Every finding on record at Republic Nursing & Rehab

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility failed to keep dented cans separated from other cans; failed to ensure all food items were properly labeled and sealed; failed to ensure transported foods were covered; failed to ensure fans, vents, and ceilings in food areas were free from dirt and debris; and when staff stacked dishes while still wet. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 115 residents.1. Review of the 2022 Food and Drug Administration (FDA) Food Code showed the following information:-Depending on the circumstances, rusted, and pitted or dented cans may present a serious potential hazard;-Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food;-If the integrity of the packaging has been compromised, contaminants may find their way into the food. Review of the facility policy titled, Storage of Dry Food and Supplies, dated April 2011, showed severely dented, rusted, leaking, and bulging cans must be placed in a separate, labeled holding area for return to the distributor.Observations on 09/15/25, at 6:03 A.M., on 09/17/25, at 12:01 P.M., and 09/18/25, at 3:00 P.M., of the canned food rack showed two 6 pound and 11-ounce (oz) cans of sandwich maker on the rack. One can had a large dent in the back and a smaller near the top. The second can had two large dents on each side.During an interview on 09/18/25, at 1:34 P.M., Dietary Aide (DA) A said the following:-Dented cans should not be on the rack with other cans;-He/she would remove a dented can from the rack and put in designated area;-He/she would not use food from a dented can.During an interview on 09/18/25, at 1:52 P.M., Dietary [NAME] (DC) B said the following:-Staff should separate dented cans from other cans;-Staff should never use food from a dented can because the air seal is cracked.During an interview on 09/18/25, at 2:20 P.M., the Dietary Manager (DM) said the following:-Staff should never use food from a dented can;-Staff should pull dented cans from the rack and store in the designated area;-He notifies the food representative for credit.During an interview on 09/18/25, at 3:54 P.M. the Administrator said staff should not use dented cans and should store in a separate designated area.2. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, updated 03/04/23, showed the following:-Facility staff must ensure their proper storage, including keeping track of when to discard perishable foods, and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated;-Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen (where applicable), or discarded.Review of the facility policy titled, Storage of Dry Foods and Supplies. dated April 2011, showed the following:-Metal or plastic containers with tight fitting covers, labeled top or side, must be used for storing opened products;-Open boxes are to be effectively sealed;-Bulk crackers, cereal, cookies, pasta, etc. are to be stored and properly labeled in sealed containers;-Food grade plastic bags are to be tightly closed after being opened.Observation on 09/15/25, at 6:03 A.M., of the kitchen showed the following: -Inside the stand-up cooler was four packages of sliced cheese wrapped in unsealed plastic wrap with no label. Two of the four packages of cheese were visibly turning hard;-Inside the stand-up cooler was a partial onion covered in unsealed plastic wrap, a bag of shredded cheddar jack cheese open to air, two gallon plastic bags containing some type of sliced meat with no label, steel container covered in aluminum foil containing a white substance with no label, steel container containing diced pork labeled 09/04 to 09/07'-Inside the dry storage area was two containers of instant mashed potatoes open to air and only one labeled,a large plastic container of thickener with a dirty lid not secured, two boxes containing bags of graham crackers both open to air and only one labeled, one opened gallon jug of soy sauce with about three-fourths used with manufacturer label to refrigerate after opening for quality, and one opened gallon jug of teriyaki sauce with about three-fourths used with manufacturer label to refrigerate after opening;-Inside the walk-in freezer were fries, chocolate chip cookie dough, French toast sticks, beef patties, rib patties, breaded pork patties, and breaded chicken tenders all in unsealed and open to air plastic bags inside of boxes;-Inside the walk-in cooler was a steal container of possible potato salad with no label.Observation on 09/17/25, at 12:01 P.M., of the kitchen showed the following:-Inside the stand-up cooler was an opened and partially used one-gallon plastic jug of sweet pickle relish labeled 06/04/24, and an eight-quart plastic container with an unsecured red lid containing about two quarts of green beans labeled 09/12;-Inside the dry storage area was box containing a plastic bag of rice unsealed and open to air, one opened gallon jug of soy sauce with about three-fourths used with manufacturer label to refrigerate after opening for quality, and one opened gallon jug of teriyaki sauce with about three-fourths used with manufacturer label to refrigerate after opening;-Inside the walk-in freezer was rib patties, cobbler crust, chocolate chip cookie dough, country fried beef steak patties, breaded pork patties, and pork egg rolls all in unsealed and open to air plastic bags inside of boxes, and a bag of diced chicken unsealed and open to air;-Inside the walk-in cooler had a large bag of several meat patties, unsealed and open to air with no label.During an interview on 9/17/25, at 1:34 P.M., DA A said the following:-Staff should store opened food in a sealed container labeled with the date opened, use by date, and item name;-Most foods can be kept refrigerated for four days.During an interview on 09/17/25, at 1:52 A.M., DC B said the following;-Staff should store opened food in a sealed container labeled with the food name, date opened, and the use by date, and nothing should be opened to air;-Opened items requiring refrigeration generally should be discarded after three days.During an interview on 09/17/25, at 2:20 P.M., the DM said the following:-All stored opened food should be sealed, labeled, and dated with the open date and use by date;-Most opened refrigerated food items should be discarded after three days;-Staff should review food dates on a daily basis and discard expired foods.During an interview on 09/18/25, at 3:54 P.M., the Administrator said opened food should be labeled, dated, and sealed. Most opened refrigerated food should be stored for three days and then discarded. 3. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination.Review of the facility policy titled, Cleaning Schedules, dated April 2011, showed the following:-It was the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks;-Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning takes listed will be posted in the dietary department and should specify days, responsible staff, and shift and be posted prior to the beginning of each week with the staff to initial when task is completed.Observation on 09/15/25, at 6:03 A.M., of the kitchen showed the following:-Vents on the ice machine had dirt and dust on them and were directly over the napkins used to roll silverware;-Fans inside the walk-in refrigerator had dirt and dust on them, and they were blowing directly over food;-The ceiling in the walk-in refrigerator had dirt and dust on it directly over food.Observation on 09/17/25, at 12:01 P.M., of the kitchen showed the following:-Vents on the ice machine had dirt and dust on them and were directly over the napkins used to roll silverware;-Fans inside the walk-in refrigerator had dirt and dust on them, and they were blowing directly over food;-The ceiling in the walk-in refrigerator had dirt and dust on it directly over food.Observation on 09/18/25, at 3:00 P.M., in the kitchen showed the following:-Vents on the ice machine had dirt and dust on them and were directly over the napkins used to roll silverware;-Fans inside the walk-in refrigerator had dirt and dust on them, and they were blowing directly over food;-The ceiling in the walk-in refrigerator had dirt and dust on it directly over food.During an interview on 9/17/25, at 1:34 P.M., DA A said the facility had a cleaning schedule, but he/she did not know who was responsible for cleaning the vents on the ice machine, or the fan and ceiling in the walk-in refrigerator.During an interview on 09/17/25, at 1:52 A.M., DC B said the facility had a cleaning schedule, and cleaning the fan and ceiling in the walk-in refrigerator was the responsibility of all dietary staff. Cleaning the vents on the ice machine is the responsibility of the dietary aides. During an interview on 09/17/25, at 2:20 P.M., the DM said the following:-Cleaning the vents on the ice machine was the responsibility of maintenance;-There was a daily and weekly cleaning schedule for the kitchen;-There was a daily 10:00 A.M. to 6:00 P.M. staff member responsible for cleaning the fan and ceiling in the walk-in refrigerator.During an interview on 09/19/25, at 1:19 P.M., the Maintenance Supervisor said it was the responsibility of maintenance to clean the vents on the ice machine.During an interview on 09/18/25, at 3:54 P.M., the Administrator said the kitchen has a cleaning schedule and there should not be dirt or dust on vents, fans or the ceiling.4. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination.Review of the facility policy titled, Dining Services Manager Responsibility, dated April 2011, showed the following:-Food must remain covered while being distributed through the hallways;-Cart should be filled as quickly as possible from start to finish without interruptions in order for food to remain hot. When filled, the cart should be immediately taken to the hall and distributed to resident. All items must be covered.Observation on 09/17/25, at 11:30 A.M., showed trays on the food cart had cups of pears that were all uncovered. At 11:58 A.M., the cart carrying the trays with uncovered pears was taken to be served and staff were observed taking the trays with the uncovered pears through halls to resident rooms.Observation on 09/18/25, at 3:52 P.M, showed trays on the food cart had cups of watermelon that were all uncovered. At 5:00 P.M., the Administrator pushed the food cart carrying the trays with uncovered watermelon to the hall to be served.During an interview on 09/17/25, at 1:34 P.M., DA A said all food should be covered during transport and the watermelon for the evening meal was not covered and should have been. During an interview on 09/17/25, at 1:52 A.M., DC B said all food should be covered during transport and the watermelon was not covered for the evening mealDuring an interview on 09/17/25, at 2:20 P.M., the DM said all food should be covered during transport.During an interview on 09/18/25, at 3:54 P.M., the Administrator said food should be covered during transport and he took a cart with uncovered watermelon on the trays to be served to residents.5. Review of the Missouri Food Code, published 2022, showed dishes are required to be air dried before being stacked and stored. Review of the facility policy titled, General Dish Room Sanitation, dated April 2011, showed the following:-All items are to be air dried. No moisture can be found on any stacked item;-All items must be stored inverted, covered, or stacked with top of dish/tray inverted unless stored in an enclosed cabinet.Observation on 09/17/25, at 12:15 P.M., in the kitchen showed medium cups stored for use upside down on a red tray with trapping water inside the cups.Observation on 09/19/25, at 8:31 A.M., in the kitchen showed cups stacked on a tray upside down with water trapped on the tray and inside the cups and small bowls stacked upright in a dish tub with water inside the bowls.Observation on 09/18/25, at 1:29 P.M., in the kitchen showed staff stacked wet plate covers next to the steam table for use.During an interview on 09/18/25, at 1:46 P.M., DA C said the following:-He/she leaves dishes out of the dishwasher for a couple of minutes so they can dry before stacking;-He/she has not been told dishes should not be stacked while wet.During an interview on 09/18/25, at 1:52 P.M., DA A said dishes should be dry before stacking. The facility does not have enough rubber mats to place dishes on for drying.During an interview on 09/18/25, at 9:51 A.M., DC B said dishes should never be stacked wet because bacteria will grow.During an interview on 09/18/25, at 2:20 P.M., the DM said all dishes should be air dried before stacking. During an interview on 09/18/25, at 3:54 P.M. the Administrator said staff should not stack wet dishes, they should be air dried before storing for use.

