/she was getting dressing changes completed appropriately. -He/she did not always want to wait until later in the morning to get up so sometimes he/she got up before his/her dressing change was completed. -When he/she was already up, he/she did not like to have to go back to bed for a dressing change. -He/she knew he/she should have his/her dressings changed daily but did not always like to have them changed so sometimes he/she said no when asked. During an interview on 12/20/24 at 3:10 P.M., the facility Medical Director said: -He/she would have expected that all ordered treatments have been provided by the facility nursing staff or the facility Wound Nurse and that those wound treatments have been documented as completed. -He/she would have expected that all completed treatments have been documented by the nurse who completed the treatment. -He/she would have expected thorough documentation of the resident refusal for the wound treatment, including further attempts to encourage the resident to comply with wound care, education and re-education provided by the nurse attempting to provide the wound care. -He/she would have expected the continuing refusals by the resident to have been reported to the attending physician as well as facility administration. 2. Review of Resident #8's Facility admission Record showed the resident was admitted on [DATE] with a diagnosis of pressure injury to his/her coccyx (tailbone). Review of the resident's POS dated 5/23/24 showed: -The resident's wound was to have been cleaned with wound cleanser, patted dry before applying nickel thick amount of Santyl (an ointment used for the debridement of pressure ulcers) to the necrotic area, covered with Calcium Alginate (a natural fibrous substance used in wound dressings) followed by a foam dressing daily and as needed for soiling. Review of the resident's Nursing Care Plan dated 6/4/24 showed: -He/she was admitted with an unstageable pressure injury on his/her coccyx. -The pressure injury was to have shown signs of healing and remain free from infection by the review date. -The facility staff was to have been administered per the physician's orders. -The facility staff was to have completed wound treatments per the physician's orders. -The facility staff was to have followed the facility policies and protocols for the prevention/treatment of skin breakdown. -The facility staff was to have monitored/documented/reported any changes in skin status, appearance, color, wound healing, signs/symptoms of infection, wound size (length, width, depth), and stage weekly and as needed. Review of the resident's POS dated 6/11/24 showed to treat the resident's coccyx was to clean with wound cleanser, patted dry before applying Dakins 0.125% moistened gauze before covering the wound with a foam dressing, daily and as needed for soiling. Review of the resident's POS dated 9/28/24 showed to clean the wound with wound cleanser, pat dry, apply collagen sprinkles to the wound bed, cover with a foam dressing daily and as needed for soiling. Review of the resident's admission MDS dated [DATE] showed he/she: -Was cognitively intact. -Required supervision for rolling, sitting to standing, standing to sitting, and transferring from the bed to the chair. -Required partial to moderate assistance for toileting, personal hygiene and lying to sitting edge of bed. -Was able to ambulate ten to 50 feet with partial to moderate assistance. -Was dependent for bathing and showering. -Was admitted with one Stage IV pressure injury and three unstageable pressure injuries. Review of the resident's POS dated 11/13/24 showed: -The resident was to receive a pressure relieving mattress. -The resident's sacral wound was to have been cleaned with would cleanser or Normal Saline, patted dry, lightly packed with quarter strength Dakins solution and covered with a foam dressing daily and as needed for soiling. -The resident's left ankle, right ankle and left heel was to have been cleaned with wound cleanser, patted dry, apply Betadine paint to eschar (dead tissue) and Calcium Alginate to the open area before covering with a Silicone dressing daily and as needed for soiling. Review of the resident's November 2024 TAR showed: -No wound care/dressing change for his/her coccyx wound was completed on 11/1/24, 11/4/24, 11/6/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, 11/11/24, 11/12/24, 11/17/24, 11/18/24, 11/19/24, 11/22/24, 11/23/24, and 11/24/24. -No wound care/dressing changes for his/her left ankle, left heel or right heel wounds were completed for-11/17/24, 11/18/24, 11/19/24, 11/22/24, 11/23/24, and 11/24/24. -No documentation was recorded as the reason why the wound care was not done. Review of the resident's Facility Weekly Pressure Injury Trend for the month of November 2024 showed he/she was admitted with the following pressure injuries: -Week one he/she had: -One Stage III pressure injury (a full thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are no exposed) on his/her left heel measuring 4.6 cm x 4,7 cm x 0.4 cm. -One Stage IV pressure injury on his/her left ankle measuring 2.4 cm x 2.0 cm x 0.4 cm. -One unstageable pressure injury on his/her right heel measuring 3.1 cm x 3.0 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.1 cm x 2.7 cm x 0.5 cm. -Week two he/she had: -One Stage III pressure injury on his/her left heel measuring 3.7 cm x 4.1 cm x 0.4 cm. -One Stage IV pressure injury on his/her left ankle measuring 2.2 cm x 2.0 cm x 0.4 cm. -One unstageable pressure injury on his/her right heel measuring 3.2 cm x 3.0 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.6 cm x 2.8 cm x 0.6 cm. -Week three he/she had: -One Stage III pressure injury on his/her left heel measuring 3.5 cm x 4.0 cm x 0.4 cm. -One Stage IV pressure injury on his/her left ankle measuring 1.1 cm x 1.1 cm x 0.4 cm. -One unstageable pressure injury on his/her right heel measuring 3.3 cm x 2.9 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.6 cm x 2.8 cm x 0.6 cm. -Week four he/she had: -One Stage III pressure injury on his/her left heel measuring 3.7 cm x 3.8 cm x 0.3 cm. -One Stage IV pressure injury on his/her left ankle measuring 1.3 cm x 1.3 cm x 0.3 cm. -One unstageable pressure injury on his/her right heel measuring 3.2 cm x 2.2 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.5 cm x 2.8 cm x 0.6 cm. Review of the resident's Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 12/3/24 at 11:35 A.M., showed: -The resident's Stage IV coccyx pressure injury measured 2.9 cm x 3.0 cm x 0.6 cm with undermining of 3.3 cm from 12:00 to 1:00 with 90% granulation and 10% slough. -The wound showed muscle exposure, no drainage and was noted as stable. -The resident Stage III left lateral ankle pressure injury measured 1.0 cm x 1.0 cm x 0.3 cm with 95% granulation and 5% slough, no drainage and improving. -The resident's Unstageable right heel pressure injury measured 3.4 cm x 1.6 cm x 0.3 cm with 10% granulation and 90% eschar, light drainage and improving. -The resident's Stage IV left heel pressure injury measured 4.2 cm x 4.1 cm x 0.4 cm with 25% granulation and 75% slough, muscle exposure, moderate drainage and improving. During an interview on 12/4/24 at 2:45 P.M., Wound Nurse A said: -The resident never got out of bed so was on a low air-loss mattress for pressure reduction. -The staff attempted to keep his/her feet off the bed by using pillows. -He/she was being seen by the outside wound care company. During an interview on 12/4/24 at 3:24 P.M., Licensed Practical Nurse (LPN) A said: -The resident never wanted to get out of bed, so the staff tried to keep his/her feet off the bed. -He/she could turn himself/herself but spent a lot of time on his/her back. During an interview on 12/5/24 at 10:50 A.M., the Outside Certified Wound Care Provider Physician's Assistant said: -He/she had never seen the resident out of his/her bed before. -The staff stated they try to get him/her to get up into the chair but the resident refuses. -The staff had him/her on a low air-loss mattress and attempted to keep his/her heels off the bed. 3. Review of Resident #2's Facility admission Record showed the resident was admitted on [DATE] with the following diagnoses: -Osteomyelitis of the spine (infection of the bone). -Sepsis (a blood stream infection). -Diabetes type II (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's POS dated 6/14/24 showed Physical Therapy (PT) and Occupational Therapy (OT) was to evaluate and treat the resident to address his/her deceased strength, decreased self-care skills and decreased overall functional ability. Review of the resident's wound note dated 11/5/24 at 4:25 P.M., showed: -The resident developed a dark circular hardened area to his/her left heel measuring 3.5 cm x 3.5 cm. -Betadine Paint (a topical antiseptic used the help prevent infection in wounds) was ordered. Review of the resident's POS dated 11/5/24 showed the resident's left heel pressure injury was to have been cleaned with wound cleanser, patted dry before applying Betadine Paint then covering with a dry dressing every other day and as needed. Note: The resident's left heel pressure injury had not yet been care planned before the resident left the facility, went to the hospital and was discharged home from the hospital, not returning to the facility. Review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Had impairment of his/her upper extremity (shoulder, elbow, wrist, hand). -Used a wheelchair. -Was totally dependent on facility staff for- --Dressing, showering/bathing, lower body dressing, applying footwear, and personal hygiene. --Rolling right and left. --Sitting to standing and standing to sitting. Sitting to lying and lying to sitting. --Bed to chair and chair to bed transfers. --Tub/shower transfers. --Had one stage III pressure injury, not present on admission. --Had an unstageable pressure injury, not present on admission. --Was at risk for skin breakdown. During an interview on 12/4/24 at 2:45 P.M. Wound Nurse A said: -The resident laid in his/her bed partially on his/her right side primarily, with his/her left foot against the bed. -He/she had severe spasms of his/her left leg causing almost constant back and forth movement of his/her left foot. -This constant movement of the inside portion of his/her left foot caused added pressure to that area which in turn, caused a pressure injury to develop. -He/she did not believe that anything could have been done to prevent the pressure injury to the resident's foot. -He/she did not try any padding to that portion of the resident's foot and the resident refused to wear off-loading booties while in bed. -The resident was on a low air-loss mattress. During an interview on 12/4/24 at 3:24 P.M. LPN A said: -The resident frequently complained of severe leg spasms and was on muscle relaxants for them. -He/she did not like to be in bed and when he/she was up, he/she insisted on wearing tennis shoes. -He/she refused to wear off-loading booties, but he/she did not believe that any padding of his/her foot was ever attempted, or any other off-loading devices were tried. During an interview on 12/5/24 at 3:15 P.M., the resident said: -He/she liked to stay in bed. -He/she did not think his/her dressing always got changed when they were supposed to. -Sometimes they put pillows under his/her feet but not always. During an interview on 12/6/24 at 10:50 A.M. the Outside Certified Wound Care Provider Physician's Assistant said: -He/she was never asked to see the resident. -He/she felt as though he/she was not always appropriately consulted on residents who would benefit from being evaluated and treated. -He/she would have expected to have been consulted on the resident as soon as the necrotic area was discovered on the resident's foot. During an interview on 12/6/24 at 11:22 A.M., the Director for Rehabilitation Services said: -He/she had been seeing the resident since admission for overall strengthening. -He/she was the one who discovered the new necrotic pressure injury on the resident on 11/5/24 and reported it to the Wound Nurse. -Since finding the new pressure injury, he/she had been working to get appropriate off-loading devices in place and a better wheelchair for the resident that would better off-load the resident's feet. -The resident did have severe muscle spasms involving his/her left foot. During an interview on 12/20/24 at 3:10 P.M., the Facility Medical Director said: -The resident should have been seen by the Outside Wound Care Provider. -He/she would have expected the facility Wound Nurse to appropriately refer the resident who was in need of further wound care evaluation and treatment. -He/she would have expected the facility Wound Nurse appropriately off-load and/or pad the resident's foot where there was extra pressure due to the resident's left/foot spasms to prevent the acquired pressure injury. -He/she would have expected the area of breakdown on the resident's foot to have been found before that area became necrotic. 4. During an interview on 12/5/24 at 1:06 P.M., Registered Nurse (RN) A said: -He/she worked primarily on the night shift but did pick up some day shifts if needed. -If there was a dressing that needed to be changed and Wound Nurse A was not in the building, he/she would always do the dressing change. -If a resident refused a dressing change, he/she would attempt more than once and if the dressing did not get changed, he/she would document everything he/she did and the refusal. During an interview on 12/5/24 at 2:21 P.M., LPN B said: -If a dressing needed to be changed and Wound Nurse A was not at the facility, he/she had no problem changing the dressing. -He/she noticed dressings that were overdue to be changed even when Wound Nurse A was in the building. -He/she believed that sometimes the dressing just did not get changed or documented. During an interview on 12/6/24 at 10:30 A.M., the Administrator, Director of Nursing (DON) and the Regional Nurse Consultant said: -Wound Nurse A had been with the facility for about a year and a half and was hired as an LPN wound nurse with w

Based on observation, interview, and record review, the facility failed to ensure a safe and home like environment when multiple leaks occurred in the facility on 1/18/24 affecting two sampled residents (Resident #2 and Resident #3) out of 14 sampled residents; the facility also failed to ensure the floors of rooms of three sampled residents (Residents #10, #6 and #4) were maintained, free of a buildup of grime and debris. The facility census was 82 residents. Review of the Facility's undated policy titled Rapid Response Guide: Flood showed the first initial action would be to rescue anyone in immediate danger. NOTE: There was no specific policy or guideline related to water leaks in resident rooms. 1. Review of Resident #3's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Other Acute Osteomyelitis (a serious infection of the bone), left ankle and foot. -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Chronic Obstructive Pulmonary Disorder (COPD- a disease process that decreases the ability of the lungs to perform ventilation). Review of Resident #3's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 12/8/23 showed: -The resident was cognitively intact. -The resident used a wheelchair and/or walker for mobility. -The resident was independent for most care except for needing Setup or clean-up assistance (helper sets up or cleans up, resident completes activity) when putting on/taking off footwear (the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable). 2. Review of Resident #2's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). -Unspecified Psychosis (when there is some loss of contact with reality) not Due to a Substance Abuse or Known Physiological Condition. Review of Resident #2's Admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident did not have any verbal behavioral symptoms directed towards other (e.g., threatening others, screaming at others, cursing at others) within the seven day look back period. -The resident needed supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as the resident completes activity) when going from a sit to lying position. -The resident needed supervision or touching assistance when lying to sitting on the side of the bed. -The resident needed supervision or touching assistance when sitting to standing. -The resident used a wheelchair for mobility. 3. During an interview on 1/18/24 at 9:37 A.M. the Administrator said there was a leak in the center of room [ROOM NUMBER]. Observation on 1/18/24 at 9:50 A.M. of room [ROOM NUMBER] showed: -An active leak in the center of room. -Resident #2's bed had been moved and was turned at an angle towards the entrance of the room and away from the center of the room. -A 32-gallon bucket in the center of the room collecting the leaking water. -Wet bath blankets (a multi-purpose product that can have many uses throughout the facility, commonly used during bed baths for warmth and privacy) around the 32-gallon bucket. -Standing water around the bath blankets on the floor. -Resident #2 was sitting in his/her bed and watching television. -Resident #3 was sitting in his/her wheelchair near the door to the bathroom watching television. During an interview on 1/18/24 at 10:34 A.M. Resident #3 said: -He/She was currently being moved out of his/her room. -He/She thought the leak had started around 4:00 A.M. -He/She thought he/she told Registered Nurse (RN) A about the leak around 5:00 A.M. that morning. -The reason why he/she told the staff about the leak when he/she did was because the leak had worsened. -The facility had not done anything with the leak except putting towels on the floor and placing a bucket underneath the leak. -He/She was really upset about the leak and was afraid that the ceiling may fall on him/her especially once the leak worsened. During an interview on 1/18/24 at 10:47 A.M. Resident #2 said: -He/She did not want to move out of his/her room because he/she was concerned about his/her belongings going missing. -He/She was upset about the leak causing him/her to be uncomfortable especially because the water leaked on him/her and his/her bed. -He/She was unsure of the exact time in which the leak had started, but thought it was around 3:00 A.M. -He/She had told staff about the leak but could not remember the exact time. -He/She thought the leak had worsened around 7:30 A.M. and the facility had not done anything to fix the leak up until that time. -He/She had wanted to change his/her bedding due to the sheets getting wet from the leak. Observation on 1/18/24 at 10:47 A.M. showed the presence of water on the floor at the left side of and close to the foot of Resident #2's bed and the presence of moist sheets on the resident's bed. During an interview on 1/18/24 at 12:47 P.M. the Administrator said: -The facility had started leak audits in all the resident rooms. -He/She thought the residents from that room would be moved into the conference room. -If any other leaks occurred in resident rooms, then the facility would have to start moving residents to other facilities. During an interview on 1/18/24 at 1:09 P.M. Licensed Practical Nurse (LPN) A said: -He/She informed the Director of Nursing (DON) about the leak once he/she saw the DON that morning. -He/She was unsure of when he/she told the DON, but the night nurse was still in the building at that time. During an interview on 1/18/24 at 1:41 P.M. LPN A said: -Resident #2's bed had already been moved away from the leak. -He/She asked Resident #2 and Resident #3 to sit in the dining room for breakfast. -He/She had not told the Maintenance Director about the leak in 307 because there were previous leaks in the building that he/she had been fixing. -It would have been night shift's responsibility to inform management and the Maintenance Director of the leak in room [ROOM NUMBER] because it occurred on night shift. During an interview on 1/18/24 at 1:46 P.M. Resident #2 said: -He/She had moved his/her bed over out of the leak area once the leak had started. -The sheets that were on his/her bed at 10:47 A.M. were the same sheets that were on his/her bed at the time of the leak. During an interview on 1/18/24 at 1:51 P.M. the DON said: -He/She had been made aware of the leak in room [ROOM NUMBER] around 7:45 A.M. that morning. -He/She had been in the building since 6:30 A.M. but had been on the other halls until that time. -He/She was new to the building and was unsure of what needed to happen, so he/she sent out a group text. -He/She was unsure if the group text that had been sent out included the Maintenance Director. During an interview on 1/18/24 at 2:55 P.M. the Administrator said: -He/She was unaware of the leak in room [ROOM NUMBER] until he/she received the group text from the DON. -He/She would have expected staff to notify him/her, the DON, or the Maintenance Director as soon as the staff were aware of the leak in room [ROOM NUMBER], especially because it had been actively leaking. During a phone interview on 1/18/24 at 2:37 P.M. Certified Nursing Assistant (CNA) B said: -Resident #2 and Resident #3 did not need a lot of care. -Resident #2 had not complained of his/her sheets being wet during his/her shift prior to moving rooms. -Resident #2's bed was made when he/she came on shift and had not changed the sheets during his/her shift. -The Maintenance Director and management had already been aware of the leak in room [ROOM NUMBER] by the time he/she knew there was a leak in 307. During a phone interview on 1/18/24 at 2:44 P.M. Registered Nurse (RN) A said: -He/She was unsure of when the leak started in room [ROOM NUMBER]. -He/She had been notified of the leak by one of the Residents around 5:50 A.M. -Once he/she was made aware of the leak, he/she went down to room [ROOM NUMBER] and saw an active leak in the middle of the room. -Resident #2 would be capable of moving his/her own bed and moved his/her bed frequently. -He/She had moved Resident #2's bed more so he/she could put the bath blankets on the floor due to the standing water that was on the floor. -He/She had discussed moving to a new room with Resident #2 and Resident #3, but they had both refused at that time. -He/She tried to call the DON about the leak in room [ROOM NUMBER], but the call would not go through. -Once he/she had finished his/her nursing duties and gave report to LPN A, he/she then told the DON verbally about the leak in room [ROOM NUMBER]. -He/She had informed the DON around 7:30 A.M. that morning. -Resident #2 did not appear wet when he/she went into the room once notified of the leak in room [ROOM NUMBER]. During a phone interview on 1/18/24 at 6:00 P.M. CNA A said: -Resident #2 and Resident #3 had not informed him/her of a leak at any time during his/her shift. -He/She was only made aware of the leak when the surveyor left a voicemail on his/her phone. -The last time he/she had seen Resident #2 and Resident #3 had been around dinner time while he/she was passing out dinner trays. -He/She had not gone back into room [ROOM NUMBER] because Resident #2 had cursed at him/her, and he/she felt threatened. -Resident #2 had also asked him/her to not come back into the room. -room [ROOM NUMBER]'s door was open and had seen a bath sheet on the floor before leaving the facility. -He/She must have been doing his/her last rounds of the shift during the time the leak occurred. -He/She had left the facility around 7:10 A.M. that morning. During a phone interview on 1/19/24 at 7:21 A.M. CNA A said: -He/She had charted Resident #2's behaviors and told the charge nurse. -Resident #2 had not exhibited any verbal behaviors towards him/her before that shift. -He/She thought Resident #2 was going to hit him/her and was really scared. During an interview on 1/19/24 at 9:28 A.M. RN B said: -All residents should be rounded on every two hours at the minimum for safety concerns. -Resident #2 had not exhibited any verbal behaviors towards him/her and would notify the DON of any behavioral issues. -The only behavior he/she had seen from Resident #2 was pacing around his room. -He/She would still have expected the CNA A or a different CNA to have rounded on Resident #2 and Resident #3 regardless of their behavioral issues. During an interview on 1/19/24 at 9:49 A.M. CNA A said: -He/She was unaware of any past behavioral issues from Resident #2 prior to that shift. -Resident #2 and Resident #3 are independent with all care. -The rounds should have been delegated to someone else because he/she had not completed them. During an interview on 1/19/24 at 12:10 P.M. Resident #3 said: -He/She never refused to change rooms once the leak occurred in his/her room. -He/She was never made aware of any plan for a room change prior to surveyor arrival to the facility. During an interview on 1/19/24 at 12:15 P.M. the Administrator and The DON said: -The DON had asked Resident #2 and Resident #3 to come out of the room once he/she was made aware of the leak in room [ROOM NUMBER]. -He/She told Resident #2 that it would be safer for him/her to move out of the room, but Resident #2 had stated that he/she would not move to a different room without knowing where his belongings were going. -By the time the DON had finished speaking with Resident #2 and Resident #3 the Maintenance Director was in the building and provided no further intervention. -The Administrator had arrived to the facility around 8:30 A.M. on 1/18/24 and had sent a message to the Maintenance Director about the leak in 307 around that time. -There was not a discussion of what happened or what was going to happen with room [ROOM NUMBER] prior to morning meeting. -The morning meeting started around 9:00 A.M. on 1/18/24 and was adjourned once management was made aware of surveyor being in the facility which was around 9:30 A.M. 19916 4. Review of Resident #10's medical record who was admitted to the facility on [DATE] and his/her admission MDS was not completed as yet. Observations on 1/19/24 at 1:45 P.M., showed the presence of a brown colored grime on floor of the resident's room and at the entrance of his/her room. Further observation showed the resident was sleeping, so he/she was not interviewed. Observation on 1/19/24 at 1:50 P.M., showed the presence of debris on the floor and a large red stain behind the bed in the resident's room. 5. Review of Resident #6's face Sheet dated 1/10/24, showed diagnoses which include quadriplegia (paralysis of the legs and arms) neuromuscular dysfunction of bladder, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest which can affects how a person feel, think and behave and can lead to a variety of emotional and physical problems). During an interview on 1/19/24 at 1:52 P.M. the resident said the housekeepers had not been to his/her room yet. Observation on 1/19/24 at 1:50 P.M., showed the presence of debris on floor and red stains behind the resident's bed. 6. Review of Resident #4's annual MDS dated [DATE], showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. Observation on 1/19/24 at 1:56 P.M. showed a heavy buildup of debris between bed and wall in the resident's room. During an interview on 1/19/24 at 1:57 P.M., the resident said the housekeepers did not pull his/her bed out for cleaning and everyone can do a little bit better job. During an interview on 1/19/24 at 2:33 P.M., the Housekeeping Supervisor said he/she expected the housekeepers to clean the debris from under the beds and at the entrance to room, after he/she observed Resident #10's room. Observation on 1/19/24 at 2:36 P.M., with the Housekeeping Supervisor, showed the buildup of debris between Resident #4's bed and the wall. During an interview on 1/19/24 at :40 P.M., the Housekeeping Supervisor said: -He/she looked at 4-5 rooms for cleanliness, at the end of the day. -He/she noticed some of these issues with lack of cleanliness in the past. MO 00229207 and MO 00230452.

Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three sampled residents (Resident #3, #4, and #5) out of five sampled residents. The facility census was 83 residents. Review of the facility Care and Services Policy dated 6/20 showed: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of long-term care facility. -Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Review of the facility Communication-Call System Policy dated 10/24/22 showed: -Purpose: To provide a mechanism for residents to promptly communicate with nursing staff. -Policy: --The facility will provide a call system to enable resident to alert the nursing staff from their beds and toileting/bathing facilities. ---The call system should be accessible to a resident lying on the floor in toileting and bathing facilities. -Procedure: --Call cords will be placed within the resident's reach in the resident's room. --Nursing staff will answer call bells promptly, in a courteous manner. 1. Review of Resident #3's Admission Record showed He/She was admitted on [DATE] with the diagnoses of Diabetes Type II (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), Hemiplegia and Hemiparesis (paralysis/weakness affecting one side of the body) following a stroke affecting the right dominant side, and history of falling. Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/10/23 showed the resident: -Was cognitively intact. -Was totally dependent on staff for assistance with Activities of Daily Living (ADL). -Required maximal assistance with toileting hygiene. -Was frequently incontinent. Review of the resident's undated Care Plan showed: -He/She had a self-care performance deficit. --He/She needed staff assistance to the extent needed to accomplish task. --He/She needed staff assistance with getting on and off toilet. --He/She required staff assistance to move between surfaces. --To encourage use of the call bell for assistance. -At risk for falls. --Needed safety movement with a working and reachable call light. --Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. --The resident needed prompt response to all requests for assistance. Review of the resident's Grievance/Complaint report dated 9/11/23 showed He/She complained that his/her call light was on and it went unanswered for most of the night on 9/10/23 which resulted in him/her being left in his/her own waste for most of the night. During an interview on 9/27/23 at 10:16 AM, the Social Services Director said the grievance for the call lights was related to clinical services so it was given to the Director of Nursing (DON) to handle but as of now the grievance was unresolved. During an interview on 9/27/23 at 11:47 A.M., Certified Nurses Aide (CNA) A said: -The last time He/She checked on the resident was after breakfast. -It should only take a couple of minutes to answer a call light, if He/She is working on the floor. -35 to 40 minutes is too long for a call light to go unanswered. -He/She left for break at around 10:50 A.M. and was back just after 11:00 A.M. -He/She did not answer the resident's call light from 11:07 A.M. through 11:47 A.M. because He/She was on break. During an interview and observation of the resident on 9/27/23 from 11:07 A.M. through 12:01 P.M. showed: -The resident's call light had been activated. -The resident was waiting for staff to assist him/her to the bathroom. -He/She thought the light had already been on for about 10 - 15 minutes. -He/She recalled making a complaint to the facility about not being able to get assistance to the bathroom and getting clean and dry when He/She has been incontinent. -He/She was normally able to control his/her bowel and bladder, but getting assistance to the bathroom sometimes took to long resulting in him/her becoming incontinent. -The staff get frustrated with him/her when He/She was incontinent. -Once staff put him/her to bed, He/She would have to wait until the follow morning to be clean up. -He/She laid in his/her diarrhea up to his/her shoulders for most of one night. -He/She did not have any skin problems prior to being admitted , but He/She believes there is an open area on his/her bottom now. -He/She rated the pain to his/her bottom 8-9 on a scale of 0-10 (0 = no pain, 10 = the worst pain). -He/She felt if the call light was answered timely, He/She could of make it to the bathroom and He/She would not be having the pain to his/her bottom. -At 11:47 A.M., CNA A opened and shut the door without making contact with the resident. -The resident had not been able to maintain control of his/her bowels and was incontinent. -He/She was upset and said I was a CNA when younger and would never treat someone this way. 2. Review of Resident #4's Admission Record showed He/She had been admitted on [DATE] with the diagnoses of Diabetes Type II, Hemiplegia and Hemiparesis following a stroke affecting the right dominant side, and unsteadiness on feet. Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Totally dependent on staff for ADLs. -Was wheelchair bound. -Was incontinent of bowel and bladder. Review of the resident's undated Care Plan showed: -He/She had an ADL self-care performance deficit related to stoke. -He/She required staff assistance with toileting and was to be clean and dry. -He/She was to checked and changed every two hours. Review of the resident's Grievance/Complaint report dated 9/26/23 showed the resident complained that he/she had thrown up and had a bowel movement on 9/22/23 when the CNA did not assist him/her to the bathroom after waiting over an hour. During an interview on 9/27/23 at 12:16 P.M., the resident said: -He/She had made a complaint to social services about not getting assistance from the staff. -He/She had been incontinent of bowel and had turned his/her call light on. -He/She was in need of assistance and went into the hall. - An unknown CNA said he/she was not responsible for him/her and went to the other hall. -The resident had not been able to get assistance from staff using the call light to go to the bathroom or to be put to bed when the resident was ready. -When he/she was dismissed by the CNA he/she was so upset he/she vomited on him/herself and was crying. 3. Review of Resident #5's Admission Record showed He/She was admitted on [DATE], and readmitted on [DATE] with the diagnoses of Diabetes Type II, Hemiplegia and Hemiparesis, following a stroke affecting the left non-dominant side, and contracture of the left upper arm and left lower leg. Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Was totally dependent on staff for all cares. -Was wheelchair bound. -Was incontinent. Review of the resident's undated Care Plan showed the resident: -Had a self-care deficit related to stroke. -Required total assistance from staff for toileting. -Required staff to check every two hours and change to make sure the resident is clean and dry. -Was incontinent of bowel and bladder. -Skin should be kept clean and dry. Review of the resident's Grievance/Complaint report dated 9/26/23 showed He/She complained that He/She was not changed for an entire shift on 9/25/23. During an interview on 9/27/23 at 12:46 P.M. the resident said: -It takes 30 minutes to an hour for a call light to be answered. -He/She had trouble getting incontinent cares done. -There were times when the staff would take the call light from him/her because He/She uses it too much. -He/She had been told to not use the call light unless He/She was dying or on the floor by staff. -He/She had bumps and itching in perineal area due to not being able to be clean and dry. -He/She had made a grievance to social services and nothing had been done. 4. During an interview on 9/27/23 at 12:02 P.M., the Nurse Practitioner said he/she expects residents to not have to wait for 35 to 40 minutes for a call light to be answered. During an interview on 9/27/23 at 12:29 P.M., Licensed Practical Nurse (LPN) A said: -He/She expected call lights to be answered within three to five minutes. -35 to 40 minutes was not acceptable for a resident to wait for a call light to be answered. During an interview on 9/27/23 at 12:54 P.M., LPN B said: -It was not acceptable for a resident to be incontinent due to not being taken to the bathroom. -He/She expected call lights to be answered in five minutes or less, unless the aides were busy. -If staff were busy, they should answer the call light and let the resident know they will return as soon as possible. -35 to 40 minutes was too long for a call light to go unanswered. -He/She was responsible to ensure call lights were being answered in a timely manner on 9/27/23 from 11:07 A.M. to 11:47 A.M. -He/She was not on the hall during the time the call light was not answered for approximately 40 minutes. -It was not uncommon for him/her to be off the hall for 40 minutes. -Unknown why the call light was not answered for approximately 40 minutes. During an interview on 9/27/23 at 2:26 P.M., the DON said: -He/She expected call lights to be answered in three to five minutes. -35 to 40 minutes was not an acceptable time for a call light to go unanswered. -It was unacceptable for a resident to be incontinent due to not being taken to the bathroom timely. -He/She was unaware of Resident #3 being incontinent or having skin issues due to waiting too long to be taken to the bathroom. -There should be no reason a resident was left all night in urine or fecal matter all night. -Residents should be checked after being put to bed and before getting up in the morning. During an interview on 9/27/23 at 2:53 P.M., the Administrator said: -He/She expected call lights to be answered immediately if possible. -35 to 40 minutes was not acceptable for a call light to go unanswered under normal circumstances. -He/She was not aware a call light went unanswered on 9/27/23 from 11:07 A.M. to 11:47 A.M. -There could have been a good reason the call light was unanswered for approximately 40 minutes that he/she was not aware of. -The nurse being off the unit to make copies and staff being on break, leaving the hall unattended, could be okay. -Residents should never be told not to use their call light. During an interview on 10/4/23 at 11:01 A.M., CNA C said: -He/She was assigned to the residents on the other hall on 9/27/23. -When CNA A went on break He/She was responsible for call lights as long as He/She was not in a room taking care of his/her own residents. -Call lights should be answered within three to five minutes. -40 minutes was not acceptable for a call light to go unanswered. -On 9/27/23 from 11:07 A.M. to 11:47 A.M. he/she was in another resident's room with one resident for approximately 10 to 15 minutes. -It was not uncommon for him/her to be alone on the hall, especially if the facility was short staffed. During an interview on 10/4/23 at 11:35 A.M., the Certified Medication Technician (CMT) said: -Everyone was responsible for answering call lights. -He/She had answered call lights and had done what he/she could for the residents. -On 9/27/23 from 11:07 A.M. to 11:47 A.M. he/she was passing his/her noon medications on the opposite hall and did not see/hear the call light going off. -Call lights should be answered within two to three minutes. -40 minutes was an unacceptable time for a call light to go unanswered. During an interview on 10/4/23 at 1:54 P.M., Regional Registered Nurse (RN) B said: -It was never appropriate for a call light to go unanswered for 40 minutes. -There were direct care staff, ancillary staff and administrative staff that could have answered the call light. During an interview on 10/4/23 at 2:00 P.M., the Regional Director said it was everyone's responsibility to answer call lights, including him/her. MO00224076

Based on observation, interview and record review, the facility failed to document wound care orders and treatment for one sampled resident (Resident #3) out of five sampled residents. The facility census was 83 residents. Review of the facility Wound Management Policy dated 6/20 showed: -Purpose: -To provide a system for the treatment and management of residents with wounds including pressure -Policy: -A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. -Procedure: -Assessment: --A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Upon identification of a new wound the licensed nurse will ---Measure the wound (length, width, depth. ---Initiate a wound monitoring record sheet for each wound. ---Implement a wound treatment per physician's order. -Wound management: --Rehabilitation services will be contacted for appropriate devices or pressure redistribution devices. --A licensed nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the attending physician. -Documentation: -Wound documentation will occur at a minimum of weekly until the wound is healed. --Documentation will include: ---Location of wound. ---Length, width, and depth measurements recorded in centimeters. ---direction and length of tunneling and undermining (if applicable). ---Appearance of the wound base. ---Drainage amount and characteristics including color, consistency, and odor. ---Appearance of the wound base. ---Description of the peri-wound (skin around the wound) condition. ---Presence or absence of new skin at wound rim. ---Presence of pain. --Licensed nurse will document effectiveness of current treatment in the resident's medical record on a weekly basis. --Update the resident's care plan as necessary. 1. Review of Resident #3's Admission Record showed he/she was admitted on [DATE] with the diagnoses of Diabetes Type II (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), Hemiplegia and Hemiparesis (paralysis/weakness affecting one side of the body) following a stroke affecting the right dominant side, and history of falling. Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/10/23 showed the resident: -Was cognitively intact. -Was totally dependent on staff for assistance with Activities of Daily Living (ADL). -Required maximal assistance with toileting hygiene. -No skin conditions assessed. Review of the Resident's undated Care Plan showed the resident: -Had a self-care performance deficit. --Staff assistance to the extent needed to accomplish task. (Note: no care plan was developed for skin issues or wounds) Review of the resident's Admission assessment dated [DATE] showed he/she had a scab to his/her right heel. Review of the resident's Skin Only Evaluation dated 9/16/23 showed: -Stage 1 pressure injury to the right heel. (Observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation). --No treatment indicated. --No pain indicated. -No care planning indicated for wound management and documented pressure ulcer (pressure injury). Review of the resident's Medication Review Report printed on 9/27/23 showed: -To cleanse his/her right heel deep tissue injury (DTI - an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) wound with wound cleaner, pat dry, skin prep on peri wound (skin surrounding the wound), apply nickel thick Santyl (an ointment used for the debridement of pressure ulcers) on center of wound and cover with dry dressing. Change every day shift Monday, Wednesday, Friday and as needed with an order date of 9/27/23. -Heel boot at all times to his/her right foot with a order date of 9/27/23. -Wound care consult with an order date of 9/27/23. (Note: No wound care, wound prevention or wound consultations prior to 9/27/23. There were two discontinued wound care orders back dated to 9/5/23.) Review of the resident's medical records showed no wound assessment or wound tracking before 10/4/23. During an interview and observation on 9/27/23 at 11:07 A.M., of the resident showed: -He/she thought there was also an open area on his/her right heel due to not being put to bed at his/her request. -He/she rated the pain to his/her heel 8-9 on a scale of 0-10 (0 = no pain, 10 = the worst pain). -Observation of the resident's right heel showed a dark black colored area approximately the size of a half dollar. During an interview on 9/27/23 at 11:47 A.M. Certified Nurses Aide (CNA) A said he/she was not aware of the area on the resident's right heel. During an interview on 9/27/23 at 12:02 P.M. the Nurse Practitioner said: -He/she was not aware of the area on the resident's right heel. -He/she verified in the electronic record that there were no current orders for wound care, wound prevention or a wound consultation. -He/she assured that a treatment would be started for the resident as soon as possible. -He/she expects all wounds to be assessed and the physician and/or Nurse Practitioner to be notified immediately. During an interview on 9/27/23 at 12:29 P.M. Licensed Practical Nurse (LPN) A said: -Resident skin assessments are to include heels. -Skin assessments were done weekly and documented in the resident chart. -He/she was not the nurse for the resident and had not assessed the resident. -If wounds were assessed the doctor should be contacted for a treatment order. During an interview on 9/27/23 at 12:54 P.M. LPN B said: -Skin assessments were done by the nurse weekly. -If a black spot or any kind of wound was noticed, he/she would notify the doctor and start the treatment. -He/she was unaware of any wounds for the resident. During an interview on 9/27/23 at 1:00 P.M. the Physician said: -He/she was aware of the DTI. -The resident was being seen by the wound care team. During an interview on 9/27/23 at 1:10 P.M. Regional Registered Nurse (RN) A said: -He/she confirmed there were no treatment orders for the resident's wounds to his/her right heel since admission. -There were orders put in on 9/27/23 that had been back dated to 9/5/23. -He/she instructed the Director of Nursing (DON) to correct the error immediately. During an interview on 9/27/23 at 2:26 P.M. the DON said: -He/she expects all wounds to be assessed, treatment initiated and risk management completed. -If resident admitted with a wound, staff should check for treatment orders. -If there are no treatment orders, the nurse should contact the physician for treatment orders. -The resident should have a wound consult for follow up and ongoing treatment. -The resident had not been seen by wound care since admission. -Skin assessments were done weekly and documented in the resident chart. -Wound care was being done by the wound nurse. -Since the wound care nurse was not longer there, the DON was responsible to ensure wound care and a assessments were being done. During an interview on 9/27/23 at 2:53 P.M. the Administrator said: -He/she expected wounds to be assessed, measured and treated per regulatory standards. -He/she was not aware of the resident's untreated heel wound. MO00224076