Based on observation, interview, and record review, the facility failed to notify the physician of a change in resident condition and abnormal laboratory results in a timely manner for one resident (Resident #1). The facility census was 94. Review of the facility policy titled, Condition Change, Resident (Observing, Recording, and Reporting), dated March 2015, showed staff are to observe, record, and report any condition change to the attending physician so that proper treatment can be implemented. Review of the facility policy titled, Lab Reporting Guidelines, dated March 2015, showed the following information: -Nurse will document resident name and lab ordered in the 24-hour report book and the date it is to be drawn; -Nurse will notify the physician of lab results via fax and follow up call (within twelve hours for routine labs and within one hour for statim (STAT - as soon as possible) labs); -Nurse will document on the lab report that the physician has been notified to include how they are notified, when, and nurse signature. 1. Review of Resident #1's face sheet (basic information sheet) showed the following information: -admitted [DATE]; -Diagnoses included congestive heart failure (CHF - chronic condition where the heart does not pump blood as well as it should), atrial fibrillation (irregular heart rate), high blood pressure, fibromyalgia (disorder that causes pain and tenderness throughout the body), chronic kidney disease (gradual loss of kidney function over time), and chronic pain. Review of the resident's Minimum Data Sheet (MDS - a federally mandated assessment tool completed by facility staff), dated 06/11/24, showed the following: -Cognitively intact; -Utilized a wheelchair for mobility assistance; -Required partial to moderate assistance with dressing, toileting, and personal hygiene; -Required set up and clean-up assistance for eating and oral hygiene; -Required supervision to touching assistance with bed mobility and transfers; -Dependent on staff for wheelchair mobility. Review of resident's Physical Therapy Evaluation, dated 06/11/24, showed the following: -Supervision or touching assistance needed for lying to sitting and sitting to standing; -Partial to moderate assistance needed with chair to bed transfer and toilet transfer; -Supervision or touching assistance needed to walk ten feet; -Partial to moderate assistance needed to wheel wheelchair fifty feet with two turns. Review of resident's Occupational Therapy Evaluation, dated 06/11/24, showed the following: -Set-up or clean-up assistance needed for eating, oral hygiene, personal hygiene, and upper body dressing; -Partial to moderate assistance needed with toilet hygiene and lower body dressing; -Substantial or maximum assistance needed with showering. Review of the resident's progress note dated 06/16/24, at 2:10 P.M., showed Licensed Practical Nurse (LPN) A documented a condition note for the resident. Resident had issues with fibromyalgia noted that day. Resident's arms have twitching on the right and the resident states there is some arm discomfort. Resident unable to stand and required total lift transfer. Resident incontinent of urine and stool, and stated he/she was not able to get up to toilet. Resident unable to feed self. Staff assisted resident with the meal. Resident ate very little and said he/she was not hungry. Resident expressed pain on movement out of bed. Four staff assisted with incontinent care and used of Hoyer lift (mechanical lift for residents who cannot bear weight) with transfer. Registered Nurse (RN) supervisor exam completed and call placed to family to update. (The nurse did not document notification of the resident's physician for the change of condition.) Review of the resident's progress note dated 06/17/24, at 1:52 P.M., showed LPN B documented resident lying in bed moaning this morning. Staff administered oxycodone (pain medication) and applied Bio freeze (topical pain relief). Resident complained of hurting all over. Therapy assisted resident out of bed at 10:45 A.M. Resident assisted back to bed and continued to moan and complain of pain. Resident stated he/she was full prior to eating lunch. Resident assisted with lunch and started to feed self, but arms noted to be weak and dropping from tray onto self. No signs or symptoms of distress noted at this time. (Staff did not document notification of the resident's physician for the change of condition.) Review of the resident's progress note dated 06/17/24, at 9:30 P.M., showed LPN C documented the resident roused to verbal stimuli and was able to answer simple questions. The resident then falls back asleep. Resident unable to feed self due to weakness and tremors of upper extremities. Resident refused evening meal and drank minimal fluids with staff assist. Resident was incontinent of bowel and bladder. Resident complained of all over generalized pain with stated relief from pain medication. (Staff did not document notification of the resident's physician for the change in condition.) Review of the resident's progress note dated 06/17/24, at 11:25 P.M., showed the Director of Nursing (DON) documented resident dependent on nursing staff for all cares and recently incontinent of bowel and bladder. (Staff did not document notification of the resident's physician.) Review of the resident's June 2024 Physician Order Report showed an order, dated 06/17/24, for complete blood count with differential (CBC - blood test that measures number of blood cells and platelets, including different types of white blood cells) and a basic metabolic panel (BMP - blood test that provides information about chemical balances and metabolism in the body). Review of the resident's laboratory results report, dated 06/17/24, showed the following: -Lab completed a blood draw on 06/17/24, at 6:15 A.M., for a CBC, BMP, and PT/INR; -Findings reported to the facility on [DATE], at 5:50 P.M.; -Elevated potassium 5.8 milliequivalent/Liter (mEq/L) (normal range 3.5-5.3 mEq/L); -Elevated blood urea nitrogen (BUN) 72 milligram/deciliter (mg/dL) (normal range 7-25 mg/dL); -Elevated creatinine 4.3 mg/dL (normal range 0.6-1.2 mg/dL); -Decreased GFR (indicates how well kidneys are function) level (define)10 mL/min (milliliter/minute) (normal range is greater than 60 mL/min). (The findings did not contain a nurse signature identifying physician notification of the abnormal labs.) During an interview on 07/24/24, at 11:55 A.M., a Lab Company Staff said labs were ordered for the resident on 06/17/24. The results for the labs were sent to the facility on [DATE], at 6:40 P.M. Review of the resident's progress note dated 06/18/24, at 9:28 A.M., showed RN E documented resident family verbalized concern for possible urinary tract infection (UTI - infection in part of the urinary system). Review of the resident's progress note dated 06/18/24, at 10:53 A.M., showed RN E documented nurse practitioner (NP)notified of family request for urinalysis (test of the urine) and new order received to obtain urine sample per family request. Review of the resident's June 2024 Physician Order Report showed the following: -An order, dated 06/18/24, to obtain a urine sample via straight catheter (hollow tube placed in bladder to drain urine), for a diagnosis of difficulty in walking; -An order, dated 06/18/24, for Hoyer lift for transfers. Review of the resident's care plan, last reviewed/revised on 07/15/24, showed on 06/18/24 staff updated the care plan to show the resident unable to bear weight for transfers. Review of resident's Physical Therapy Discharge, dated 06/19/24, showed the following: -Substantial to maximum assistance needed for lying to sitting; -Dependent for sitting to standing, chair to bed transfer and toilet transfer. Review of resident's Occupational Therapy Discharge, dated 06/19/24, showed the following: -Set-up or clean-up assistance with eating; -Partial to moderate assistance needed for oral hygiene -Substantial or maximum assistance needed with toilet hygiene, upper body dressing, and showering; -Dependent for lower body dressing. Review of the resident's progress note dated 06/19/24, at 12:00 A.M., showed RN E documented urine sample obtained. Resident's urine was yellow, cloudy, and had a foul odor. Review of the resident's progress note dated 06/19/24, at 2:38 P.M., showed RN E documented resident seen by NP. Last lab results seen and showed possible renal failure (condition in which kidneys lose the ability to remove waste and fluids from the body). Staff received new order to send resident to hospital (three days after staff identified the change in condition and two days after staff received abnormal labs for the resident). Review of resident's hospital after visit summary, dated 07/02/24, showed diagnoses of UTI, severe sepsis with septic shock (condition in which body responds improperly to an infection), bacteremia (bacteria in the blood), acute kidney injury (condition where kidneys are suddenly not able to filter waste products from the blood), acute encephalopathy (condition that causes brain dysfunction). During interviews on 07/22/24, at 1:35 P.M., and on 07/24/24, at 11:51 A.M., LPN B said the following: -He/She would obtain vital signs, assess the resident, document findings, and notify the physician and family for any change in a resident condition; -The resident required increased assistance from staff and had an increase in pain and weakness sometime after admission to facility; -The family was aware of resident's change in condition; -He/She does not know if the physician was notified; -He/She should have notified the physician for the resident's change in condition, but can not recall if he/she did; -Lab results are faxed to medical records office and are placed in a box for nurse retrieval; -Administration staff are responsible for placing lab results in box; -Nurses should check for lab results once per shift; -Laboratory calls facility to report abnormal results; -Nurses should call abnormal labs in to the physician. During an interview on 07/24/24, at 11:24 A.M., the resident's NP said the following: -He/She will order STAT labs for acute concerns; -He/She was onsite at the facility on 06/19/24 and reviewed lab work that indicated the resident was in renal failure; -He/She did not recall the date of the lab work he/she reviewed; -He/She had the resident sent to the hospital for evaluation; -He/She did not recall being notified of any significant change in the resident's condition or concerns with lab results prior to being onsite 06/19/24; -The facility should notify him/her or the physician immediately of any significant changes in a resident's condition; -Routinely ordered labs should be reviewed by the facility for any urgent concerns and contact the NP or physician immediately if there are concerns. During interviews on 07/22/24, at 2:19 P.M. and 3:38 P.M., LPN A said the following: -He/she would assess the resident, obtain vital signs, call the physician for orders, and contact family for a change in resident condition; -He/She observed a change in the resident's condition, obtained vital signs, and notified the RN supervisor and the residents family; -He/She did not contact the physician due to normal vital signs and comments made by family and supervisor. During an interview on 07/22/24, at 3:54 P.M., RN H said the following: -Changes in condition should be reported to the charge nurse immediately; -Changes in condition should be reported to the physician immediately by the charge nurse and documented in the nurses notes. During an interview on 07/24/24, at 11:03 A.M., LPN F said the following: -Abnormal findings such as a change in vital signs, functional status, or mentation would indicate a change in condition; -He/She would obtain vital signs, document, and notify physician, family, and RN supervisor for any change in resident condition; -Lab results are faxed to facility and nurses and physicians can view them online; -Lab calls facility for critical results; -Guidelines of abnormal lab values are posted at the nurses' station which shows the nurse when to contact the physician; -He/She would call the physician for critical lab results; -Facility policy is to notify physician of abnormal lab results. During an interview on 07/24/24, at 11:23 A.M., LPN D said the following: -Change in condition should include any changes from the resident's baseline; -He/She would obtain vital signs, gather information on current labs, vitals, medications, notify physician, and document findings and any orders; -Nurses report lab values to the physician via email or online; -Lab calls facility for critically high or low lab values; -Facility policy is to notify physician as soon as possible of lab results. During an interview on 07/24/24, at 12:56 P.M., the Assistant Director of Nursing (ADON) said the following: -Lab results are received to medical records and can also be viewed online; -Nursing staff are to check each shift for received lab results; -Nursing staff are to review received labs for any immediate concerns and notify the physician if concerns are noted; -The physician is to be notified of any changes in condition immediately by the charge nurse or abnormal labs and documented in the progress notes. During an interview on 07/24/24, at 12:20 P.M., the DON said the following: -Nurses should conduct an assessment and notify the physician and family for any change in resident condition. -A change of condition could include increased fatigue, change in functional abilities, and new onset of weakness. -Lab results are faxed to the front office. -He/she expects nurses to check for lab results. -Nurses should immediately notify physician of critical lab results. -There is no set procedure for lab results. -There is no facility policy related to labs. During an interview on 07/24/24, at 12:32 P.M., the Administrator said the following: -Resident changes in condition are to be reported to the physician immediately by the charge nurse and documented in the progress notes; -Lab results are received to the front office fax and are checked multiple times daily by nursing staff; -The physician is to be notified in a timely manner of any abnormal lab results by the charge nurse. MO00239092 41559