Based on interview and record review, the facility failed to ensure resident dignity was maintained for one sampled resident (Resident #1) when on 8/31/23 there was an allegation that Certified Medication Technician (CMT) A threw water on the resident, out of three sampled residents. The facility census was 78 residents. On 9/1/23 the Administrator was notified of the past noncompliance which occurred on 8/31/23. On 8/31/23 the facility administration was notified of the incident and the investigation was started. CMT A was suspended on 8/31/23 and later terminated. No employees were allowed to work prior to reeducation completed 8/31/23. The deficiency was corrected on 8/31/23. Review of the facility's policy titled Privacy and Dignity dated June 2020 showed: -The staff assist residents in maintaining self-esteem and self-worth. -Staff treat residents with respect including respecting their social status, speaking respectfully, and listening carefully. 1. Review of Resident #1's face sheet showed he/she admitted to the facility with the following diagnoses: -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Peripheral Vascular Disease (PVD- inadequate blood flow to the extremities). -Congestive Heart Failure (a weakness of the heart that leads to the build-up of fluid in the lungs and surrounding tissues). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/20/23 showed the resident was cognitively intact. Review of the facility's investigation report dated 8/31/23 showed: -The incident occurred just before 12:00 P.M. on 8/31/23. -The resident stated the staff member would not tell him/her what his/her medications were used for and then threw water at him/her. -CMT A stated that he/she had explained the medication to the resident and had not thrown water on the resident. -CMT A stated that the resident had made a gesture like he/she did not wanted to take the medication and bumped the water cup, spilling the water onto him/herself. -The charge nurse for the hall stated that the resident had told him/her the same story. -In conclusion, the alleged incident could not be verified and it was determined that the issue was related to customer service/dignity rather than abuse. During an interview on 9/1/23 at 10:07 A.M. the resident said: -CMT A gave him/her six to eight pills to take. -He/she had asked CMT A about the medication. -CMT A told the resident he/she would not understand and would not explain what the medication was for. -CMT A then started to backed away from his/her bed and called him/her a bitch. -When CMT A got to the end of his/her bed he/she threw the water that was for him/her to take his/her medications. -The water landed on the wall, his/her monitor by his/her bedside, all-over him/her, and his/her face. -CMT A then left the his/her room. -There were no witnesses to the altercation. During an interview on 9/1/23 at 11:50 A.M. the Director of Nursing (DON) said: -All staff were expected to treat each resident with respect and dignity. -CMT A had not given the resident appropriate customer service or care. During an interview on 9/1/23 at 1:09 P.M. the resident said: -He/she felt shocked and outraged by the altercation. -He/she received his/her medications and his/her linens had been changed after the altercation occurred. During an interview on 9/1/23 at 1:30 P.M. the Admissions Coordinator said: -A staff person, maybe a housekeeper had called him/her over to the resident's room after the altercation occurred. -He/she observed the resident wet from the chest down, with some water on the top of the resident's head. -There had also been water on the resident's mattress. During interview on 9/1/23 at 1:33 P.M. CMT A said: -He/she was not normally assigned to the hall that the resident was on. -He/she had explained all of the resident's medications to the resident. -The resident had made a gesture towards him/her like he/she did not wanted the medication and then the resident bumped the cup of water and it spilled on him/herself. -The water spilled all over the resident, but could not describe specifically where the water had landed on the resident. -The resident had told him/her to get out if his/her room. During an interview on 9/1/23 at 1:54 P.M. Certified Nurses Aide (CNA) B said: -He/she had been working on the resident's hall when the altercation occurred. -He/she had gone into the resident's room to do a normal check of the resident. -He/she had not been asked by CMT A to assist the resident in getting changed. -Once he/she entered the room the resident reported the incident to him her. -He/she observed the resident and it had looked like water had been thrown at the resident. -The bottom of the resident's bed, the wedge pillow, and the resident's knees were wet. -He/she then reported the incident to the Admissions Coordinator and stayed with the resident. -The Admissions Coordinator, the charge nurse, and the DON all came in to the room, so he/she left the room to get supplies to change the resident and resident's bed linens. -He/she performed a full bed change and the rest of the shift went on as normal. MO00223816

Based on interview and record review, the facility failed to meet the medical needs of one sampled resident (Resident #3) who was admitted to the facility on [DATE] with the diagnosis of end stage renal disease (a stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) and required hemodialysis (a treatment for people whose kidneys are failing). On [DATE] and [DATE] the resident was scheduled for hemodialysis and the facility did not ensure transportation was appropriate and available. From admission on [DATE] through [DATE] he/she had received no medications per physician orders. On [DATE] he/she received only partial medications per physician orders. The resident physician was not notified or consulted until the resident had a significant change in condition and was sent to the hospital on [DATE]. The facility census was 84 residents. The Administrator was notified on [DATE] at 10:43 A.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Record review of the facility's Hemodialysis Policy, review/revised [DATE], showed: -This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet special medical, nursing, mental, and psychosocial needs of residents receiving Hemodialysis. -The facility will coordinate and collaborate with the dialysis facility to assure that: --The resident's needs related to dialysis treatments are met. --The provision of the dialysis treatment and care of the resident meets current standards of practice for the safe administration of the dialysis treatments. --Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team. --There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. -The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes. -The licensed nurse will communicate to the dialysis facility via telephone communication of written format, such as a dialysis communication form or other form that will include, but not limit itself to: --Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis staff. --Physician/treatment orders, laboratory values, and vital signs. --Nutritional/fluid restriction management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered. --Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatment. --Dialysis adverse reactions/complications and/or recommendations for the follow up observations and monitoring and/or declines in condition related to the vascular access site. --Changes and/or declines in condition unrelated to dialysis. -The facility will immediately contact and communicate with the attending physician, resident/representative, and designated dialysis staff (nephrologist, registered nurse) any significant changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan. -The facility will assure that arrangements are made for safe transportation to and from the dialysis facility. -The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. -The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record. -The facility will coordinate with the dialysis facility for rescheduling of the resident's dialysis treatment if canceled. -The facility will ensure that the physician's orders for dialysis include: --The type of access for dialysis (graft, arteriovenous shunt (fistula), external dialysis catheter) and location. --The dialysis schedule. --The nephrologist name and phone number. --The dialysis facility name and phone number. --Transportation arrangements to and from the dialysis facility. --Any medication administration or withholding of specific medications prior to dialysis treatments. --Any fluid restriction if ordered by the physician. Record review of the facility's Medication Reordering Policy date, reviewed/revised [DATE], showed: -It is the policy to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications in a timely manner to meet the needs of each resident. -The facility will utilize a systematic approach to provide or obtain routine and emergency medications in order to meet the needs of each resident. -Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. -In the event of new orders, the facility is allowed 24 hours to begin a medication unless otherwise specified by the physician. -For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container. Record review of the facility's Medication Administration Policy, dated review/revised [DATE], showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. -Correct any discrepancies and report to nurse manager. 1. Record review of the resident's Discharge Summary from the hospital, dated [DATE], showed: -He/she was discharged in fair condition to a skilled nursing facility. -Principal Problem was diverticulitis in large intestine. -Active Problems: --End stage renal disease on dialysis. --Vaginal bleeding. --Severe obesity. --Low blood pressure. -Discharge medication orders: --Cholestyramine 4 gram packet, 1 packet, oral, two times daily. --Epoetin alfa-epbx 20,000 unit/ml injection, 4000 units Intravenous (IV) every Tuesday, Thursday and Saturday for anemia in chronic kidney disease (end stage renal disease on dialysis). --Hydroxyzine 25 mg capsule, two capsules, oral, three times a daily as needed for anxiety. --Lactobacillus-insulin 10 billion cell capsule, two capsules, oral, daily probiotic. --Lurasidone 60 mg tablet, 60 mg oral daily with dinner for schizophrenia with mood changes. --Cinaclcet 60 mg table, 60 mg oral, daily with breakfast for renal failure. --Medroxyprogesterone (Provera) 10 mg tablet, oral, daily for abnormal uterine bleeding. --Midodrine 5 mg tablet oral three times daily with meals for feeling dizziness upon standing due to drop in blood pressure. --Sevelamer carbonate (Renvela) 800 mg tablet, 1600 mg, oral, three times daily with meals for chronic kidney disease. --Apixaban (Eliquis) 5 mg tablet, oral, two times daily for coronary heart disease. --Clonazepam (Klonopin) 1 mg tablet, oral, two times daily as needed for anxiety. --Lidocaine 5% patch, two patches, transdermal, nightly, remove and discard patch within 12 hours for pain or as directed by the physician. --Oxycodone 5 mg immediate release tablet, oral, every six hours as needed for pain.-Pantoprazole 20 mg, oral, two times daily for GERD. --Folic acid/vitamin B complex and C 0.8 mg tablet, oral, every evening supplement. -Hemodialysis diet. -He/she had been assessed by psychiatry and was felt to be incapacitated in regards to medical decision making. Record review of Resident #3's Admission Record showed: -He/she was admitted to the facility on [DATE] with the following diagnosis: -Morbid (severe) obesity (is a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions). -End stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for dialysis to maintain life). -Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). -Cognitive Communication Deficit (difficulty with thinking and how someone uses language). -Diverticulosis (a condition in which small, bulging pouches develop in the digestive tract) of large intestine without perforation or abscess without bleeding. -Diverticulitis (an inflammation or infection in one of more small pouches in the digestive tract) of intestine without perforation or abscess without bleeding. Record review of the resident's All-Inclusive Admission, dated [DATE], showed: -He/she had moderate cognitive impairment. -Medical conditions: --Sepsis (infection in the blood stream). --Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). --Dialysis -Assistive Devices: --Manual wheelchair and mechanical lift. -Bedridden, maximum assist, non-weight bearing, obese and weakness. Record review of the resident's Care Plan, dated [DATE], showed: -Special Instructions: Dialysis Tuesday/ Thursday/Saturday 1:15 P.M. chair time, had to go to dialysis with a sling on. -He/she received dialysis, will have minimized risk of complications related to dialysis. -Auscultate Bruit and palpate thrill to arteriovenous (AV) fistula/shunt every shift. -Notify physician of abnormalities/absence. -Check and change dressing daily at access site as ordered. -Do not draw blood or take blood pressure in arm with shunt. -Encourage resident to go for the scheduled dialysis appointments. -Monitor and treat for side effects of cramping, fatigue, headaches, itching, anemia, and osteoporosis/osteopenia. -Monitor dialysis site as ordered. -Monitor intake and output. -Monitor labs and report to physician as needed. -Monitor vital signs before and after dialysis. Notify physician of abnormalities. -Monitor/document/report new/worsening edema (swelling) and weight gain. -Monitor/document/ report any signs/symptoms of infection to access site (redness, swelling, warmth or drainage). -Administer medications as ordered by the physician. Record review of the resident's Physician Order Sheet (POS) and Medication Administration Record (MAR), dated [DATE], showed medications were ordered to start [DATE] at 8:00 A.M. -Cinacalcet HC I60 mg tablet in morning for renal failure. Missed [DATE] A.M. dose to [DATE] A.M. dose. -Lurasidone HCI 60 mg tablet daily for schizophrenia. Missed [DATE] A.M. dose to [DATE] A.M. dose. -Metoprolol ER 25 mg tablet daily for high blood pressure. Missed [DATE] A.M. dose to [DATE] A.M. dose. -Provera 10 mg tablet daily for abnormal uterine bleed due to hormonal imbalance. Missed [DATE] A.M. dose to [DATE] A.M. dose. -Apixaban 5 mg tablet twice daily for coronary heart disease. Missed [DATE] A.M. & P.M. doses to [DATE] A.M. dose. -Cholestyramine 1 packet twice daily for renal failure. Missed [DATE] A.M. & P.M. doses to [DATE] A.M. dose. -Lidocaine Cream Apply to affected areas twice daily for pain. Missed [DATE] A.M. & P.M. doses to [DATE] A.M. dose. -Pantoprazole 20 mg tablet give 2 tablets twice daily for GERD. Missed [DATE] A.M. & P.M. doses to [DATE] A.M. dose. -Midadodrine HCI 5 mg tablet three times a day for dizziness up on standing due to a drop in blood pressure. Missed [DATE] all three doses to [DATE] A.M. dose. -Renvela 800 mg tablet three times a day for kidney disease. Missed [DATE] all three doses to [DATE] A.M. dose. --NOTE: No orders for type of access for dialysis (graft, arteriovenous shunt, external dialysis catheter), dialysis schedule, dialysis facility name and phone number, nephrologist name and phone number, transportation arrangements to and from the dialysis facility, any medication administration or withholding of specific medications prior to dialysis treatments and any fluid restriction if ordered by the physician. No documentation that the nurses provided care to the dialysis site every shift for patency by auscultating for a bruit (a sound heard over an artery of vascular channel, reflecting turbulence of flow) and palpating for a thrill (is a vibratory sensation felt on the skin overlaying an area of turbulence). Record review of the resident's Appointment Sheet undated showed: -His/her name and date of birth. -Appointment dates Tuesday/Thursday/Saturday. -Name of treatment center, address and phone number. -Transportation company name and pickup time and end time. --NOTE: No other information was completed on the Appointment Sheet (wheelchair, round trip, reason for visit, physician's name and other medical information. Record review of the resident's Alert Note, dated [DATE], showed: -Dialysis Tuesday/Thursday/Saturday chair time at 1:15 P.M. had to go to dialysis with a sling. Record review of the resident's Orders of Administration Note, dated [DATE], showed medications on order. Record review of the resident's medical record showed no documentation the resident attended dialysis as scheduled on [DATE]. Record review of the resident's Order of Administration Note, dated [DATE], showed medications yet to be delivered. Record review of the resident's Skilled Nurse's Note, dated [DATE], showed: -Resident unable to attend dialysis due to transportation problems. To be rescheduled. Record review of the resident's Admission History and Physical, dated [DATE], showed: -Visit via Telehealth with the physician. -New admit recent hospitalization for altered mental status and acute sepsis. -He/she was in bed unable to stay on track with conversation. -No edema, morbidly obese, receives dialysis three times a week, eating and drinking well, working with therapy, yells out for staff, alert and able to make needs known. -Follow and continue all orders and appointments per hospital discharge plan. -Continue treatment plan as prescribed and medications continued. -Unable to discuss plan of care with the resident due to cognitive impairment. Record review of the resident's Discharge Minimum Data Set (MDS, is a federally mandated assessment instrument to be completed by facility staff for care planning), dated [DATE], showed: -He/she had moderate cognitive impairment. -Short term memory was okay able to recall after 5 minutes. -Independent decisions consistent/reasonable. -Bed and wheelchair bound. -Transfers with a Hoyer lift. -Extensive to total assist with activities of daily living (ADL) except eating, he/she was independent. -Did not reject cares. -No inattention, disorganized thinking or altered level of consciousness. -Verbal behaviors one to three days a week. -Other behaviors one to three days a week not directed towards others. --NOTE: Dialysis was not marked under Special treatments. Record review of the resident's Nurse's Note dated [DATE] at 8:16 P.M., showed: -Certified Nursing Aide (CNA) A notified Licensed Practical Nurse (LPN) A the resident had brownish substance coming from his/her stomach and vaginal area. -LPN A went in to clean the resident up and found the fold areas to be raw. -The resident was very confused and fighting. -Vital signs were taken and the resident's blood pressure was critically low. -The on call physician was notified and via Telemedicine gave an order to send the resident to the hospital. During an interview on [DATE] at 4:55 P.M., Certified Nursing Assistant (CNA) A said: -He/she said the resident was doing well on [DATE]. -He/she was the one who found the resident having a brownish discharge and notified the nurse on [DATE]. -The resident was hurting during clean up. -The resident was not fighting or confused just said it hurt during peri care. During an interview on [DATE] at 5:00 P.M., Licensed practical Nurse (LPN) A said: -On [DATE], the resident was a little confused. -He/she thought the resident had a bowel movement until he/she assessed the resident. -The resident was resistant to cares. -He/she took the resident vital signs and the resident had critically low blood pressure and called 911. -He/she then called the on-call physician through Telehealth and the physician gave the order to send the resident to the hospital. -He/she was alert and orientated able to make needs known but still had some confusion, no edema and no