Based on observation, interview, and record review, the facility failed to use appropriate infection control measures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants when staff failed to provide a clean barrier for supplies, failed to appropriately wash hands, and failed to appropriately utilize personal protective equipment for one resident (Resident #2) during wound care and one resident (Resident #3) during blood sugar checks and insulin administration. The facility census was 94. 1. Review of the facility's policy and procedure for Wound Care and Treatment, dated March 2015, showed the following: -Medications should be for one designated resident only except for large volume liquids. These may be poured into a cup to take to the bedside; -Set-up supplies on a clean surface at bedside. Cover the surface with a clean, impervious barrier prior to setting supplies down. Supplies are never placed on the bed. -Place soiled scissors on one corner of the setup, not touching any other supplies. -Clean scissors with 60 seconds of contact with alcohol and place on clean corner of setup. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included diabetes mellitus (condition where blood sugar is too high), cerebrovascular accident (damage to the brain due to interruption of blood supply), right sided hemiplegia (paralysis), and high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/13/24, showed the following: -Difficulty communicating; -Total dependence for mobility, transfers, toileting, and dressing; -Required moderate staff assistance with eating; -Resident had a pressure ulcer. Review of the resident's July 2024 Physician Order Sheet (POS) showed an order, dated 07/11/24, to clean left ischial (rounded bone that extends from the curved bone that makes up the bottom of the pelvis) wound with wound cleanser, pat dry, apply medifil 11 particles (wound dressing) 1/4 thick to wound surface (do not pack tightly; allow for expansion of particles) cover with non-adherent dressing and then foam dressing every three days and as needed. Review of the resident's care plan, dated 07/18/24, showed the following: -Resident has an open area on his/her buttocks. -Staff should ensure good infection control measures and personal protective equipment (PPE) are used with resident. -Resident had history of pressure ulcers and is at risk for additional skin impairments. Observation on 07/22/24, at 10:32 A.M., showed the following: -Licensed Practical Nurse (LPN) B obtained supplies from the treatment cart and entered the resident's room to provide wound care. -LPN B placed the wound care supplies, including wound cleanser bottle, bandage, gauze, wound medication, and scissors, on resident's bed without a barrier (possibly contaminating supplies or resident's bed with infectious organisms). -LPN B washed his/her hands and placed gloves. The LPN did not don a gown. -The LPN provided wound care to resident and then removed his/her gloves and picked supplies up from the bed and placed them on resident's dresser. -LPN B washed hands and then picked supplies up from the dresser and placed wound cleanser and scissors on top of treatment cart without cleaning them (possibly contaminating treatment cart or other residents with infectious organisms). -LPN B then pushed treatment cart to the nurses' station and walked away leaving scissors and wound cleanser on top of cart. 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included diabetes mellitus, chronic kidney disease (gradual loss of kidney function), and congestive heart failure (CHF - condition where heart doesn't pump blood as well as it should). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required substantial to maximum staff assistance with dressing, transfers, and bed mobility; -Required moderate staff assistance with eating; -Received insulin injections. Review of the resident's care plan, dated 07/11/24, showed staff did not care plan related to the resident's diabetes diagnosis. Review of the resident's July 2024 POS showed the following: -An order, dated 04/15/24, for accucheck (machine used to check blood sugar level) three times a day before meals; -An order, dated 06/18/24, for Novolog Flex Pen insulin (medication used to lower blood sugar) per sliding scale. If blood sugar was less than 70 milligrams/deciliter (mg/dL) call the physician; if blood sugar was 120 mg/dL to 160 mg/dL, give one unit of insulin; if blood sugar was 161 mg/dL to 200 mg/dL, give two units of insulin; if blood sugar was 201 mg/dL to 240 mg/dL, give three units of insulin; if blood sugar is 241 mg/dL to 280 mg/dL, give four units of insulin; if blood sugar is 281 mg/dL to 320 mg/dL, give five units of insulin; if blood sugar was 321 mg/dL to 360 mg/dL, give six units of insulin; if blood sugar was greater than 360 mg/dL, call physician. Observation of blood glucose testing and medication administration on 07/22/24, at 10:53 A.M., showed the following: -LPN G prepared the resident's supplies for a blood glucose reading at the medication cart located at the nurses' station. -The LPN entered the resident's room after he/she applied gloves and gathered supplies. The LPN placed all supplies on the resident's blanket (potentially contaminating supplies and resident belongings). -The LPN pierced the resident's finger with a lancet and placed the used lancet on the resident's bed. The LPN applied blood to test strip. The LPN placed the glucometer (machine used to test blood sugar) with test strip inserted on the resident's bed. -The LPN covered resident, gathered supplies from bed, turned room light off, and walked to the nurses' station while wearing used gloves. -LPN G placed the glucometer and a test strip containing blood on the medication cart without a barrier (potentially allowing the cart to encounter infectious organisms). -The LPN removed his/her used gloves, sanitized his/her hands, and cleaned the glucometer. The LPN did not clean the medication cart where the used glucometer was placed. -The LPN checked orders for insulin and obtained and prepared the resident's insulin pen from the medication cart. -The LPN entered the resident's room with gloves on and placed the insulin pen on the bed (causing possible contamination of resident belongings or medication). The LPN administered the medication and placed the pen down on the resident's bedding. -LPN G covered resident and gathered used pen from bed, turned off the room light and walked to nurse station while wearing used gloves. The LPN obtained medication cart keys from his/her pocket, unlocked the medication cart, opened the drawer, and obtained an alcohol wipe with used gloves on. LPN G cleansed the insulin pen with the alcohol wipe, removed a clean glucometer from a cup on cart, and placed insulin pen and glucometer in the cart drawer while still wearing the same gloves used for resident care. (LPN G's used gloves had possibly contaminated all items touched after leaving the residents room with infectious organisms.) -The nurse then removed gloves and went to wash hands. 3. During an interview on 07/22/24, at 1:35 P.M., LPN B said the following: -Staff should place wound care supplies on a clean table in resident room; -He/She used a barrier for wound supplies sometimes; -He/She did not think of using a barrier while providing wound care on Resident #2; -Nurses should clean scissors between resident care; -He/She did not think to clean scissors with Resident #2, but cleaned them later; -Staff should dispose of used gloves and wash hands prior to leaving resident room. 4. During an interview on 07/22/24, at 2:19 P.M., LPN A said the following: -Nurses should place wound care supplies and glucometer on a barrier in resident rooms; -He/She would not place any supplies down on a resident bed; -Staff should clean scissors with a bleach wipe between residents; -Staff should not wear gloves out of room after resident care. 5. During an interview on 07/22/24, at 3:00 P.M., the Assistant Director of Nursing (ADON) said the following: -Supplies should be on a clean bedside table or field and not placed on a resident bed; -Staff should sanitize supplies used by multiple residents before and after use; -Staff should dispose of used gloves and perform hand hygiene; -Staff should not wear used gloves out of resident room. 6. During an interview on 07/22/24, at 3:00 P.M., the Director of Nursing (DON) said the following: -It is not acceptable to place supplies on a resident's bed; -Staff should disinfect supplies used by multiple residents. 7. During an interview on 07/24/24, at 12:32 P.M., the Administrator said the following: -Staff are expected to follow appropriate infection control procedures; -He was unsure of the specifics; -The ADON is in charge of infection prevention. MO00239092 41559

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination when staff stacked clean dishware inside one another trapping moisture; the facility failed to keep dented cans separate from other canned goods; and failed to ensure dry food containers were properly sealed. This could potentially affect all the residents. The facility census was 82. 1. Review of the facility's policy titled, Dishwashing, by Nutrition and Dining Services Manual, dated May 2015, showed the following information: -Rack dishes and trays in appropriate rack; -Rack cups, bowls, and glasses upside down; -Allow items thoroughly dry before unloading racks or storing items. Review of the 1999 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observation on 03/11/24, beginning at 8:42 A.M., showed two small metal steam table pans stacked on each other with water droplets trapped inside. Observation on 03/12/24, at approximately 1:00 P.M showed the following: -Four small metal pans for the steam table stacked on one another with water droplets trapped between pans; -Five large metal pans for the steam table stacked on one another with water droplets trapped between pans -Sixteen small plastic dessert cups stacked on one another with water droplets trapped between cups; -Eleven plastic trays stacked on one another with water droplets trapped between trays; -Ten white ceramic plates stacked on one another with water droplets trapped between plates; -Five small ceramic bowls stacked on one another with water droplets trapped between bowls. During an interview on 03/14/24, at approximately 1:35 P.M., Dishwasher M said he/she was not aware that dishes could not be stacked while wet and said that is how he/she has always done this. During an interview on 03/14/24, at approximately 1:40 P.M., Dietary Aide (DA) N said he/she said he/she was not aware that dishes could not be stacked wet. During an interview on 03/14/24, at approximately 1:55 P.M., Cook P said the following: -He/she did not know the dishes were being stacked while they were still wet; -If he/she had been aware, he/she would have made sure this was not happening. During an interview on 03/14/24, at approximately 4:45 P.M., the Administrator said the following: -Dishes should be air dried; -Once the dishes have air dried, they can be stacked. 2. Review of the facility's policy titled, Storage of Dry Food and Supplies, by Nutrition and Dining Services Manual, dated May 2015, showed severely dented, rusted, leaking, and bulging cans must be placed in a separate, labeled holding area for return to the distributor. Review of the 1999 Food Code, issued by the FDA, showed the following information: -Food packages should be in good condition and protect the integrity of the contents so the food is not exposed to potential contamination. -Food held for credit, such as damaged products, should be segregated and held in an area separate from other food storage. -Food packages that are damaged, spoiled or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods and should be kept in separate and segregated areas. -Damaged packaging may allow the entry of bacteria or other contaminants into the contained food. Observation on 03/11/24, beginning at 8:42 A.M., showed the following canned good items to be dented or to have a compromised seal: -A 6.5 pound can of diced peaches; -A 6.8 pound can of fancy shredded sauerkraut. During an interview on 03/14/24, at approximately 1: 45 P.M., DA O said the following: -The kitchen does not keep any canned food that has dents and showed where the dented cans belong; -He/she was not aware of the two dented cans on the shelf. During an interview on 03/14/24, at approximately 1:55 P.M., Cook P said the following: -All dented cans should be separated away from the good cans; -He/she not aware of any dented cans not separated because staff are good about this. During an interview on 03/14/24, at approximately 4:45 P.M., the Administrator said dented cans should be separated and sent back to the supplier. Dented cans should not be mixed in with the canned food that was going to be consumed. 3. Review of the facility's policy titled, Storage of Dry Food and Supplies, by Nutrition and Dining Services Manual, dated May 2015, showed the following information: -Metal or plastic containers with tight fitting covers, labeled top or side, must be used for storing opened products; -Open boxes are to be effectively re-sealed; -Bulk crackers, cereal, cookies, pasta, etc. are to be stored and properly labeled in sealed containers. Observation on 03/11/24, beginning at 8:42 A.M., showed the following bags of dry food items not in any containers with bags open and exposed to the air: -One 20 pound bag of panko breadcrumbs; -One 20 pound bag of yellow corn meal; -One 50 pound bag of pinto beans. During an interview on 03/14/24, at approximately 1: 45 P.M., DA O said the following: -He/she was not aware of the bags of open food; -He/she said they should be closed up properly. During an interview on 03/14/24, at approximately 1:55 P.M., Cook P said the following: -He/she thought all of the dry food items were stored properly and had not realized there were open bags; -He/she said the bags should have been put into large plastic containers. During an interview on 03/14/24, at approximately 4:45 P.M., the Administrator said the following: -Dry food should be stored in a closed tight and sealed container; -Items found open during observations should have been sealed properly.