sign or symptoms of missed dialysis appointments. Record review of the resident's Hospital transfer form, dated [DATE], showed: -Diagnosis of end stage renal disease and morbid (severe) obesity. -Hypotension (low blood pressure). -Device AV shunt in left arm. Record review of the resident's Hospital History and Physical, dated [DATE] at 2:45 P.M., showed: -He/she admitted to the emergency department (ED) on [DATE] with an altered mental status from the facility after no receipt of dialysis for over one week due to transportation issues. -He/she on arrival to the ED was found to have atrial fibrillation (a-fib, abnormal heart rhythm) RVR (rapid ventricular response) and hypotensive (high blood pressure) in ,d+[DATE]s, his/her blood pressure did not improve with IVF (intravenous fluid) resuscitation and a central line was inserted and vasopressors initiated. -Lab work revealed hyperlakemia (potassium level in your blood that's higher than normal), acute kidney injury, lactic acidosis (occurs when the body produces too much lactic acid and cannot metabolize it quickly enough), and leukocytoisis (elevated white blood cell count). -He/she was alert and oriented times 1 and unable to relay if he/she was anuric (lack of urine). During an interview on [DATE] at 10:27 A.M., the Dialysis Clinical Manager said: -The resident was to have dialysis on [DATE], but transportation did not show up. -Transportation was set up on [DATE] for dialysis treatment by the facility receptionist. During an interview on [DATE] at 11:31 A.M., the Receptionist said: -He/she sets up transportation for appointments. -He/she provided the transportation company the following information: --Name, date of birth, date of appointment, location of the appointment reason for the appointment. -Dialysis set up transportation for the residents unless dialysis wanted him/her to set up the transportation. During an interview on [DATE] at 4:18 P.M., admission office said: -The resident arrived on [DATE] on a stretcher around 8:00 P.M. -All appointments were put into the computer with the date and time of residents appointments. -He/she notified the receptionist of the appointments needing transportation. -The receptionist set up all transportation. -The hospital would set up the dialysis appointments, but the facility was responsible for setting up transportation. During an interview on [DATE] at 9:41 A.M., the Dialysis Regional Operations Director said: -Missed dialysis increased potassium levels that can cause death, fluid overload, hospitalization and possible death. -Death rate can go up 30% with a missed dialysis treatment. -Dialysis will try and set up transportation, but it was the nursing homes responsibility to transport and pick up the residents. -The facility could have used an ambulance for transportation. During an interview on [DATE] at 12:04 P.M., the assistant Director of Nursing (ADON) said: -The admission staff and the receptionist were responsible for setting up transportation for appointments including dialysis. -Transportation was set up for Resident #3 to go to dialysis on [DATE] by the dialysis company, but the transportation company sent a car to transport the resident. -The resident was not ambulatory and used a wheelchair for mobility. -The resident missed dialysis on [DATE]. -Transportation was set up for the resident dialysis appointment on [DATE] by the facility receptionist, but the resident's wheelchair was too wide for the wheelchair lift. -Resident did not go to dialysis on [DATE]. -Transportation was set up for [DATE] but the resident went to the hospital on [DATE]. -The physician should have been notified of the missed dialysis appointments and followed any new orders given. -Upon admission all medications were ordered from the pharmacy. -The facility just switched to a new pharmacy on [DATE]. The date the resident was admitted to the facility. -The orders were put into the computer for the pharmacy to fill. -The facility nurses and CMTs did not know the pharmacy could not receive the orders, because the computer systems were not fully integrated. -All orders needed to be faxed to the pharmacy to be filled until [DATE] when the systems were integrated together. -Staff called pharmacy copious times inquiring about delivery of medications. -The medications arrived late on [DATE]. -The staff administered the over the counter medications and/or from the emergency kit medications available at the facility. During an interview on [DATE] at 2:40 P.M., the administrator said: -The receptionist was given the appointment on a form to set up transportation from the nurses or admission office. -Dialysis set up the [DATE] transportation for Resident #3 on [DATE]. -The facility does have a facility van to transport residents to appointments, but the tags are expired and there was something wrong with the van. -He/she hoped to have the van up and running soon. -He/she was given one week notice that the facility would be changing pharmacies. -The switch over did not go easily. -Residents should not miss any medications unless a new admit and waiting for the orders to be filled. -Residents should not miss appointment due to transportation problems. -Did not know the medication orders needed to be faxed to the pharmacy. -The pharmacy did not inform the facility about faxing the orders. During an interview on [DATE] at 2:45 P.M., the Director of Nursing (DON) said: -The appointments were set up by the nurses and the receptionist set up the transportation. -For new admits the admission office notified the receptionist to set up the transportation for the resident. -New pharmacy started [DATE]. -The facility had to fax all orders to the pharmacy until [DATE]. -After [DATE]th the orders could be put into the computer and the pharmacy would receive the orders. -The facility was still faxing the orders to make sure the pharmacy received the orders. -The night shift nurse had to call the pharmacy 24 hour hot line number to get Resident#3's medications, but had to leave a voice mail. -The pharmacy never called back. -The resident's medications arrived on the late night delivery on [DATE]. -The first delivery of the resident's medications from the pharmacy was around 4:00 P.M. and then again around 10:00 P.M. During an interview on [DATE] at 10:19 A.M., Pharmacist A said: -The pharmacy did not receive the orders for the resident's medications until after they closed on [DATE]. -Orders were filled and sent out on evening delivery on [DATE]. During an interview on [DATE] at 9:22 A.M., Family Member A said: -The resident would have never refused dialysis, because he/she knew that dialysis was keeping him/her alive. During an interview on [DATE] at 9:53 A.M., Physician A said: -He/she was not notified of the resident missing medications for 3 days or that the resident had missed dialysis for a week. -The nurses should notify him/her when a resident misses medications and dialysis. -He/she did a Telehealth interview with the resident on [DATE]. -You can never go a week without dialysis or he/she would be at the facility to assess the resident. -He/she was not aware the resident had missed the two dialysis appointments. -He/she was not aware the resident had been sent to the hospital. -He/she would expect residents to be given medications as ordered. -He/she would expect residents to go to dialysis as ordered. -He/she should be notified if appointments were missed and expect staff to reschedule the appointments. NOTE: At the time of the 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. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00203673

Based observation, interview, and record review, the facility staff failed to provide adequate interventions and monitoring to prevent falls for residents assessed by the facility as having a risk for falls and with a history of falls, affecting two sampled residents (Residents #5 and #7) who sustained injuries as a result of their falls, and three sampled residents (Residents #1, #4, and #8) with non-injury falls; and ensure the safety of residents during transfers with a mechanical lift (devices used to transfer persons who can not be lifted manually or require more than two persons to transfer) and follow the facility's mechanical lift policy and procedures, affecting two sampled residents (Residents #1 and #10), of 15 sampled residents. The facility census was 66 residents. Record review of the facility's undated Lifting and Transferring of Residents policy and procedure showed, the residents are lifted and transferred safely in all instances. The policy showed: -Nurses assess and determine lifting and transfer requirements and the procedure used for each resident; -All residents must be lifted or transferred according to the determined procedure; -Residents who require assistance in transferring are transferred using a gait/transfer belt or with a lift; -All members of the nursing staff, nurses, and nursing assistants are responsible for using good body mechanics, knowing the proper procedures and properly operating assistive devices; -Approved techniques for lifting, transfer and body mechanics are discussed and demonstrated during each orientation program for nursing personnel; -Mechanical lift procedures are used on any resident unable to independently pivot or transfer. The procedure directed staff to do the following: -Assess to determine physical limitations, tubing or equipment that must be moved, and the ability of the resident to follow directions. -Prepare for the move by providing privacy, suitable clothing for the resident, chair or wheelchair, enough space to move safely and the application of a transfer belt or lift. -During the move, consider where and when equipment will be transferred. -Lock the wheels on the bed or wheelchair. -The designated method of lifting and transferring of a resident is indicated in the plan of care and Minimum Data Set (MDS, a federally mandated assessment tool required to be completed by facility staff for care planning). -Adjustments are made to the plan of care as needed. Record review of the facility's undated Mechanical Lift policy and procedure showed a mechanical lift is used appropriately to facilitate transfers of residents, all nursing personnel use the mechanical lift, and least two people are present while resident is being transferred with the mechanical lift. The procedure directed staff to: -Wash hands before and after the procedure; -Explain procedure to the resident and provide privacy; -Place the lift sling under the resident, making sure the position of the seat is close to the knees; -Set the base legs to the widest position under the resident, keep the resident centered between the legs of the base and facing toward the person who is operating the mechanical lift; -Lower the lift and place hooks in the appropriate holes of the lift sling with hooks facing away from the resident; -Using the lever, gently raise and move resident to their destination; -Lower the resident and position them comfortably; -Unhook and remove the sling; wipe the sling with germicide solution after each use, narrow the base's legs, and return the lift to the storage area. Record review of the Facility Fall Prevention Policy and Procedure revision dated November 2005, showed staff were to assess residents for risk of falls, follow-up and evaluate falls of the residents in order to assess the resident's condition, identify the reason for the fall, and prepare a plan of care to reduce the potential for future falls. The policy's purpose was to outline the process for assessment, monitoring and post fall interventions to prevent and to reduce future fall occurrences. The procedure included: -Upon admission, the licensed nurse will assess residents for initial fall risk. Residents that score a 10 or greater will be considered "at risk" for falls. -The licensed nurse will develop a plan of care that addresses the fall risk factors. -Following the completion of the Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff), if the resident triggers a risk for falls, the resident will have further assessment utilizing the Fall Resident Assessment Protocol (RAP) guidelines. The plan of care would be enhanced to further minimize the fall risk if indicated. -The resident's fall risk will be re-evaluated, quarterly, annually, with a significant change in condition, and following a fall event. -Following a resident's fall, the licensed nurse will assess the resident for injury and necessary treatment. -Following assessment by a licensed nurse, the resident may be returned to the wheelchair, geri-chair or to bed, as appropriate. -The charge nurse will notify the nursing supervisor and/or the Director of Nursing (DON) or Designee. -Neurochecks (an assessment of level of consciousness, orientation, changes in speech and communication, blood pressure, hand grip, dizziness, unsteady balance, pupils reaction to light) will be completed for all unwitnessed falls or known head injuries. -The licensed nurse will notify the physician of the fall events and the resident's condition, including but not limited to vital signs, noted injuries, level of consciousness and information on how the fall occurred, if available. -All new physician's orders [REDACTED]. -If the situation is an emergency, the charge nurse, nursing supervisor or DON or designee may call 911 and request transfer of the resident to the acute hospital emergency room for evaluation. -The charge nurse shall notify the responsible party of the fall event and any interventions that have resulted from the event. -The nurse's progress note will contain pertinent information related to the fall and condition of the resident upon assessment (date, time, assessment of the resident, emergency care rendered physician notification, instructions, and family notification). -The nursing Post Fall Assessment will be completed by the charge nurse within 24 hours to assist in identifying contributing factors to the event. -The licensed nurse will complete an incident report for internal communication between the center and its legal counsel, and is not a part of the medical record. -The DON designee will ensure the incident report is completed by the end of the shift in which the fall occurred and forward the report to the Administrator. The Administrator or designee will forward reportable events to its legal counsel. -The DON or designee will review the circumstances, documentation and other factors related to the fall incident for completion, accuracy, and details provided by the charge nurse as to the cause of the event. The "Post Fall Assessment" completed by the charge nurse will be reviewed by the DON or designee for contributing factors and follow up. The information gleamed from this review will be used to improve the resident's fall prevention plan as well as the center's fall prevention program, where indicated. -The licensed nurse's observation, assessment and documentation, including neurochecks, will be performed a minimum of 72 hours or as indicated by the resident's condition, with notification of the physician as necessary. -The care plan will be updated, post fall, identifying the fall and goals and approaches to reduce the potential of future reoccurrence. Information gleamed from the resident and appropriate witnesses to the fall may be used in developing approaches to prevent future falls. -A Post Fall Assessment meeting will be completed by the Interdisciplinary team (IDT) within 72 hours of the fall. The Post Fall Assessment may include items in the Resident Assessment Protocol guidelines, chart review and investigative findings. Recommendations to reduce the potential for future falls will be care planned as appropriate. -Referral to the rehabilitation department may be initiated for assessment to determine if gait, perception, functional or cognitive impairments may have been contributing factors. It will be completed and returned to the DON or designee for follow up on recommendations. -Post falls will be reviewed as indicated by the IDT at the weekly fall and restraint assessment committee meeting for evaluation of frequency, circumstances, and recommendations for further fall prevention. -The Administrator will review all incidents to ensure appropriate follow up on events, including Quality Assurance and Assessment (QAA) Committee tracking and trending of events. -The Center will log and track all incidents monthly and evaluate time of day, place of event, and circumstances surrounding the event for follow up. Recommendations for intervention and prevention to be made by the QAA Safety Subcommittee and reviewed at the QAA Committee meeting. 1. Record review of Resident #5's annual MDS dated [DATE], showed the resident: -Was able to understand others and make himself/herself understood. -Had moderate impairment of cognition. -Required extensive assist of one staff person for transfers. -Did not ambulate in the room or the corridor. -Required extensive assist of one staff person for dressing, eating, toilet use, personal hygiene and bathing. -Was always incontinent of bowel and bladder. -Was not on a toileting program -had a history of [REDACTED]. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was able to understand others and make himself/herself understood. -Had moderate impairment of cognition. -Required extensive assist of one staff person for transfers. -Did not ambulate in the room or the corridor. -Required extensive assist of one staff person for dressing, eating, toilet use, personal hygiene and bathing. -Was always incontinent of bowel and bladder. -Was not on a toileting program. Record review of the resident's Fall Care Plan with a review date of 2/28/13, showed interventions that included: -Orient the resident as needed to the environment and call light system. -Place the call light within reach while in the room, and check the resident every two hours during rounds and as needed (PRN). -Remind the resident to utilize his/her call light prior to ambulating/transferring. -Answer the call light promptly and keep frequently used items within resident reach. Record review of the resident's (MDS) data set [DATE], showed the resident at risk for falls with a score of 11 (total score of 10 or above deems a resident at risk for falls). The neurological (nervous system) section identified the resident as having weakness in both upper extremities and both lower extremities. The musculoskeletal section identified the resident had limited upper and lower range of motion in his/her extremities. Review of the resident's (MDS) data set [DATE], showed the resident at risk for falls with a score of 14, and showed the resident as at risk for falls. The resident continued to have right and left lower extremity weakness and limited upper extremity range of motion. Record review of the resident's Physician Communication and Progress Note for New Symptoms, Signs, and Other Changes form (SBAR) dated 4/29/13, showed the resident: -Sustained a non-witnessed fall with possible injury to his/her head after hitting it during the fall. -Was found lying on the floor on his/her left side in front of the bed with the call light next to the resident. -Complained of pain to the left side of his/her head after falling. -Rated his/her pain at a seven on a pain scale of zero to ten. -Staff identified they thought the resident may have been "restless in bed." -The physician was notified and staff attempted to notify the family twice before the resident was sent to the emergency room . Record review of the resident's April 2013 Medication Record Administration Record (MAR), showed no documentation of the resident exhibiting any behaviors including restlessness. Record review of the resident's Incident/Accident Investigation Interview dated 4/29/13, showed the Certified Nurse Assistant (CNA) said the resident stated he/she was reaching for their call light and ended up rolling out of bed. Record review of the resident's April 2013 Physician order [REDACTED]. Record review of the resident's 4/29/13 emergency room History and Physical, showed [DIAGNOSES REDACTED]. -Diabetes mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) with neuropathy (damage to the nerves resulting in sensory loss in the extremities), Parkinson's disease (a progressive disorder of the nervous system that affects your movement characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait), and osteoarthritis (a degenerative disease of the bones and joints). Record review of the resident's emergency room notes dated 4/29/13, showed: -The resident said he/she was reaching for his/her call light and rolled out of bed onto the floor. -Resident said he/she had a "headache" because he/she hit their head. -The primary Impression: Fall with mild scalp contusion (a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise). -The resident was discharged back to the facility. Record review of the resident's Interdisciplinary Team Review/Care Plan dated 4/30/13, showed: -The resident changed to a different room on 3/27/13. -The resident had a fall 4/29/13 at 3:40 P.M. reaching for the call light. -The resident had a history of [REDACTED]. -Risk factors identified which included: new environment, hand contracture, diminished eyesight, Parkinson's disease, gait instability, neuropathy, psychotropic medications, dementia, history of infection, weakness, antiseizure medications, history of falls, pain, narcotics, and seizures. -The resident was receiving the following medications: [REDACTED] --Sinemet (a medication used to treat Parkinson's disease). --Gabapentin (a medication used to treat seizures and nerve pain). --Keppra (an anticonvulsant medication used to treat epilepsy). --Cymbalta (a medication used to treat depression). -Additional interventions included: --To provide a High-Low bed, --Conduct an urine analysis, --Place a mattress at his/her bedside, --For the resident to request assist as needed, --For the resident to demonstrate the use of his/her of call light, --To rearrange furniture to match what it was in his/her old room. -No care plan intervention was added directing staff to provide the resident with a soft touch call light (a call light with a soft touch bulb for easier depression instead of a button). Record review of the resident's daily and every shift charting record dated 4/30/13 at 2:00 P.M., showed: -The resident was on fall monitoring. -The staff reinforced for use of the call light and the call button kept within reach. Observation on 5/14/13 at 4:40 P.M., showed the resident: -Resting in bed with his/her eyes closed. -The call light was not within his/her reach. -The call light was on the floor approximately one foot from the resident's bed. -The resident's room equipped with a regular push button type call light, and not equipped with a soft touch call light. Observation on 5/15/13 at 5:42 P.M., showed the resident's call light was on the floor approximately one foot from his/her bed, the resident's room equipped with a regular push button type call light, and not equipped with a soft touch call light. Observation on 5/16/13 at 8:45 A.M., showed the resident's call light on the floor under the leg of the bedside table and not within his/her reach, the resident's room equipped with a regular push button type call light, and not equipped with a soft touch call light. Observation on 5/16/13 at 9:10 A.M., showed after the resident was transferred back to bed by staff, the resident's call light remained on the floor by the head of the bed, and the call light was not within the reach of the resident. Staff closed the door to the resident's room when they exited the room leaving the call light on the floor, not within reach of the resident. The resident's room was equipped with a regular push button type call light, and not equipped with a soft touch call light. During an interview on 5/22/13 at 10:45 A.M., CNA K said the expectation for resident call lights was: -To answer the call within a "fashionable" time. -If the resident is in the room, staff should place the call light within the reach of the resident. -If the resident is not in the room, the staff should place the call light on the bed, or attach it to the assist bars. -The CNAs receive a Care Sheet on how to take care of the residents. -Staff should keep items within reach for the resident, and check on them periodically. -Regarding Resident #5, the resident cannot push the call light even if it is within his/her reach. During an interview on 5/22/13 at 11:40 A.M., Registered Nurse (RN) A said the expectation for resident call lights was: -To keep the call light accessible to the resident. -If the resident is up, put the call light across the bed. -If the resident is in the bed, the call light should be pinned to the resident's pillow, bed sheet or the side rail of the resident's bed. -The resident could not really push the call light. -The resident was supposed to have the soft touch call light because of the resident's tremors; as it is more difficult for him/her to push the button. -The RN said that the resident rolls out of bed because he/she becomes "angry." Observation on 5/22/13 at 11:45 A.M., showed no soft touch call light in the resident's previous room before he/she transferred to the isolation room, or in the current isolation room that the resident occupied. A standard button call light was in both rooms. 2. Record review of Resident #7's face Sheet showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's Physician's Telephone Orders dated 1/2/13, showed the resident was to receive restorative care three to five times weekly for 90 days for bilateral (both sides) lower extremity exercises, activity and ambulation to maintain his/her current level of functioning, and was to receive restorative care three to five days a week for one week for standing and upper extremity training. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was cognitively impaired with an inability to sit/remain motionless and periods of restlessness. -Had a self care deficit and needed extensive assistance from staff to bathe, dress, eat and toilet. -Had unsteady balance and required the extensive assistance of one person to ambulate and transfer from surface to surface. -Was unsteady moving on/off of the toilet and was only able to stabilize with staff assistance. -had a history of [REDACTED]. Record review of the resident's (MDS) data set [DATE], showed he/she: -Was alert with modified independent cognitive skills for decision making. -Had balance problems and was unsteady to: Sit-to-standing position, walking, turning around, transferring off of the toilet, and surface transfers. -Needed one person assistance for transferring. -Was continent of bowel and occasionally continent of bladder. -Had a Fall Risk score of 14 (a score of 10 or above deemed the resident was at risk for falls), and showed the resident used a wheelchair for mobility. Record review of the resident's Podiatry Evaluation dated 3/15/13, showed the Podiatrist examined the resident's feet and noted the resident was non-ambulatory with pain in his/her limbs, had difficulty walking, and had a nail fungus and a skin ulcer on his/her right medial foot that was treated and bandaged. Record review of the resident's Physician Communication and Progress Note (SBAR-situation, background, assessment and request) dated 3/18/13, showed: -The CNA lowered the resident to the floor on 3/18/13 at 10:00 A.M. -The primary reason that the resident was at the nursing home was for fainting and collapse. The resident denied pain. -The resident's assessment/appearance was not documented. It showed, "no" to shortness of breath, pain or being more confused. -Staff were to monitor the resident's vital signs and observe the resident. -Nursing staff was called to the resident's room and the resident was sitting on the floor in front of his/her wheelchair in the bathroom with a gait belt on and in place. The unidentified CNA reported that he/she lowered the resident to the floor. The nurse assessed the resident. The resident did not complain of any pain or discomfort and was able to move all of his/her extremities. The nurse notified the resident's responsible party, physician and the Assistant Director of Nursing (ADON). Record review of the resident's Incident Report dated 3/18//13, showed: -On 3/18/13 at 10:00 A.M., the CNA lowered the resident to the floor in the bathroom. -The resident did not have any injuries and the resident's condition prior to the incident was "confused." -Comments showed (under the interventions section) the CNA (unidentified) observed the resident slipping out of his/her wheelchair and prevented the resident's fall by lowering him/her to the floor. -The final disposition of the resident showed the employee completed inservice training on lifting and positioning (2/25/13) and lifting safely to prevent injury. -The report did not show any interventions implemented for the resident that would decrease his/her chance of falling when in the bathroom. Record review of the resident's Physician's Telephone Order dated 3/21/13, showed a physician's orders [REDACTED]. Record review of the resident's Physician Communication and Progress Note (SBAR) dated 3/27/13, showed: -The resident fell on [DATE], and he/she had stayed the same (had not gotten better or worse). -The primary reason that the resident was at the nursing home was for fainting and collapse. The resident denied pain. -He/she possibly had a UTI. -Staff were to monitor the resident's vital signs and observe the resident, with new physician's orders [REDACTED]. -Comments showed a Certified Medication Technician (CMT) notified the nurse that the resident fell . The resident was sitting on the toilet and was found on the floor. The resident had a hematoma (a swelling or mass of blood) on his/her left forehead. The resident did not complain of any pain or discomfort and was able to move all of his/her extremities. Record review of the resident's Incident Report dated 3/27/13, showed: -On 3/27/13 at 12:55 P.M., the resident fell in the bathroom, getting off of the toilet by himself/herself. -The resident's fall was unwitnessed. -The resident had a hematoma with bruising/discoloration to his/her left forehead. -The resident did not complain of pain. -The resident's responsible party, physician, Administrator and DON were notified of the resident's fall. -There was no follow-up documentation to show if the incident was documented in the resident's nursing notes, interventions that were initiated, or to show the final disposition of the resident, as a single line was drawn diagonally through this section of the form. Record review of the resident's Care Plan updated 3/27/13, showed the resident had impaired mobility and was at risk for falls and injuries related to a history of falls. The resident had a history of [REDACTED]. The Care Plan showed the resident fell on [DATE] at 12:55 P.M., due to a "self transfer" off of the toilet. The resident sustained [REDACTED]. -Administering medications and obtain labs per physician's orders [REDACTED]. -Orienting the resident as needed to his/her environment and keep frequently used items within his/her reach. -Keeping his/her call light within reach while the resident was in his/her room, answering his/her call light promptly, and checking the resident every two hours and as needed. -Reminding the resident to use his/her call light prior to ambulating/transferring. -Provide a clean clutter free and well lighted environment. -Assuring proper assistive devices and footwear are in good working order and utilized correctly by the resident. -Providing physical and occupational therapy evaluation and treatment if indicated. -Encouraging the resident to alternate activity with rest. -Notifying the resident's physician and family of a change in the resident's status. -Risk factors showed the resident was over [AGE] years old, took psychotropic and narcotic medications, had [DIAGNOSES REDACTED]. -Additional interventions included a physician visit, to provide a floor mat at the resident's bedside, psychiatry consultation, eye and ear exam, and participating in the restorative program. -There were additional interventions showing a urinary labs were obtained due to urination frequency that were negative as of 3/27/13, a floor mat was initiated for the resident on 3/21/13, the resident was to continue restorative care, and nursing staff was educated to remain with the resident while toileting if the resident consented. Record review of the resident Physician's Telephone order dated 3/27/13, showed a physician's orders [REDACTED]. Record review of the resident's Urinalysis dated 3/28/13, showed the resident did not have a UTI (tests were negative). Record review of the resident's Physician's Notes showed no physician's notes dictated in April 2013. Record review of the resident's SBAR dated 4/7/13, showed: -The resident fell on [DATE] at 4:30 A.M., and his/her condition had stayed the same (had not gotten better or worse). -The primary reason that the resident was at the nursing home was for fainting and collapse, the resident did not bear weight well, and he/she denied having any pain. -The resident was more confused. -Staff were to monitor the resident's vital signs and observe the resident, with new physician's orders [REDACTED]. -Comments showed the resident was sitting beside his/her bed on the floor. The resident said he/she rolled out of his/her bed. The nurse noted old bruising above the resident's left eye. Two staff transferred the resident into his/her wheelchair. The resident had no bruising or redness to his/her buttocks. Record review of the resident's Incident Report dated 4/7/13, showed: -On 4/7/13 at 4:30 A.M., staff found the resident on the floor beside his/her bed, and he/she did not know how he/she got there. He/she said he/she rolled out of bed. There were no new injuries noted. -The resident's fall was unwitnessed. -The resident was resting quietly in his/her bed before the incident. -The resident had an old bruise above his/her right eye. -The resident did not complain of pain. -The resident's responsible party, physician, Administrator and DON were notified of the resident's fall. -There was no follow-up documented, and a single line was drawn diagonally through this section on the form. Record review of the resident's Care Plan updated on 4/7/13, showed the following updates: -The resident fell on [DATE] at 4:30 A.M., due to rolling out of his/her bed. -The resident's last fall was on 3/27/13. -Additional risk factors showed high blood pressure, low blood pressure, incontinence, and lack of coordination. -Additional interventions implemented: A diagnostic and medication review, a high-low bed, to provide bed bolsters (foam wedges that are attached to a sheet that is designed to establish bed perimeters without the use of bed side rails) (4/8/13), a pain assessment and a therapy evaluation. Record review of the resident's (MDS) data set [DATE], showed the resident's Fall Risk score was 14. It showed he/she continued to have intermittent confusion, was chair bound (wheelchair), had balance problems, and had predisposing diseases to increase his/her fall risk. Record review of the resident Physician's Telephone order dated 4/8/13, showed a physician's orders [REDACTED]. Record review of the resident's SBAR dated 4/20/13, showed: -Staff found the resident sitting on the floor in the bathroom on 4/20/13. Things that made the condition worse was that the resident sitting alone in his/her recliner. -The primary reason that the resident was at the nursing home was for fainting and collapse, muscle weakness, difficulty ambulating and kidney disorder. It showed the resident was forgetful and gets up without assistance. The resident did not remember the incident. -The nurse assessed that the resident forgets to ask for assistance and was confused. -There was no documentation or identification of any suggestions. -Comments showed the resident was found sitting on his/her buttocks in the bathroom. There were no injuries noted and the nurse notified the resident's physician, responsible party, and the DON of the incident. Record review of the resident's Incident Report dated 4/20/13, showed: -On 4/20/13 at 4:45 P.M., staff found the resident sitting on the floor in the bathroom on his/her buttocks in front of his/her wheelchair. -The resident's fall was unwitnessed. -The resident had previously been sitting in his/her recliner. -The resident had no injuries and had full range of motion in his/her extremities. -The alleged fall was from his/her wheelchair. -The resident's responsible party, physician, Administrator and DON were notified of the resident's fall. -There was no follow-up documented, and a single line was drawn diagonally through this section of the form. Record review of the resident Physician's Telephone orders showed physician's orders [REDACTED]. -Dated 4/20/13, discontinuing his/her Fentanyl (pain medication that is administered through the skin) patch 25 micrograms (mcg); and to administer Fentanyl patch 37.5 mcg every 72 hours. -Dated 4/23/13, for physical therapy to evaluate and treat the resident due to falls. -Dated 4/23/13, to discontinue the physical therapy evaluation due to the responsible party declining therapy services at this time. Record review of the resident's Care Plan updated 4/24/13, showed the following updates: -The resident fell on [DATE] at 4:45 P.M., while trying to transfer himself/herself from his/her wheelchair to the toilet. -The resident's last fall was on 4/7/13. -Additional interventions showed anti-rollback bars (for his/her wheelchair) were placed, the resident's restorative care program was discontinued on 4/3/12, the resident's pain medication was increased on 4/20/13, another urinalysis was ordered (4/22/13) and staff was awaiting the culture and sensitivity test, review of the resident's fall history, and they were treating the resident's cellulitis (infection and inflammation beneath the skin) with an antibiotic for ten days (starting on 4/24/13). -The care plan did not address interventions to prevent future falls in the bathroom (example: increased toileting, more frequent monitoring, and/or not leaving the resident unattended). Record review of the resident's Physician's Telephone Order dated 5/3/13, showed a physician's orders [REDACTED].

Based on observation, interview, and record review, the facility staff failed to keep one of 14 sampled residents (Resident #3) free from verbal abuse/mental abuse when observation by the Department of Health and Senior Services (DHSS) surveyor on 1/31/12 at 6:30 A.M. showed Certified Nurse Assistant (CNA) A in the presence of CNA B, leaned forward to within one foot from the resident's face as the resident laid in his/her bed and said in a very loud harsh tone of voice to the resident, "What's wrong with you? Today is not your bath day, I changed it." CNA A shook his/her right index finger at the resident in a threatening manner and said to the resident, "Don't do me." The resident then immediately began to cry. Further, CNA A failed to follow the resident's care plan which directs staff on how to interact with the resident and to speak calmly and clearly to the resident. On 1/31/12, CNA B, the eyewitness employee of the incident, did not report CNA A's verbal abuse/mental abuse of the resident to the facility's Administrator until the DHSS surveyor intervened. Staff interviews showed that CNA A had previously spoken to residents in a harsh and loud manner. Facility staff failed to follow the facility's policy to report verbal abuse of a resident to the Administrator or designee immediately as directed in the facility's abuse prevention policy affecting two of 14 sampled residents (Residents #3 and #14). The facility's census was 82 residents. Record review of the facility's policy and procedure titled, "Abuse Prevention" dated 3/1/06, showed the following information: -It is the policy of this Center to maintain the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property; -The purpose is to ensure the resident's rights are protected by providing a method for the prevention, reporting and investigation of any type of alleged resident abuse; -Training of employees upon orientation and on an ongoing basis on issues related to abuse prohibition practices, neglect, and state and federal resident rights; -Training included how staff should report their knowledge related to allegations without fear of reprisal; -The importance of protecting residents from potentially abusive situations; -The facility prevention program included education of staff related to the need to communicate any concerns that they observe or that have been reported to them to the Social Services department or other department head designated to coordinate the complaint procedure; -Educating residents, families, and staff to the fact that reports may be verbal or written; -Supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, and directing residents who need toileting assistance to urinate or defecate in their bed. All staff will be trained to report any such observations to the appropriate department head or charge nurse who will then report to the Administrator and the Director of Nursing (DON) services; -The investigation should flow with no time lapse and may include an immediate interview with the alleged victim, perpetrator, staff and others who may have witnessed the incident. Assure each individual that the interview will be confidential; -The physician and family will be notified of the alleged incidents and findings; -The protection of residents during the investigation includes the suspension of an employee pending the investigation; -Subsequent disciplinary action, up to and including termination depending upon the results of the investigation; -Separation of the resident and the alleged perpetrator from other residents who may be at risk; -All staff will be trained to report incidents immediately to the Administrator or designee including mistreatment, neglect, abuse, exploitation, injury of unknown origin, misappropriation of resident property, a missing resident, drug diversion and unanticipated death; -Alleged violations and substantiated incidents will be reported to the State agency immediately and to all other agencies as required and in accordance with State law. 1. Record review of Certified Nurse Assistant (CNA) A's employee file showed he/she was hired to work for the facility on 8/6/08, and signed an acknowledgement form titled, "Preventing Resident Abuse" and receiving training for preventing resident abuse and received a copy of the form. The form stated the employee received training on mandated reporting. and understood that the employee's supervisor or Administrator would answer any questions about the policy. Record review of CNA A's Disciplinary Action Record dated 5/3/11, showed the facility management documented CNA A: -Refused to comply with a direct order from a supervisor; -Covered his/her ears and kept walking away when the Administrator attempted to speak to him/her about a resident not receiving his/her shower; -Began yelling at the Administrator: "I can never get a word in with the Administrator." "Oh Jesus," he/she never listened, he/she always wanted me to do everything; -The warning was given with the assumption that any more violations of this kind or any other kind would result in termination. Record review of CNA A's employee annual performance appraisal dated 8/8/11, showed the Assistant Director of Nursing (ADON) documented the employee had: -Met the facility's expectations for quality of work, for quantity of work, for organizational skills, for problem solving, and initiative; -Met and exceeded some of the facility's expectations for dependability; -Met the facility's expectations for interpersonal skills, with the exception of being below their expectations in regard to cooperating with other employees in a professional and courteous manner; -Under the comment section, the ADON documented the employee needed to continue to work on his/her comments. He/she had to learn how to think before he/she spoke. At times the employee would speak inappropriately; -Under the area requiring further development, the facility documented the employee had to work on customer service skills. Record review of the facility's inservice titled "Abuse, Neglect, Exploitation, Resident Rights, and Customer Service" dated 9/2/11, showed Certified Nurse Assistant (CNA) A attended the inservice. Record review of Resident #3's admission face sheet showed the resident: -Was admitted to the facility on [DATE] for aftercare following a hip replacement; -Had [DIAGNOSES REDACTED]. Record review of the resident's care plan dated 9/29/11, showed staff identified the resident had an altered cognitive status with short term memory loss, impaired decision making, and forgetfulness; and had risk factors of being in a new environment, acute or chronic pain, having a psychiatric diagnosis, debility (a weakened state), received psychoactive (mind altering) medications, and had mental [MEDICAL CONDITION]. Staff developed a goal for the resident to maintain his/her current level of functioning and the resident would respond to his/her name through the next review. The care plan instructed staff to: -Call the resident by name, face the resident when speaking, and to speak calmly and clearly; -Provide orientation daily and as needed during conversation; -Identify themselves and explain procedures prior to starting them; -Encourage the resident to participate in cares and activities of the resident's choice; -Answer the resident's questions using short and simple sentences; -Maintain a consistent routine and provide orientation as needed; and -Allow the resident time to think, react, respond, and express his/her feelings. Record review of the resident's Level II Screening (a pre-admission screening completed by the State to determine whether a long-term care facility could meet the needs of a resident with a [DIAGNOSES REDACTED]. -The resident had a [DIAGNOSES REDACTED]. -The resident was diagnosed with [REDACTED]. -The resident functioned at about the three - four year old level; -The resident had speech that was unclear/slurred; -The resident was oriented to person and place; -The resident did not make good decisions; -The resident had poor insight; -The resident was admitted to the facility for care following surgery for [REDACTED]. -The facility was able to provide the required rehabilitative services. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff), dated 12/26/11, showed staff documented the resident: -Had adequate hearing; -Had clear speech; -Was understood by others; -Was able to understand others; -Was able to recall 14 of 15 items asked to remember during the Brief Interview for Mental Status (BIMS); -Had no signs of [MEDICAL CONDITION] (false perceptions of reality); -Had no behaviors during the previous seven days; -Had not rejected care during the previous seven days; -Required extensive to total staff assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene; -Required help in part of his/her bathing activity from one staff; -Did not walk during the previous seven days; -Required staff set up, supervision, and cueing to eat; and -Required the use of a wheelchair. Record review of the resident's Psychiatric Evaluation dated 1/8/12, showed the resident's psychiatrist documented the following: -The resident was seen to review the resident's treatment response, safety, and tolerability and to provide psychiatric follow up and care; -To assess the potential drug interactions and the relative risks and benefits of treatments; -The resident was interviewed after review of the records and progress with the staff; -The resident appeared worried, but liked sharing the names of his/her dolls by his/her wheelchair; -The resident had recent surgery to the right hip; -The resident was disabled, failed independent living, attended special education classes, and liked activities; -Lived with a parent most of his/her life; -Had more than two episodes in the previous month of [MEDICAL CONDITION], hallucinations, disorganized speech; -The resident was a poor historian, but was comfortable with his/her current nursing home placement, and was cooperative and friendly; -He/she provided support and redirection. There were no medication side effects or sedation; -His/her plan was to control the resident's [MEDICAL CONDITION], provide routine follow up, provide cognitive-behavioral therapy; -The resident's [MEDICAL CONDITION] medication included [MEDICATION NAME] (an antipsychotic mind-altering medication to treat mental illness) 150 milligrams every evening at bedtime and would evaluate its use related to the resident's safety concerns in the future months. Record review of the resident's Licensed Nurse's Progress Notes dated 1/11/12, showed the resident refused to be turned during the night and cried when staff attempted to provide care. Record review of the resident's Social Services assessment dated [DATE], showed the Social Service staff documented the resident: -Was readmitted to the facility on [DATE], following a hospitalization for the resident's right hip infection; -Really wanted to go home with his/her parent and dog and got sad about being at the facility; -Was to remain at the facility until he/she was able to walk; -Was able to make his/her needs known and follow direction; -Had indications of depression and anger at times, the resident cried, got upset, staff had to talk the resident through his/her emotional times and explain everything would be okay, and the resident's desire to go home was the root to most of his/her emotions; -Saw a psychiatrist on 1/9/12, and the facility was waiting for the physician's reports; -Had no change in behavior since admission; -Spent most of his/her days in the media room, drawing, socializing with other residents, and was very pleasant and friendly. Record review of the Social Service Notes dated 1/25/12, showed staff documented the resident was crying in the media room. The Social Service staff determined the resident needed to lay down, but was afraid staff would not get the resident back up when he/she wanted to get up. The Social Service staff reassured the resident, and he/she would make sure someone got the resident up. Observation and interview on Tuesday, 1/31/12 at 6:30 A.M., showed CNA A and CNA B walking rapidly down the hall toward Resident #3's room. CNA A said in a loud harsh voice in the hallway, "I'm not going to put up with this today." CNA A and CNA B entered the resident's room. The DHSS surveyor entered the resident's room behind CNA A and stood within one arm's length slightly to the right side of CNA A. The resident's privacy curtain was open and the resident's outer door was open. The resident's bed was located on the far side of the room. CNA B walked to the opposite side of the resident's bed, near the wall and window, and began opening the resident's bedside chest of drawers while looking downward. The DHSS surveyor witnessed CNA A lean forward to within one foot from the resident's face as the resident laid in his/her bed and heard CNA A say in a very loud harsh tone of voice to the resident, "What's wrong with you? Today is not your bath day, I changed it." CNA A shook his/her right index finger at the resident in a threatening manner and said to the resident, "Don't do me." The resident then immediately began to cry. CNA A turned to leave the resident's room and said to the DHSS surveyor, "I did not know you was there." CNA A said the resident's shower days were scheduled for Mondays and Thursdays. CNA A then left the room. The resident continued to cry and CNA B consoled the resident by patting the resident's arm, and reassured the resident he/she would receive a bed bath. During an interview on 1/31/12 at 7:10 A.M., CNA A (who was nervous and sweating during the interview) said he/she was not aware he/she sounded harsh toward the resident and he/she would apologize to the resident. He/she acknowledged there would never be a reason to speak to a resident in a harsh tone, including those residents with mental [MEDICAL CONDITION]. He/she changed the bath schedule two weeks ago with his/her supervisor's approval. He/she identified and explained the different types of abuse were verbal abuse, mental abuse, physical abuse, and neglect, and he/she attended an inservice for abuse four months ago. During an interview on 1/31/12 at 7:25 A.M., CNA B said to the two DHSS surveyors that he/she had worked for the facility for three and one-half months. He/she had gone to the north hall shower room that morning to inform CNA A the resident wanted to have a shower before going out to a doctor's appointment (outside the facility). At first CNA A said "yes," the resident could receive a shower, and then changed his/her mind and said "no" the resident could not receive a shower. CNA B was not happy with CNA A's response and said CNA A yelled at the resident saying, "Today is not your bath day, and you know that." CNA B said CNA A spoke in a loud, harsh voice to the resident, and everyone on that end of the hall could hear CNA A yelling at the resident. CNA B acknowledged that CNA A had verbally abused the resident. CNA B said the resident was very upset and cried after the incident and he/she consoled the resident after CNA A left the room. This upset him/her because the resident could have been his/her own family member. He/she had not yet reported the incident to his/her charge nurse or the Administrator until the DHSS surveyor reminded CNA B that he/she was a mandated reporter for incidents of abuse. Record review of the Administrator's written statement on 1/31/12 at 7:30 A.M., showed the Administrator documented: -CNA B informed the Administrator of the alleged verbal abuse between CNA A and the resident; -The Administrator went to CNA A immediately and requested his/her presence in the Administrator's office; -CNA A was very nervous during the interview and stated he/she was sick; -CNA A was short of breath and breathing very labored; -CNA A said he/she spoke to the resident about not getting a bath today; -The Administrator excused CNA A and said he would