Based on observation, interview, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as possible when staff failed to care plan transfer method and failed to obtain therapy's assessment and recommendations of how to safely transfer one resident (Resident #1) who was non-weight bearing and when staff failed to ensure access to smoking materials were limited to residents assessed able to keep them when two residents (Resident #36 and #66) kept smoking materials in an unsecured manner. The facility census was 82. 1. Review of a facility policy entitled Transfer Activities (Nursing Guidelines Manual, March 2015) showed the following: -Purpose to transfer the resident from bed to chair, toilet or tub safely; -Obtain assistance of another individual if necessary for safe transfer; -Depending upon the amount of assistance required, the nurse may either support the resident on his/her affected side or stand in front of the resident. Support may be provided by use of a waist belt; -Do not support the resident under the arms as this prevents the resident from using his/her unaffected extremity. Do not allow resident to put arms around your neck; -If resident is unable place resident in sitting position. Place yourself with your legs apart and your knees flexed, facing the resident; grasp the resident around the waist, supporting his/her back. Assist to a standing position by straightening you knees and supporting the resident's knees inside your knees; step toward the chair, supporting the resident in the same manner, until resident is positioned in front of the chair. Review of Resident #1's face sheet (gives basic profile information) showed the following information: -admitted [DATE]; -Diagnoses included cerebral palsy (a group of conditions that affect movement and posture), muscle weakness, muscle wasting and atrophy (partial or complete wasting away of a part of the body), and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 12/19/23, showed the following information: -Severely impaired cognition; -Dependent on another person for mobility using a wheelchair, personal hygiene/showers, activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting), dressing, movement from lying to sitting on the side of the bed, and transfers from bed/chair; -Required assistance to roll from side to side and to move from sitting to lying down. Record review of the resident's care plan on 03/13/24 showed the care plan did not address how staff should transfer the resident safely. Observation on 03/13/24, at 11:25 A.M., showed the resident lay on his/her bed, yelling out. and crying. Certified Nurse Aide (CNA) A said the resident had just been changed and redressed. CNA A assisted the resident to sit up on the side of the bed. The resident's feet did not reach the floor. CNA A told the resident that he/she was going to transfer the resident over to his/her wheelchair for lunch. The CNA A said the resident was not able to stand and the resident refused to allow staff to put a gait transfer belt on him/her and said, We just do it like this. CNA A faced the resident and leaned over toward the resident, instructing the resident to put his/her arms around the CNA's neck. The resident did so. The CNA held the resident around the waist, picked him/her up, turned and placed the resident in the wheelchair. The resident then stopped crying. The resident's feet did not touch the floor during the transfer. CNA A said, We get it done quickly, because he/she hates to be touched. Observation on 03/14/24, at 11:30 A.M., showed the resident lay on his/her bed, crying. CNA A assisted the resident to sit up on the side of the bed. The resident's feet did not reach the floor. CNA A told the resident that he/she was going to transfer the resident over to his/her wheelchair for lunch. CNA B stood on the opposite side of the resident's bed, several feet away from the bed, and did not touch the resident. CNA A faced the resident and leaned over toward him/her. The resident put his/her arms around the CNA's neck to hold onto the CNA. CNA A put his/her arms around the resident's waist, picked him/her up, turned and placed the resident in the wheelchair. The resident then stopped crying. The resident's feet did not touch the floor during the transfer. Review of the resident's care plan,updated 03/13/24, showed the following: -Start date 03/13/24 for resident does not tolerate a gait belt being used for transfers. He/she is a one person assist for transfers. -Resident will be safely transferred without the use of a gait belt. -Staff will transfer resident without a gait belt. If staff does not feel safe transferring with one assist, they will get a second staff member to assist with the transfer. During an interview on 03/14/24, at 1:05 P.M., Certified Occupational Therapy Assistant (COTA) C and the Director of Therapy Services said the following: -Staff nurses would request an evaluation on admission or if a resident had a fall or other changes. -They would assess the resident and make recommendations for restorative therapy or for transfer abilities. -Both staff said a resident must be able to bear weight in order to do a gait belt assist to transfer; otherwise, the resident should be transferred using a Hoyer (mechanical) lift. -F a resident won't tolerate the lift or gait belt, staff should request an evaluation and recommendations by the therapy department. -Neither COTA A nor Director of Therapy Services had been asked to assess the resident. They were not aware of how staff was transferring the resident and said one staff picking up the resident was probably not safe. During an interview on 03/13/24, at 11:37 A.M., CNA B said he/she transferred the resident just like CNA A just did; the resident puts his/her arms around my neck, facing me, and I lift her from bed to the shower chair and back. CNA B said the resident cannot bear weight on his/her legs. During an interview on 03/14/24, at 3:18 P.M., Certified Medication Technician (CMT) D said the facility started a new mini care plan that is posted on each resident's closet door. It shows basic assist needs, including how they transfer. CMT D did not know how staff transferred the resident. During an interview and observation, in the resident's room on 03/14/24, at 3:25 P.M., CNA E said he/she transferred the resident by having the resident put his/her arms around the CNA's neck. The CNA then picked up the resident and put him/her in the wheelchair or back to bed. CNA E sometimes staff pick up the resident from the side, cradling him/her with one arm under the resident's back and one arm under the knees. Then they lift the resident from bed to chair or back to the bed. CNA E pointed out the new mini care plan on the outside of the resident's closet door. The form contained a line marked Transfers, which had been written as one person assist, without clarification on the procedure. During an interview on 03/14/24, at 3:29 P.M., with Registered Nurse (RN) F and Licensed Practical Nurse (LPN) G, the RN said the facility just started new summary care plans that week that are posted on the front of the residents' closet doors showing assist needs and how the resident transfers. RN F and LPN G both said on admission the nurse assesses the resident to determine their transfer ability and assist needs. If the resident's status changes at any point, the nurse can ask the therapy department to evaluate the resident and write a recommendation regarding mobility and transfers. LPN G said the resident is a one person transfer without a gait belt. The resident holds on around the CNA's neck, and the CNA picks up the resident and moves him/her. If the resident is unfamiliar with a staff member, he/she gets more upset, so they use two people (one whom the resident knows) for the transfer. RN F and LPN G did not know if therapy had ever evaluated the resident or given a recommendation regarding transfers. RN F said the resident cannot bear weight on her legs. They just do a bear hug lift to transfer the resident. During an interview on 03/14/24, at 4:40 P.M., with the Administrator and the Director of Nursing (DON), the DON said the facility recently started posting brief care plans on the residents' closet doors showing staff the residents' basic care and assist needs. If the aides note a change in a resident's mobility or transfer ability, they should tell the nurse. The nurse will request a therapy evaluation and recommendations. If a resident is not able to bear weight on their legs, staff should use a Hoyer lift or a slide board for transfers. If the resident will not allow the mechanical lift, staff should use a gait belt if it is tolerated. The resident likes to grab around the aide's neck and hang on while they lift him/her, because it makes her feel safe. The Administrator and DON were unsure whether or not therapy was involved. Someone besides the aides should make the determination on how to transfer a resident. Therapy should be involved in an assessment and care planning for transfers. The DON said the resident's care plan, updated yesterday, showed the resident's intolerance of gait belt use and specifies a one person assist and two if a staff doesn't feel safe. 50185 2. Review of the facility's smoking policy, dated March 2015, showed the following information: -Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate smoking preferences; -Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues; -The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision; -Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking according to the facility smoking schedule; -The staff will review the status of a resident's smoking privileges periodically and consult as needed with the DON and the attending physician; -Independent smokers shall be permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. Residents may only keep disposable safety lighters. All other forms of lighters, including matches shall be prohibited; -Residents with independent smoking privileges may not give smoking articles to other residents with restricted smoking privileges; - Residents without independent smoking privileges may not have of keep any types of smoking articles, including cigarettes, tobacco, etc. except when they are under direct supervision. -The facility may check periodically to determine if the residents have any smoking articles in violation of smoking policies. Staff shall confiscate any such articles and shall notify the charge nurse. (The facility policy did not address how to ensure smoking supplies were secured from other residents not deemed as safe to have access to cigarette supplies.) 3. Review of Resident #36's annual MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Staff indicated the resident used tobacco at that time. Review of the resident's smoking risk assessment, dated 02/13/24, showed the following information; -Resident smokes cigarettes hourly; -No problem smoking in unauthorized areas; -No problem with carelessness of smoking supplies; -No problem smoking cigarettes from ash trays; -No problem inappropriately providing smoking materials to others; -No problem with begging or stealing smoking materials from others; -No problem with general awareness and orientation; -No problem with general behavior and interpersonal interaction; -Ambulates with minimal problem using rollator walker; -No problem with capability to follow safe smoking guidelines; -Assessed as safe smoker- follow facility policy. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -The resident used a walker; -Independent with mobility. -Staff did not indicate the resident's tobacco use status. Review of the resident's care plan, last revised on 03/07/24, showed the following information: -Resident currently smokes cigarettes independently; -The resident has a history of running out of cigarettes and having no more money to buy more; -He/She tries to bum or buy cigarettes from peers/staff and/or borrow money to purchase more cigarettes; -Smoking times have changed to no smoking between 10:00 P.M. to 6:00 A.M. If not following times, notify charge nurse; -Educate the resident that he/she should not ask staff/peers to use their own money to purchase his/her cigarettes and suggest that he/she do a better job at watching his/her consumption throughout the month, so the resident does not run out; - Explain to the resident where designated smoking areas are located. Remind as needed. Observation and interview, on 03/14/24, showed the following: -At 8:39 A.M., the resident lay in bed, resting with eyes closed, facing away from his/her walker. One pack of cigarettes and disposable lighter lay on top of the resident's rollator walker; -At 11:18 A.M., the resident lay in bed awake. One pack of cigarettes and disposable lighter continue to be in same placement (on top of walker); -At 12:41 P.M., the resident left his/her room using the rollator walker. The pack of cigarettes and disposable lighter continue to lay on top of walker. The resident said about four to five residents smoke. All of them can go out independently. Staff does not accompany them at this time. If a resident is physically and mentally able, they can go alone. The facility is strict about their smoking rules. During an interview on 03/14/24, at 8:55 A.M. Certified Nursing Assistant (CNA) Q said the resident smokes independently. During an interview on 03/14/24, at 9:24 A.M., CMT R said the resident is independent with smoking. The resident was supervised when he/she came back from last emergency room visit due to being in a wheelchair, and not being able to get out the door on his/her own. 4. Review of Resident #66's face sheet showed the following: -Most recent admitted [DATE]; -Diagnoses included unspecified dementia (a set of symptoms that over time can affect memory, problem-solving, language and behavior) and chronic obstructive pulmonary disease (COPD - persistent respiratory symptoms like progressive breathlessness and cough), and acute respiratory disease (shortness of breath, wheezing, spasm, persistent cough, blood in sputum affecting the lungs, bronchus and respiration). Review of the resident's annual MDS, dated [DATE], showed the following: -Diagnosis of anxiety; -Cognitively intact; -Current tobacco user Review of the resident's smoking assessment, dated 03/01/24, showed the following: -Resident smokes cigarettes; -Resident smokes hourly; -Smoking in unauthorized area is marked as a minimal problem; -Careless while smoking is marked as a minimal problem; -Smokes cigarettes from ash trays marked as no problem; -Begs or steals smoking materials from others is marked as no problem; -General awareness and orientation/ability to understand safe smoking requirements is marked as a minimal problem; -General behavior and interpersonal interaction shows no problem; -Mobility is marked as a minimal problem; -Capability to follow facility safe smoking guidelines is marked as a minimal problem; -Assessed as safe smoker - follow facility policy. Review of the resident's care plan, last revised 03/06/24, showed the following: -Resident is currently a smoker; -Resident is found to be safe and independent with smoking; -Resident is able to keep smoking materials with him/her. Observation and interview on 03/13/24, at 2:10 P.M., showed the following: -Resident laying down, flat on his/her back with his/her arms folded behind his/her head and wearing glasses; -Two packs of cigarettes and a lighter laying on the bedside table; -He/she said he/she was going to try to take a nap; -He/she said he/she is able to go out to smoke at any time and it's whenever he/she feels like having a cigarette; -He/she said some people have certain times they can go out because they need staff to help them; -He/she keeps his/her own cigarettes and lighters at all times; -These are kept on his/her bedside table. Observation on 03/13/24, at approximately 3:35 P.M., showed the following: -The resident was seen sleeping, facing the wall and his/her back was towards the door; -A pack of cigarettes and a lighter were lying on the bedside table. 5. During an interview on 03/14/24, at 8:55 A.M. CNA Q said there were smoke times when he/she first started working at the facility. Residents were on restriction at first. Now, all residents are independently smoking. Residents must know the code to the door and be able roll/walk themselves out to the smoking area and get back in independently. Everyone on his/her hall has had an assessment showing they are safe to smoke independently. Nurses keep cigarettes and lighters. The residents must ask the nurse for supplies when they are ready to go out. Residents receive two cigarettes every time they go out to smoke. Supplies should not be kept in the resident rooms. During an interview on 03/14/24, at 9:24 A.M., CMT R said he/she believes the process for smoking is having scheduled smoke breaks. Most smokers are with it. They are allowed to go out as they want. For the residents that require supervision, the staff will stay with them while they smoke. They also stayed with the residents during the COVID outbreak and during the cold part of winter. If residents are independent, they keep their own supplies with them. They usually keep the smoking supplies on their walkers. Supervised smokers have the nurse keep smoking supplies in the nurses' cart. When it's time to smoke, the staff accompanying the resident obtains the supplies from the nurse and staff goes with the resident to smoke. Nurses let him/her know if a resident is supervised smoking or independent. The criteria to be independent with smoking is the resident has gotta be with it and able to take themselves in and out of the building. During an interview on 03/14/24, at 2:09 P.M. CNA S said there is one resident on C-hall that wanders throughout the facility, including into other residents' rooms. During an interview on 03/14/24, at 2:09 P.M. CMT D said there are a couple residents that do wander throughout the facility and into other residents' rooms. During an interview on 03/13/24, at 2:20 P.M., LPN H, said the following; -Residents can go out to smoke any time they choose, unless they have to be supervised; -If the resident is supervised, they would have to go to the charge nurse and they will be given their cigarettes and lighter. During an interview on 03/14/24, at 2:45 P.M., RN F said all smokers are currently independent smokers and they are allowed to have their supplies. Residents can go out whenever they want unless it's below freezing or too hot. Upon admission, if a resident is a smoker, they go through a period of supervised smoking until they prove themselves as capable of smoking independently. Nursing staff does the smoking risk assessments to determine if they should be independent or not. Supervised smokers cannot keep their supplies in their room. The charge nurse keeps them in the medication cart. The residents have designated smoking times and assigned staff to take them for smoking. The staff will come and get their supplies and take the residents out. There are residents that wander the facility and into other rooms. He/She is not sure how the facility ensures that the wandering residents do not gain access to the smokers' supplies. One resident is known for wandering into other resident rooms and has been accused of stealing items such as sunglasses, but he/she is not sure if the accusation is true. During an interview on 03/14/24, at 4:26 P.M., with the Administrator and DON, the DON said the process for smokers is to complete an assessment upon admission, which determines if the residents are safe to smoke independently safely. The facility also completes this assessment if there is a change of condition, or any rules have been broken. Staff will revoke their independent privileges and make them supervised smokers in those cases. Independent smokers can smoke whenever they want, pending weather. Supervised smokers are to be accompanied when they smoke and only go out during certain times. Independent residents keep their own supplies themselves. Supervised residents must keep their supplies at the nursing stations and must request their supplies. Independent smokers usually keep their supplies on them, or inside their walkers. There are no residents that wander the facility, and smokers are also very protective of their supplies. 37358

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment for all residents and staff when the facility staff did not keep walls, baseboards, and vents clean in the kitchen area. The facility census was 82. 1. Observation on 03/11/24, beginning at 8:42 A.M., showed the following areas were dirty with grease, lint, and debris: -The walls and baseboards behind the ovens; -The baseboards underneath the metal, three-bin kitchen sink; -The space behind the ice machine, between the unit and wall; -The ceiling vents; -The ceiling air conditioning unit. During an interview on 03/14/24, at approximately 1:45 P.M., Dietary Aide O said he/she does do a lot of cleaning, but had not noticed the baseboards or up high like any of the ceiling vents or on the air conditioner. During an interview on 03/14/24, at approximately 1:55 P.M., Cook P said the following: -The baseboards, air conditioner, and ceiling vents, should be cleaned on a regular basis; -He/she said it has been done before, but it had been a long time; -He/she said it is difficult to move the heavy equipment out to get to those areas. During an interview on 03/14/24, at approximately 4:45 P.M., the Administrator said the following: -Kitchen staff are all responsible for cleaning: -Staff should be following a cleaning schedule; -The Dietary Manager is responsible for overseeing the cleaning task; -Staff should be doing the cleaning of all areas they can reach; -Maintenance is responsible for cleaning the ceiling vents and air conditioning unit.

Based on record review and interview, the facility failed to complete a comprehensive and individualized care plan, including interventions, to address the use of antianxiety medications for one resident (Resident #56) and receipt of hospice services for one resident (Resident #89). The facility had a census of 82. Review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed the following: -The interdisciplinary care plan team, with input from the resident, family, and/or legal representative. will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff); -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred, at least quarterly or when changes occur that impact the resident's care. 1. Review of Resident #56's face sheet (a general information sheet) showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia (a set of symptoms that over time can affect memory, problem-solving, language and behavior), psychotic and mood disturbance (disorders-a group of illnesses affecting thinking, communicating, understanding and behaviors), and anxiety (a feeling of worry, nervousness or unease). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included anxiety; -Resident had severely impaired cognition. Review of the resident's March 2024 Physician Order Sheet (POS) showed the following: -An order, dated 12/14/23, for buspirone (an antianxiety medication) 10 milligrams (mg), one tablet by mouth at bedtime; -An order, dated 12/14/23, for buspirone 5 mg, one tablet by mouth, once a day, scheduled at 8:00 A.M. Review of resident's progress notes showed the following: -On 02/20/24, at 2:09 P.M., the resident's Nurse Practitioner (NP) reviewed resident's medication record and verified continuation of current orders for psychotropic medications with dose reduction clinically contraindicated without improvement in anxiety, behaviors, and insomnia or current therapy. The dose reduction may cause destabilization and exacerbation of symptoms with decline in function. Resident to continue Buspar (buspirone) 5 mg by mouth every morning, and Buspar 10 mg by mouth daily at bedtime. -On 03/07/24, at 10:27 A.M., received new order to increase buspirone to 7.5 mg by mouth daily at 8:00 am due to dementia with agitation; Review of resident's March 2024 POS showed the following orders: -An order, dated 03/07/24, for buspirone 7.5 mg, one tablet by mouth, once a day at 8:00 A.M. Review of resident's progress notes showed the following: -On 03/08/24, at 10:19 A.M., psychotic medication change made to increase 8:00 A.M. buspirone to 7.5 mg daily; -On 03/10/24, at 3:54 A.M., change of dosage continued to be monitored with no behaviors noted. Review of the resident's current care plan, last revised on 03/11/24, showed staff did not address the resident's use of psychotropic medications. During an interview on 03/14/24, at 4:40 P.M., the Director of Nursing (DON) the use of psychotropic medications should be care planned. 2. Review of Resident #89's face sheet showed the following: -Most recent admitted [DATE]; -Diagnoses included anxiety, type II diabetes mellitus (diabetes characterized by high blood sugar, insulin resistance, and a lack of insulin, occurring when cells resist the normal effect of insulin), acute/chronic respiratory failure (difficulty to breathe on own) with hypoxia (deficiency in the amount of oxygen reaching tissues), hypertension (high blood pressure)and disorientation (losing one's sense of direction). Review of resident's progress note dated 02/24/24, at 2:19 P.M., showed hospice present for admission to the services and obtain permission from family for continuity of care. Review of resident's significant change MDS, dated [DATE], showed hospice care had been added. Review of resident's February 2024 POS showed an order, dated 02/26/24, for hospice evaluation and services. Review of the resident's current care plan showed staff did not address hospice services on the resident's care plan. During an interview on 03/14/24, at 4:40 P.M., the DON said the resident's care plan should have included hospice services. During an interview on 03/14/24, at 4:50 P.M., the Administrator said hospice evaluations hospice will evaluate a resident and then the MDS/Care Plan Coordinator will add it to the care plan. 3. During an interview on 03/13/24, at 10:28 A.M., the MDS/Care Plan Coordinator said the following: -He/she had been working at the facility since October 2023; -He/she was trained until February 2024 and then took over the MDS duties; -He/she had not done care plans until this past week; -He/she thinks the person who trained him/her had not done the care plans either; -He/she was told by the one training him/her that nurses do the care plans; -He/she just realized in the past week or two that he/she was supposed to be doing them. 4. During an interview on 03/14/24, at 4:40 P.M., the DON said the following: -The MDS/Care Plan Coordinator is responsible for adding information to the care plans; -He/she would expect to see concerns like behaviors and hospice to be care planned; -Nurses do not enter information on the care plan; -If something new comes up, a change in condition, the nurses communicate with the MDS/Care Plan Coordinator. 5. During an interview on 03/14/24, at 4:50 P.M., the Administrator said the following: -The MDS Coordinator would be the one to add anything to care plans; -Corporate came and trained the MDS/Care Plan Coordinator for a week and every couple of weeks since then; -This would include any significant changes like behaviors or hospice.