speak to him/her at a later time; -The Administrator went to the Assistant Director of Nursing's (ADON) office, where the surveyors were at 8:15 A.M. and was informed the surveyors considered this as "abuse;" -Immediately, CNA A was called into the Administrator's office and suspended pending their investigation of the incident; -CNA A was remorseful and understood why he/she was suspended; -CNA A said, "But I've been so good and didn't mean any harm." During an interview on 1/31/12 at 7:35 A.M., Licensed Practical Nurse (LPN) B, the charge nurse on the unit where the resident resided, said no staff had reported to him/her that any form of abuse had occurred toward a resident today. During an interview on 1/31/12 at 7:42 A.M., CNA C said he/she had worked for the facility for three years. He/she had not heard anyone speaking loudly to any resident this morning. In the past, he/she heard CNA A yelling at residents. He/she warned CNA A more than once to think about how he/she spoke to the residents, because CNA A was loud. CNA A acknowledged understanding what CNA C meant. CNA C acknowledged verbal abuse was when a person yelled or screamed at the residents. CNA C refused to give any specific details, but again said he/she had warned CNA A about his/her manner of speaking to the residents. During an interview on 1/31/12 at 7:55 A.M., the Administrator said CNA B had reported to him the incident involving CNA A toward the resident. He said CNA A seemed nervous and was sweating when suspended from duty. He suspended CNA A while they investigated the incident. During an interview on 1/31/12 at 7:58 A.M., the ADON said CNA A usually spoke in a loud voice and required coaching (educating). No staff have ever reported to the ADON, CNA A to be verbally abusive to any resident in the past. He monitored all the residents whenever he was in the building. Record review of a written statement written by the Director of Nursing (DON) and signed as an accurate account of the incident by CNA B dated 1/31/12 at 9:45 A.M., showed: -On 1/31/12 at 6:15 A.M., CNA B entered the resident's room and the resident said he/she was going to the doctor today; -The resident acknowledged CNA L from the night shift had washed him/her up; -The resident said he/she was ready to get up; -The State surveyor asked permission from the resident's doorway to watch CNA B use the mechanical lift to get the resident up, and the resident agreed; -The State surveyor left the area to watch a treatment; -The resident asked CNA B, "Do I get a bath today before going to the Doctor?" -CNA B replied, "Let me go see." -CNA B went to the facility bath house (a room where residents receive showers or baths), and stated, "Before I get the resident up, does he/she get a bath today?" -CNA A replied, "No, his/her bath days are Monday and Thursday." -CNA A said, "It's not fair, because you called in yesterday on the resident's bath day, you know how his/her parent was, the resident would tell the parent when the resident got over there." -CNA A did not reply to the statement and CNA B said he/she would inform the resident of not getting a bath; -The resident acknowledged he/she was not going to get a bath before his/her doctor's appointment and CNA B and CNA L began dressing the resident at 6:35 A.M.; -CNA A entered the room at 6:35 A.M., and was extremely loud and stated, "Don't do me, don't do me," "What is today?" "You know you don't get a bath today." -The resident replied, "I didn't know." The resident became tearful; -The resident's room door was closed all but a small crack in the door; -CNA A left the resident's room and nearly bumped into the State surveyor standing in front of the closed door, Note: The DHSS surveyor was inside the resident's room at which time he/she observed CNA A's verbal abuse/mental abuse of the resident which is documented in the observation and interview on 1/31/12 at 6:30 A.M. beginning with CNA A and CNA B, etc.; -CNA A turned around and asked the resident using a quieter inside voice, "Do you want CNA A to wash the resident down before you leave?" The resident replied, "Yes." -CNA A stated to the State surveyor, "I didn't know anyone was out here." -CNA A and CNA L finished dressing the resident and CNA L stated it was time for him/her to go home; -CNA B and CNA C transferred the resident from the bed into a wheelchair with the State surveyor observing; -The resident was not tearful; -CNA B took the resident to the dining room and went to find the ADON or the Administrator and another resident requested his/her assistance to use the bathroom at 6:50 A.M.; -CNA B provided care to the resident then asked the North station's LPNs if they had seen the ADON. The LPNs replied, "No." -CNA B said two State surveyors stopped him/her near North nursing station and surveyor asked what he/she witnessed earlier that morning with CNA A and Resident #3, and CNA B told them (the two DHSS surveyors) above described event regarding (name of Resident #3); -The State surveyor thanked CNA B for being honest, asked CNA B if he/she considered that incident as verbal abuse and CNA B replied, "Yes." CNA B observed CNA A being loud and rude "a couple of Thursdays ago." -CNA B said CNA A said, "Don't do that again. I don't want to see the resident first thing in the morning. I'll get to him/her when I get to him/her." CNA A said this in front of the resident in a loud and rude voice two weeks ago in the morning time; -Many times the resident is tearful when he/she cannot find his/her doll or a pen, hat, puzzles, any little thing; -If the resident didn't get what he/she wanted, the resident cried and became agitated; -CNA B described verbal abuse as cursing, being rude, or having a mean tone of voice; -CNA B said CNA A was loud, rude, and screaming at the resident with a rude demeanor and gestures in the way CNA A was moving his/her body; -CNA B said CNA A did not make any threatening statements to the resident, did not curse at the resident, did not call the resident names, and did not show intent to harm the resident; -CNA B said CNA A had not been feeling well and he/she guessed CNA A was not having a good day for him/her; -CNA B had seen CNA A be loud and rude with the resident when the resident asked to get a bath; -He/she would report any abuse, neglect, or exploitation of a resident immediately to his/her immediate supervisor, DON, ADON, Administrator, or he/she would report it to the State hotline. During an interview on 1/31/12 at 10:38 A.M., LPN A said he/she routinely arrived at the facility at 5:50 A.M. every morning. He/she heard CNA A speak very loudly in a harsh tone this morning while providing care to a resident who was three rooms away from Resident #3's room. He/she heard CNA A say: -"Don't do me." He/she explained this was a slang term used by their (CNA A's culture) culture to threaten others and meant, "Don't (expletive) with me, you know your bath days are Mondays and Thursdays."; -Staff need to approach the resident in a friendly manner; -CNA A called in sick the previous day causing the resident not to receive his/her scheduled shower; -He/she acknowledged this was verbal abuse toward the resident; -He/she did not report the incident today because it was witnessed by the State surveyor; -He/she heard CNA A speak in a loud harsh voice in the past to other residents; and -He/she never reported CNA A in the past to the administration because, CNA A always said he/she was just joking. During observation and an attempted interview with the resident on 1/31/12 at 11:30 A.M., showed the resident had returned from his/her physician's appointment and was sitting in his/her wheelchair in his/her room. The resident was unable to answer any questions related to the incident earlier in the day with CNA A. The resident shook his/her head to confirm he/she had returned from his/her doctor's appointment. Record review of a written interview between the Administrator with the resident and the resident's Durable Power of Attorney (DPOA) dated 1/31/12 at 11:30 A.M., showed -The resident returned from his/her physician appointment; -The resident and DPOA were sitting in the front lobby; -The resident said his/her appointment went fine but, "They hurt me."; -The DPOA said the resident was given a good report regarding his/her leg and things were coming along well; -The DPOA said he/she had seen less of the resident feeling anxious and crying out; -The DPOA said the resident would still say people were "hurting her" but that the DPOA thought it was the resident's therapy trying to help the resident walk causing the resident to hurt; -The DPOA said the resident never verbalized anyone injuring him/her and never verbalized being in fear of injury by anyone at anytime. Record review of the written interview by the DON and signed as an accurate account of the incident from LPN A on 1/31/12 at 11:50 A.M., showed: -LPN A observed CNA A enter the resident's room from the hallway as he/she prepared to enter the room next door to the resident's room; -LPN A administered a treatment three rooms up the North hall with the door closed with a State surveyor observing the treatment; -LPN A heard CNA A state, "Your bath day is Monday and Thursday, you're not getting a bath today." Don't do me, don't do me." LPN A did not hear the resident's reply; -LPN A stated CNA A's voice was loud and rough, but he/she did not hear any cursing; CNA A was arguing with the resident. Note: The interview did not address why LPN A did not report this interaction with CNA A toward the resident to the management of the facility.; -LPN A had not observed CNA A to be verbally abusive by cursing or arguing with residents, he/she only heard CNA A be loud in the hall with staff members. During an interview on 1/31/12 at 12:40 P.M., CNA D said CNA A was always talking crazy to the residents. CNA D said CNA A was "very rude and inappropriate to the residents." Staff act as though they are scared of CNA A. Staff are afraid to report CNA A because "they fear getting their tires slashed." CNA A talks "crazy" to everyone and speaks to the residents in a "degrading manner as though they were children." Some of the CNAs on the unit where the resident resides are friends with CNA A and probably would not report a friend. Record review of the resident's psychology consultation titled, "Diagnostic Evaluation" dated 2/1/12, showed the psychologist documented: -The resident had a problem of depression, crying, and inappropriate behavior; -The resident had intellect disability and [MEDICAL CONDITION]; -The resident had a supportive family; -He/she observed the resident to be tearful, but the therapist was able to stop the tearfulness and interact with the resident; -The resident responded by crying when the resident's anxiety was elevated; -He/she questioned the resident about any other situation or event that made him/her cry recently and the resident stated "no"; -The resident's medical record showed documentation of the resident having tearful episodes at various times; -Crying appeared to be an attention seeking behavior which enabled the resident to get rewards; -The therapist recommended staff to provide support and encouragement to the resident, and the resident may respond to a behavior modification program which reinforced positive interaction and reduced crying as an attention seeking method. During an interview on 2/1/12 at 11:10 A.M., LPN A said he/she had witnessed CNA A speak loudly in the past to the charge nurse on duty. LPN A would not elaborate on any other specific details related to when he/she warned CNA A to speak in a lower volume or friendly tone. Record review of a written statement by the DON and signed as an accurate account of the incident by CNA L on 2/1/12 at 12:45 P.M., showed: -He/she was in the resident's room on the day of the incident (1/31/12) assisting the resident's roommate in the bathroom, when CNA A entered the resident's room and walked straight to the resident; -CNA A began yelling at the resident, "When are your bath days? When are your bath days?" "Don't f-ing play with me." CNA A leaned over the resident supporting himself/herself with one hand on the bed frame and one hand on the resident's bed rail; -CNA A answered the resident's questions; -CNA L could not see CNA A's face but heard the resident reply in a quiet, normal tone of voice for the resident; -CNA L said, "I knew for a fact the State surveyor was going to report the incident because of the look on the surveyor's face, and the State surveyor was writing stuff down." During an interview on 2/1/12 at 2:10 P.M., CNA B said he/she had reported to the Administrator, the incident that occurred yesterday with Resident #3, and he/she acknowledged it was important to tell the truth about CNA A's behavior, because his/her job was important to him/her. On a previous day when Resident #3 had a doctor's appointment, he/she asked CNA A what time the resident would receive his/her shower. CNA A replied, in an inappropriate tone, "I'll get to it, when I get to it." He/she warned CNA A, "Watch your mouth." CNA A spoke more appropriately afterward. Record review of the written statement of the incident by the DON and signed as an accurate account of the incident on 1/31/12 by CNA A dated 2/1/12 at 3:10 P.M., showed: -CNA A arrived to work on 1/31/12 at 5:45 A.M. and was having trouble breathing, was not feeling well, having congestion, and diarrhea; -CNA A said he/she entered Room # (room number of Resident #3) approximately 6:50 or 6:55 A.M. and said that (first name of CNA B), (first name of Resident #3) and himself/herself present; walked to (first name of resident), leaned over with hands on knees and stated x 3, "When your bath day (first name of the resident)? Please don't do me today. OK, I'll go."; -Employee (CNA A) states, "Don't do me means don't get on my nerves."; -Also said by CNA A to the resident, "See when your appointment is and get you cleaned up today," and (first name of resident) replied, "OK."; -(First name of CNA A) states, "Resident not upset when CNA walked out and was not crying when CNA walked out."; -(First name of CNA A)'s back to the resident room door. CNA A turns around and started walking towards the door. Observed surveyor in hallway outside open resident room door and privacy curtains were open. Note: The DHSS surveyor was inside the resident's room at which time he/she observed CNA A's verbal abuse/mental abuse of the resident which is documented in the observation and interview on 1/31/12 at 6:30 A.M. beginning with CNA A and CNA B, etc.; -CNA A states he/she walked out of room past surveyor. States he/she and surveyor did not speak. Note: Based on the observation and interview by the DHSS surveyor on 1/31/12 at 6:30 A.M. the following occurred, CNA A turned to leave the resident's room and said to the DHSS surveyor, "I did not know you was there."; -At approximately 7:15 A.M., two surveyors asked CNA A what he/she thought abuse was. CNA A said abuse was, "resident upset what done,"; -CNA A met with the Administrator, was suspended pending an investigation, and was asked to clock out of the facility; -CNA A was asked, "Have you been verbally or physically abusive to a resident at facility?" CNA A answered, "No. If I hear or see anything crazy/not proper, I tell (first name of the Administrator)."; -CNA A was asked, "What do you think is verbal abuse?" and CNA A said abuse is, "Loud talking," and "Cursing." Record review of the facility's "Disciplinary Action Record" for CNA A dated 2/7/12, showed the facility had documented: -The facility had a written report of CNA A being insubordinate on 5/3/11; -CNA A was suspended from working on 1/31/12 pending the investigation; -CNA A was terminated from employment on 2/7/12; -The employees must maintain acceptable standards of respect and professional conduct toward residents, visitors, co-workers, and vendors; -On 1/31/12 at approximately 6