Based on observation, interview, and record review, the facility staff failed provide care per standards of practice when staff failed to obtain a physician's order for hospice and update the resident's care plan to reflect admission to hospice for one resident (Resident # 6). The facility census was 82. Review of the facility's policy titled, Physician's Orders, dated March 2015, showed the following: -Physician's orders must be signed by the physician and dated when such order was signed; -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors. Review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed the following: -The interdisciplinary care plan team, with input from the resident, family, and/or legal representative, will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred, at least quarterly or when changes occur that impact the resident's care. 1. Review of Resident #6's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/07/24, showed an admitted [DATE]. Review of the resident's face sheet showed the resident was admitted to hospice on 08/02/23. Review of the resident's current Physician Order Sheet showed staff did not document an order for hospice services. Review of the resident's care plan, updated on 03/11/24, showed staff did not address the resident receiving hospice services. During an interview on 03/14/24, at 9:45 A.M., Licensed Practical Nurse (LPN) H said the following: -Nurses add orders when received from the doctor; -Residents require an order for hospice; -He/she looked in the electronic record and found on the resident's face sheet that indicated the resident was on hospice, but he/she could not locate an order for hospice; -He/she said the resident should have an order since the resident is on hospice; -He/she knows hospice would be included on a resident's care plan and should be listed on the resident's care plan. During an interview on 03/14/24, at 9:55 A.M., Certified Med Tech (CMT) I said the following: -If a resident is on hospice, he/she doesn't believe they need an order; -The resident is on hospice; -The resident's care plans are located in their closets and in the electronic health records (EHR); -He/she doesn't know if the care plan would list whether a resident is on hospice. During an interview on 03/14/24, at 10:05 A.M., Certified Nurse Aide (CNA) J said the following: -He/she can see some of the resident's care plan on the EHR; -When a resident is on hospice, it's listed on their care plan; -The resident is on hospice so this should be on his/her care plan. During an interview on 03/14/24, at 10:15 A.M., LPN K said the following: -Nurses receive the orders and the nurse that receives the order is responsible for putting that into the resident's EHR; -Residents on hospice should have an order in their records; -The resident is on hospice; -He/she looked in the resident's record and said the resident does not have a current order for hospice; -The resident should have an order for hospice; -He/she said the MDS Coordinator is responsible for care plans; -He/she doesn't know if hospice would be listed on the resident's care plan. During interviews on 03/14/24, at 10:22 A.M., 10:30 A.M., and 3:30 P.M., the MDS Coordinator said the following: -He/she knows now that he/she is responsible for completing and updating the care plans; -He/she was told in the beginning that the nurses are doing the care plans; -He/she is told by the nurses or morning meetings when there needs to be updates to care plans; -Resident's should have an order for hospice services; -Hospice should be included on the resident's care plan. During an interview on 03/14/24, at 4:46 P.M., the Administrator and Director of Nursing (DON), said the following: -Care plans are in the resident's closets; -Staff are asked about input for resident care plans; -Nurses do not enter care plans, they communication with the MDS Coordinator, and he/she looks over notes every day and go over these in the morning meeting; -Hospice should be listed on the care plan; -MDS Coordinator is responsible for completing the care plans.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with standards of practice when the facility failed to have a physician's diagnosis for continuous positive airway pressure (CPAP - machine that uses mild air pressure to keep breathing airways open while one sleeps) and failed to address the CPAP on the care plan or on the Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) for one resident (Resident#83). The facility had a census of 82. Review of the facility's policy titled, MDS and Care Planning Guidelines, dated 10/01/15, showed the following information: -It is the policy of the facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) Manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the facility's titled Continuous Pressure Airway Pressure (CPAP) Administration, undated, showed the following information: -Purpose to administer continuous airway pressure to maintain open airway to the resident with obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep) or respiratory problems when sleeping. (The policy did not address the need for a diagnosis for CPAP use, the need to care plan CPAP use and care, or addressing the CPAP use on the resident's MDS.) 1. Review of Resident #83's face sheet (a brief information sheet about the resident) showed the following information: -admitted [DATE]; -Diagnosis included Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance, and allergic rhinitis (inflammation (redness and swelling) of the inside of the nose). (Staff did not list a diagnosis related to obstructive sleep apnea or CPAP use.) Review of the resident's admission MDS, dated [DATE], showed staff did not indicate CPAP use by the resident on admission or while a resident. Review of the resident's Physician Order Sheet (POS), current as of 03/14/24, showed the following: -An order, dated 01/05/24, to apply CPAP at 4 cmH2O (pressure most commonly used to measure breathing on respirators) via nose mask every night at bedtime for sleep apnea. Review of the resident's nursing progress notes showed staff the following: -On 01/05/24, at 3:15 P.M., the resident had new tubing for CPAP. Staff spoke with the provider about the settings and provider informed this nurse to leave current setting and if needed verify setting with family. The resident was admitted to the facility with CPAP and used it every night per family. The family did not remember the setting. Currently setting was at 4 cmH2O. New order received to apply CPAP at 4 cmH2O via nose mask every night for sleep apnea. Review of the resident's quarterly MDS, dated [DATE], showed staff did not list a diagnosis related to obstructive sleep apnea or CPAP use. Review of the resident's POS, current as of 03/14/24, showed an order, dated 03/01/24, to change CPAP tubing and mask every three months. Review of the resident's care plan, last reviewed 03/07/24, showed the following: -The resident had a diagnosis of insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep); -Staff should provide a quiet environment; -Staff should encourage the resident to stay up during the day and sleep at night; -The resident required assistance with activities of daily living (ADL's - dressing, grooming, bathing, eating, and toileting) tasks related to cognitive deficits, dementia, chronic pain, and weakness. (Staff did not care plan related to the resident's use of a CPAP, the care of the CPAP, or or sleep apnea diagnosis.) Observation of the resident's room showed the following: -On 03/11/24, at 9:30 A.M., a CPAP machine with mask and hose connected was setting on the bedside table at the head of the resident's bed; -On 03/13/24, at 1:30 P.M., a CPAP machine with mask and hose connected was setting on the bedside table at the head of the resident's bed. Review of the resident's Medication Administration Record (MAR), current as of 03/14/24, showed staff documented the following: -CPAP at bedtime as ordered; -Change of the tubing, filters, and mask as ordered; -No diagnosis listed on the MAR of sleep apnea. During an interview on 03/14/24, at 9:50 A.M., Certified Nurse Aide (CNA) L said that he/she is able to locate each resident's special needs on their care plan in the computer. He/she worked day shift and did not have any duties assigned to CPAP use for the resident. During an interview on 03/14/24, at 9:40 A.M., Licensed Practical Nurse (LPN) K said that all resident special equipment and individual needs will be located on the MAR and care plan, this would include CPAP. He/she did not know that the resident had a CPAP because the task does not pop up on the task list for his/her shift. He/she did not know if this information should be on the MDS. During an interview on 03/14/24, at 9:58 A.M., LPN H said that resident's individual needs and services should be on the care plan, including CPAP use. Anything in the care plan should have a diagnosis for that area of care. During an interview on 03/14/24, at 3:30 P.M., the MDS Coordinator said that all specialty items should be on resident care plans and MDS, including use of a CPAP. He/she did not know until this week during the survey that that CPAP used needed to be on the care plan. He/she did not know that the resident had a CPAP. During an interview on 03/14/24, at 4:46 P.M., the Administrator and Director of Nursing (DON), said the following: -CPAP use should be listed on the care plan; -CPAP use should have a corresponding diagnosis; -CPAP use should be on the MDS; -The MDS coordinator is responsible for completing the care plans.

Based on record review and interview, the facility failed to ensure that one resident's (Resident #17) with Post-Traumatic Stress Disorder (PTSD - disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) had his/her PTSD diagnosis listed in the medical record, failed to ensure the resident's PTSD was noted on the resident's care plan to include triggers and interventions, and failed to ensure staff were knowledgeable of the resident's history of PTSD. The facility census was 82. Record review of the facility assessment, updated December 2023, showed the following information: -Individualized care plans are developed for each resident to ensure each resident within the facility has their physical, mental, psychosocial, spiritual needs met. Review showed the facility did not provide a policy related to PTSD. Review of the facility's policy titled, MDS and Care Planning Guidelines, dated 10/01/15, showed the following information: -It is the policy of the facility to use the most current Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) Resident Assessment Instrument (RAI) Manual and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. 1. Review of Resident #17's face sheet (a brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with other behavioral disturbance, dysphagia (difficulty or discomfort in swallowing), repeated falls, overactive bladder (condition in which the bladder squeezes urine out at the wrong time), generalized anxiety disorder, and sleep apnea (sleep disorder in which breathing repeatedly stops and starts). (Staff did not list a diagnosis related to trauma or PTSD.) Review of the resident's electronic medical record showed an emergency room noted, dated 03/15/22, that included a PTSD diagnosis from 02/01/08. Review of the resident's initial admission assessment, dated 08/31/20, showed staff did not document regarding PTSD. Review of the resident's quarterly MDS, dated [DATE], showed staff did not list the a diagnosis of PTSD. Review of the resident's care plan, last reviewed 01/05/24, showed the following information: -Resident had behavioral symptoms and high anxiety; -Staff should redirect the resident as needed for nervousness, anxiety, and scared behavior; -Resident had experienced insomnia; -Staff should discourage daytime napping; -Staff should encourage resident to go to bed at the same time everyday and wake up at the same time everyday; -Resident had impaired decision making related to dementia; -Staff should encourage resident to verbalize feelings, concerns, and fears. (Staff did not address a diagnosis of PTSD, the resident's triggers, or interventions related to PTSD.) Review of the resident's physician progress notes, dated 02/07/24, showed the resident had a past medical history of PTSD. Review of the resident's annual MDS, dated [DATE], showed the resident's diagnoses included progressive neurological conditions, dementia, anxiety disorder, depression, and PTSD. Review of the facility provided Matrix (a form requested on survey entrance with brief details of resident care needs), completed on 03/11/24, showed the following staff identified the residents as having Alzheimer/dementia, using an anti-anxiety, anti-depressant, and anti-psychotic medications, had falls with injury and had PTSD. During an interview on 03/12/24, at 3:05 P.M., the Director of Nursing (DON) was not aware of the resident having a diagnosis of PTSD. During an interview on 03/14/24, at 9:40 A.M., Licensed Practical Nurse (LPN) K said that all resident special needs and cares should be on the care plan, including PTSD. He/she thought that PTSD would specifically have approaches needed for the resident in the care plan. He/she had received past in-services included special need training, dementia, and PTSD. He/she said that the resident's diagnosis list should accurately reflect the resident's medical history. He/she was not aware of any resident on the hall assigned with PTSD. He/she was not aware that the resident had PTSD. During an interview on 03/14/24, at 9:50 A.M., Certified Nurse Aide (CNA) L said that resident's individual needs are on resident care plan in the computer. He/she was not aware of any resident with PTSD on the assigned hall. He/she was not aware that the resident had PTSD. He/she said that staff can tell some residents have PTSD by signs they may exhibit. During an interview on 03/14/24, at 9:58 A.M., LPN H said that residents with PTSD will have a care area in their care plan and also there would be information on the computer face sheet under code status related to PTSD. He/she usually discusses resident symptoms/triggers with doctor for types of care needs. He/she said that PTSD should be in the care plan and on diagnosis list. He/she did not work with the resident and was not aware the resident had PTSD. During an interview on 03/14/24, at 11:41 A.M., the DON said that the MDS Coordinator found the PTSD diagnosis on the resident's past hospital records and from the recent provider note, dated 02/07/24, and placed it on the recent MDS. The MDS Coordinator was recently employed in that position and did not know the information should also be on the care plan. During an interview on 03/14/24, at 3:30 P.M., the MDS Coordinator PTSD should be included on the resident's care plan. He/she talks with staff and reviews medical records for the seven day look back period required for the MDS. He/she did not know that information was to be on the care plan until this week. During an interview on 03/14/24, at 4:46 P.M., the Administrator and DON, said the following: -PTSD should be listed on the resident's care plan; -There should be a diagnosis related to the PTSD for the resident; -The MDS coordinator is responsible for completing the care plans.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) included accurate nutritional and weight loss information for one resident (Resident #28). The facility census was 82. Review of the facility provided document titled, MDS and Care Planning Guidelines, dated 10/01/15, showed the following information: -It is the policy of the facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) Manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. 50237 1. Review of Resident #28's face sheet showed the following information: -admitted [DATE]; -Diagnoses included chronic kidney disease-stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of the body), Type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). Review of the resident's quarterly (and most recent) MDS, dated [DATE], showed the resident weighed 156 pounds with no significant weight loss identified. Review of the resident's weights showed the following: -On 12/11/23, the resident weighed 156 pounds; -On 01/01/24, the resident weighed 142 pounds (a 14 pound (8.97%) weight loss). Review of the resident's significant change MDS, dated [DATE], showed the following: -Staff documented the resident's weight as 142 pounds; -Staff did not identify significant weight loss present. Review of the resident's weights showed the following: -On 01/08/24, the resident weighed 140.2 pounds; -On 01/09/24, the resident weighed 140 pounds; -On 01/15/24, the resident weighed 137.4 pounds; -On 01/19/24, the resident weighed 136.2 pounds; -On 01/22/24, the resident weighed 134 pounds; -On 01/29/24, the resident weighed 134.2 pounds. Review of the Registered Dietitian's note dated 01/30/24, at 8:49 A.M., showed the resident's current weight as 134 pounds, a 5.5% loss in the last month, and an overall loss of 13% loss in the last 6 months. Review of the resident's care plan, reviewed/revised 03/07/24, showed monitor the resident's weight per physician order and as needed. The resident had recent abnormal weight loss due to not eating. During an interview on 03/14/24, at 3:30 P.M., the MDS Coordinator said she looks back on quarterly nutrition reports for weights. The Dietary Manager in the kitchen and the dietitian run reports that she uses when collecting information for the MDS. Restorative is responsible for obtaining weekly and monthly weights. He/she did a significant change MDS on 01/05/24 and agrees that the resident's weight was 142 pounds. During an interview on 03/14/24, at 4:26 P.M., with the Administrator and DON, they said if a resident has weight loss, it should be addressed in morning meetings. The facility has weekly weight loss meetings and they discuss weights in those meetings. The MDS Coordinator is present during those meetings. They have a weekly weight variance report they review. If a resident has a significant weight loss, it should be marked on the MDS. The resident has had a significant weight loss since December 2023/January 2024 and it should have been reflected on the MDS.

Based on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from verbal and physical abuse by staff when one staff (Certified Nursing Assistant (CNA) A) yelled at the resident and forcefully pushed the resident by the shoulders to sit down. The facility census was 103. Review of the facility policy titled Abuse Prohibition, dated November 2016, showed the following: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse; -Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Verbal abuse is defined as any use of oral, written, or body language that includes disparaging or derogatory terms to resident or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability; -Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlled behavior through corporal punishment. 1. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia, hypertension (high blood pressure), and atherosclerotic heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the wall of the arteries that supply blood to the heart). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/17/23, showed the following: -Severely cognitively impaired; -The resident was not steady. Resident only able to stabilize with human assistance with moving from seated to standing position, walking, turning around facing the opposite direction while walking, moving on and off the toilet, and surface to surface transfers. Review of the resident's care plan, last reviewed 07/07/23, showed the following: -Resident had behavioral symptoms, including becoming agitated/anxious/scared, with a history of physical aggression towards others; -Staff should attempt to improve resident's mood with conversing, pictures, snacks, nap/sleep, singing, activity, or hug is he/she will allow; -Staff should encourage attendance to group functions and if not, provide one-to-one interactions to enhance self-esteem, mood. Review of the facility investigation, completed on 07/29/2023, showed the following: -A statement provided by Licensed Practical Nurse (LPN) C showed that said on 07/29/23, at 2:30 P.M., CNA B reported that he/she observed CNA A slam the resident into his/her chair because the resident would not stay in the chair. He/she then observed the resident strike CNA A with a stuff animal causing CNA A's glasses to fall off. CNA was heard saying to the resident, Thanks for knocking my fucking glasses off, I hope they are not broken. The LPN reported the allegation of abuse to the Assistant Director of Nursing (ADON); -A statement provided by CNA B that showed the resident was standing up in the dining room on D hall and CNA A pushed his/her shoulders, forcing the resident to sit down. The resident swung a stuffed animal back at CNA A, knocking off his/her glasses. CNA A began to yell at the resident in his/her ear, Thanks a lot for hitting me and knocking off my freaking glasses. During an interview on 07/29/23, at 11:53 A.M., CNA A said the following: -On 07/28/2023, during shift change from day to evening, he/she was receiving report outside the dining room. The report included, the resident had been restless. Staff had attempted to put the resident in a Broda (a tilt-in-space positioning) chair, but it did not work and he/she was placed back in a regular wheelchair with a body alarm. He/she heard staff in the dining room telling the resident to sit down in his/her wheelchair because the resident kept trying to stand up. He/she went in the dining room and told the resident he/she needed to sit down and had his/her hands on the resident's shoulders. The resident did not sit down and swung at him/her a couple of times. He/she said he/she may have raised his/her voice more than he/she should while telling the resident to sit down. He/she was able to sit the resident down by pushing harder on the resident's shoulders than he/she should have pushed. The resident then hit CNA A in the face with a stuff animal and knocked his/her glass off. He/she then yelled at the resident something like, I don't need my freaking glasses broken He/she said his/her actions were somewhat abusive, and he/she should have walked away with the first swing by the resident. During an interview on 07/29/23, at 10:31 A.M., CNA/Certified Medication Technician (CMT) D said staff should never yell at a resident, demand a resident sit down, or push a resident by the shoulders to sit down. This would be considered abuse and should be reported to the charge nurse immediately. He/she would ensure the resident's safety first. During an interview on 07/29/23, at 10:45 A.M., CNA/CMT E said staff should never yell at a resident, demand a resident sit down, or push a resident by the shoulders to sit down. This would be considered abuse and should be reported to the charge nurse immediately. During an interview on 07/29/23, at 10:57 A.M., LPN F said staff should never yell at a resident, demand a resident sit down, or push a resident by the shoulders to sit down. That would be considered abuse and should be reported to the charge nurse immediately. Charge nurse should remove the alleged perpetrator from resident care, assess the resident and ensure safety, and notify family and physician. During an interview on 07/29/23, at 1:19 P.M., the Director of Nursing (DON) said the following: -Staff should ensure resident safety first when made aware of an abuse allegation and then immediately report the allegation to the charge nurse; -Alleged perpetrators are immediately removed from resident care and suspended pending an investigation; -A thorough investigation is completed, including interviews with residents and staff, resident assessments and notifications to family, guardians and physicians; -Staff should never yell at a resident or push a resident in a forceful way to sit down. She would consider this to be abusive. -She considered this allegation regarding CNA A to be abuse. During an interview on 07/29/23, at 1:39 P.M., the Administrator said the following: -Staff should ensure resident safety first following an abuse allegation and then report the allegation to the charge nurse immediately; -The charge nurse would remove the alleged perpetrator from resident care and report the allegation to the ADON, or DON; -The alleged perpetrator would be suspended pending an investigation; -Staff should never forcefully push a resident to sit down, and he would consider this to be abuse; -Staff should never yell at a resident or tell a resident to sit down forcefully, and he would consider this to be a respect/dignity issue. MO00222179

Based on interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 47) of three residents reviewed for abuse out of a total sample of 45 residents was free from abuse. This deficient practice resulted in physical harm to R47 when R189 hit R47 with his cane resulting in bruising, scratches, and reddened areas on R47's person and resulted in psychosocial harm when R47 stated he was afraid during the altercation with R189. Findings include: Review of the policy provided by the facility titled, Abuse Prohibition, dated [DATE], indicated . It is the purpose of this facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, & exploitation of any resident . assist the facility staff members in recognizing incidents of abuse . ABUSE is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . 1. Review of an undated Resident Face Sheet, found in R47's electronic medical record (EMR) under the Resident, tab indicated R47 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R47's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated R47 had a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated R47 was severely cognitively impaired. This MDS indicated R47 had short-and-long term memory problems, required extensive assistance of one person for bed mobility, extensive assistance of two staff for transfers, and no behaviors. Review of R47's nursing Progress Notes, found in EMR under the Resident, tab indicated on [DATE] the nurse was called to R47's room to assess R47 after he was injured by his roommate (R189). The progress note revealed the . Resident was visibly shaken but verbalized 'I'm made of tougher stuff than that' . The progress notes indicated R47 stated R189 hit him several times with a cane to his face, abdomen, and wrist/forearms. The progress notes revealed . Bruising was noted to left periorbital area [around the eye] with trace swelling; redness noted on bridge of nose. Swelling and bruising noted on right wrist. Purple hematoma [bruise] noted on left ring finger, 0.2 cm [centimeter] scratch on left lateral forearm. Redness noted to the right side of abd [abdomen]. Swelling noted to the left knee . Review of R47's nursing Progress Notes, found in EMR under the Resident, tab indicated on [DATE] R47 had a follow up skin assessment that revealed redness and bruising to the left eye, redness to the abdomen, swollen area to right outer wrist, purple area to the skin to the left hand between the fourth and fifth knuckles. The skin assessment indicated R47 sustained a 0.2 cm open area to the left outer arm and swelling to the left knee. The nursing progress notes revealed R47 was still shaken up from the altercation with R189 and his hands were visibly shaking with tremors. 2. Review of an undated Resident Face Sheet found in R189's EMR under the Resident, tab indicated R189 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R189's quarterly MDS with an ARD of [DATE] indicated a BIMS score of four out of 15 which indicated R189 was severely cognitively impaired. This MDS indicated R189 had short-and-long term memory problems, required supervision with set-up from one staff member for bed mobility and transfers, was able to use a cane or a walker for ambulation, and had no behaviors documented. Review of R189's nursing Progress Notes, found in EMR under the Resident tab and dated [DATE] revealed R189 stated .'I shouldn't have hit that guy. He's had it coming for a long time. I totally started this'.When asked why he did this he states, 'He grabbed my cane'. The EMR indicated R189's family and physician were notified and R189 was sent to a local hospital for evaluation and treatment. Per review of the EMR, this was the first aggressive incident R189 had. Review of the facility's investigation, provided by the facility, in response to R47 and R189's altercation revealed a thorough investigation and timely reporting to the State Survey Agency (SSA). There was evidence to support the facility took steps to protect R47 from R189 after the altercation was initiated by R189. During an interview on [DATE] at 9:21 AM, R47 confirmed he was hit with a cane by R189 and when he was hit, he stated he was scared since R189 acted crazy. R47 stated he was in bed when the incident happened. R47 confirmed he was hit in the face, arms, and the abdomen. R47 stated the night it happened, R47 stated he did not believe his call light was working and called for a staff member. R47 stated this upset R189 and R189 walked over to him and hit him repeatedly. R47 stated no staff member asked him if he was scared. R189 had expired prior to this survey. During an interview on [DATE] at 1:41 PM, the Housekeeping/Laundry Supervision confirmed she was the one who heard hollering and went to check on R47. The Housekeeping/Laundry Supervisor stated she immediately reported the incident to the nurse and to a Nursing Assistant (NA). The Housekeeping/Laundry Supervisor stated R47 reported to her R189 hit him with R189's cane. The Housekeeping/Laundry Supervisor stated R47 had a red mark on his eye, wrist, and on his abdomen. The Housekeeping/Laundry Supervisor stated R47 was unable to get himself out of bed. The Housekeeping/Laundry Supervisor stated R47 told her he did not want R189 back in his room and stated the resident might come back and finish the job. The Housekeeping/Laundry Supervisor confirmed R189 was placed in a different room immediately after the incident. The Housekeeping/Laundry Supervisor was asked if R189 was abusive towards R47, and she stated R47 could not defend himself. The Housekeeping/Laundry Supervisor confirmed she provided a written statement to the facility during the investigation of the resident-to-resident incident. During an interview on [DATE] at 2:14 PM, NA3 confirmed she overheard R189 hit R47. NA3 stated R189 came to the nursing station, and she directed him to take a seat. NA3 stated R47 was very upset and stated R189 hit him. NA3 stated she then went to get the nurse. NA3 stated R47 had some redness on his wrists and around his eye. NA3 stated R47 told her R189 began to hit him with his cane and R47 then grabbed his cane and R189 proceeded to punch him in the face. NA3 was asked if the interaction between R189 and R47 was abusive and NA3 stated it was. NA3 confirmed she provided a written statement to the facility during the facility's investigation of the resident-to-resident incident. During an interview on [DATE] at 2:23 PM, the Assistant Director of Nursing (ADON) was interviewed and confirmed she was on-call when R189 hit R47 with a cane. The ADON stated she met with R47 after the incident and R47 confirmed R189 hit him with a cane. The ADON was asked if she believed the incident between R189 and R47 was abuse and she stated it was. During an interview on [DATE] at 3:48 PM, the Administrator was asked how the facility takes measures to protect residents who were admitted to the facility. The Administrator stated staff were educated on identifying abuse, the prevention of abuse, and when to report an allegation of abuse. The Administrator stated R189 had no prior behaviors or aggression towards residents. The Administrator stated the facility took immediate action to prevent further abuse by removing R189 and placing him in another room and sending him to the hospital to be evaluated. The Administrator stated frequent checks were completed on R189 during this time and stated R189 would have benefited from a psychiatric stay but the family of R189 did not want him to be placed in a psychiatric hospital. The Administrator confirmed there were no further incidents from R189 towards residents.

Based on observation, interview, review of facility policy, review of temperature logs, and review of the Food and Drug Administration (FDA) Code, the facility failed to monitor the dish machine temperatures and ensure that the dish machine was providing the correct amount of chemicals needed to sanitize dishware. These failures had the potential to increase the risk of food borne illnesses and affect 101 out of 104 residents living at the facility who received food from dietary services. Findings include: Review of the FDA Code 2017 revealed, Adequate cleaning and sanitization of dishes and utensils using a ware-washing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize. For example, high temperature machines depend on the buildup of heat on the surface of dishes to accomplish sanitization. If the exposure time during any of the cycles is not met, the surface of the items may not reach the time-temperature parameter required for sanitization. Contact time is also important in ware-washing machines that use a chemical sanitizer since the sanitizer must contact the items long enough for sanitization to occur. In addition, a chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization. During an initial tour of the kitchen on 04/04/22 at 12:03 PM, Dietary (D) 1 began the dishwasher and then took a test strip to the water collected at the bottom of the machine and confirmed there were no chemicals present on the test strip. D1 then provided the log for the dishwasher titled Dishroom [sic] Temperature-Low Temperature Machine, for April 2022 and there were no temperatures recorded from 04/01/22 to 04/04/22. D1 confirmed the log was not completed during this observation/interview. At 12:07 PM D1 ran the dish washer and at the conclusion placed a new test strip at the bottom of the machine and again confirmed there were no chemicals present on the test strip. At 12:08 PM, D1 ran a third test on the dish machine and again confirmed there was no chemical present. At 12:10 PM the Certified Dietary Manager (CDM) stated he would call and get a technician out. The CDM was shown the dish machine log and stated the temperature and chemicals were to be tested after each meal. Review of a document titled Service Report, dated 04/05/22, indicated the dish machine was not getting any sanitizer. This service request was completed after the initial tour of the kitchen conducted on 04/04/22. During an interview on 04/08/22 at 8:29 AM, the Registered Dietician (RD) stated the expectations for the sanitizer was to reach 50 parts per million and the results of both the temperatures and the sanitizer were to be logged in three times per day.

Based on observation, interview, and record review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee made good faith attempts to identify and correct quality deficiencies when they did not develop or implement appropriate action plans to correct on-going, systemic issues. This deficient practice had the potential to affect all of the residents in the facility. The facility census was 104. Findings include: The facility failed to ensure one of three sampled residents was free from abuse. (Refer to F600) The facility failed to ensure one of two sampled residents was free from a chemical restraint. (Refer to F605) The facility failed to ensure adequate personal grooming opportunities for two of four sampled residents. (Refer to F677) The facility failed to identify and implement effective interventions related to falls for two of five sampled residents. (Refer to F689) The facility failed to develop and implement a process to ensure accurate receipt and reconciliation of controlled substances occurred. (Refer to F755) The facility failed to develop and implement an effective infection prevention and control program that included a functional antibiotic stewardship program for recording incidents of infections, surveillance, tracking and trending, and the corrective actions taken by the facility, failed to ensure one resident was offered the pneumonia vaccine, and failed to ensure one staff member was vaccinated, or had a qualifying exemption for COVID-19. (Refer to F880, F881, F883, and F888) Review of the undated QAPI Plan recorded the purpose of QAPI in the facility was to take a proactive approach to continually improve the way the facility provided care for and engaged with the residents, caregivers, and other partners, and that all employees were expected to participate in ongoing QAPI efforts . Additionally, the QAPI plan recorded that the scope of the QAPI plan encompassed all segments of the facility, and aspects of service and care were measured against established performance goals. Key monitors were measured and trended on a quarterly basis, and the QAPI committee would analyze performance to identify and follow up on areas of opportunity. The facility would continually identify opportunities for improvement, and PIP's would be implemented in accordance with CMS' protocols for conducting PIP's including: -Measurement of performance using objective quality indicators. -Implementation of system interventions to achieve improvement in quality. -Evaluation of the effectiveness of interventions. -Plan and initiation of activities for increasing or sustaining improvement. Review of the facility Performance Improvement Project (PIP) Inventory dated as reviewed on 1/19/2022 recorded the following: Project: Fall Prevention initiated on 1/1/2019. Current phase: monitoring. Changes initiated: numerous interventions. Indicated/Measures (what is being monitored): monthly falls and quality measure (QM) reports. Status (what are the indicators/measure results as compared to the goals or thresh-holds? Have any unintended consequences or barriers been identified? How are they being addressed?): not currently triggering on [NAME] is the only notation. The PIP inventory lacked the indicators necessary to measure results, lacked goals and thresh-holds, lacked consequences/barriers identified, and how those were being addressed. Additionally, the PIP inventory lacked evidence that the facility had identified, developed, and implemented PIP's for quality deficiencies identified in the building for abuse, chemical restraints, personal grooming, siderails, receipt and reconciliation of controlled medications, and infection prevention and control. During an interview on 4/8/2022 at 11:01am, the Director of Nursing (DON) indicated that the facility reviewed the quality measure reports, past surveys, and grievances to determine the areas that are issues within the building that the facility would need to develop an action plan for. Additionally, the (DON) indicated that she would look at the infection reports from the lab and the antibiotic use in the facility, but had not monitored the actual infection control program, or identified the lack of surveillance of infections in the building. The DON further indicated that the facility did not have a process to reconcile their controlled substances, or to track and ensure that pharmacy recommendations to the physician were followed up on timely. During an interview on 4/8/2022 at 1:13pm the Administrator indicated that the QAPI committee would review the reports of falls, any grievances, quality measures, and past surveys to determine what areas the facility needed to focus on and develop action plans. The facility had identified an issue with meal service and resident complaints of cold food, and had developed and implemented an action plan to correct the issue. Additionally, the Administrator indicated the facility had identified an issue related to falls and had just initiated a new fall program, and that the facility had systems in place to correct the deficient practice, but they [the facility] did not document the action plans, or have actual PIP's developed.

Based on interviews, reviews of facility policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. Findings include: Review of a document titled, Centers for Disease Control (CDC) . National Healthcare Safety Network (NHSN) . Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities ., dated 01/20, indicated, . Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. When conducting surveillance, facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data regardless of who is performing surveillance . Review of the facility policy titled, Infection Prevention and Control Program, undated, indicated . maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors and healthcare workers. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory and accrediting agencies . The IP responsibilities for infection prevention and control include but may not be limited to . Conducts surveillance for facility associated infections and/or communicable diseases . In collaboration with Administration and Medical Director . Communicates infection prevention and control data to facility leadership, appropriate leadership committees, facility staff, public health department . During an interview on 04/08/22 at 9:03 AM, the Infection Control Nurse (ICN), who was also the Infection Control Preventionist, stated she only enters data of when a resident was started on an antibiotic into the infection control log. The ICN stated she did not track, monitor, and/or provide corrective action on infection control matters. During an interview on 04/08/22 at 11:34 AM, the Medical Director confirmed she attended the Quality Assurance meetings and stated the facility did discuss infection control during these meetings, but they may not have been as good as they used, such as identifying trends, prior to COVID-19. During an interview on 04/08/22 at 10:46 AM, the DON stated she was not aware the ICN was not tracking and trending information infection control matters.

Based on interview, record review, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. This failure had the potential to affect all 104 residents of the facility. Findings include: Review of a undated policy provided by the facility titled, Antibiotic Stewardship Program, indicated . Optimizing antimicrobial use for treatment and prophylaxis of infections among patients/residents in order to improve clinical outcomes, provide the most cost-effective treatment and reduce adverse events that are associated with antimicrobial use . Control antimicrobial resistance through proper use of antimicrobials . Reducing the occurrence of 'super bugs' which can often be multi-drug resistant . The Infection Preventionist/Designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription . The Infection Preventionist/Designee will be responsible for auditing the completeness of antibiotic prescribing documentation to include the dose, route, start date, end date, days of therapy and indication . The Infection Preventionist/Designee will monitor antibiotic imitation. This is done by taking the number of new antibiotics starts for a single indication (i.e., [CONDITION(S)] (urinary tract infection), dividing by total number of resident-days, and report of any instances of C. difficile or antibiotic resistant infections such as [CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus aureus) (a staph infection which has become resistant to many antibiotics) or E. (Escherichia) coli (can cause bloody diarrhea, severe stomach cramps, and vomiting). This report will be discussed with the Medical Director, Pharmacist Consultant, and Lab Consultant during the quarterly Quality Assurance Meeting . Review of a document provided by the facility titled, Infection/Antibiotic Log, from September 2021 through January 2022, revealed residents were identified, along with the associated infection. The name of the antibiotic was not identified, the symptoms of the infection associated with the antibiotic was not identified, the pathogens were not identified, the laboratory tests and if a culture and sensitivity was ordered was not identified on these logs. The start and end dates of the antibiotics were identified on these documents. During an interview on 04/08/22 at 9:03 AM, the Infection Control Nurse (ICN) who was also the Infection Control Preventionist, stated she completes data entry for antibiotic use at the end of the month. During this interview the ICN provided her manual for antibiotic use and stated the facility used McGeer's criteria for assessing antibiotic use. The ICN stated the nurses on the floor complete the McGeer's (infection control surveillance tool to identify patient symptoms of infection and if an antibiotic is necessary) criteria for a resident who was on an antibiotic. The ICN stated the laboratory and culture results were in each resident paper chart and was not in the electronic medical records. The ICN was asked how she monitors residents who were placed on an antibiotic at the beginning of each month if she only pulls a report at the end of the month and the ICN stated she only enters if a resident was placed on an antibiotic on the form in the manual and does not search for laboratory results or cultures obtained on a resident who was placed on an antibiotic. The ICN was asked how she was able to determine if a resident was placed on an appropriate antibiotic and the ICN stated the floor nurses were to do this and again repeated she only entered if a resident was on an antibiotic in her tracking log. The ICN stated she provides a copy of the log to the Administrator each month. When the ICN was asked how she was able to determine how clusters of infections were identified, the ICN stated the Director of Nursing (DON) might do this. The ICN stated she did not provide any education to the clinical or care giving staff on infection control matters and stated the education was provided by the DON and the Assistant Director of Nursing (ADON). The ICN stated she did not know what an antibiogram (a report developed by the facility to display organisms present in specimens across a selected time along with the susceptibility of each organism). The ICN stated there was no tracking and trending in the information in the antibiotic log for each month from September 2021 through January 2022. During an interview on 04/08/22 at 10:46 AM, the DON stated the responsibilities of the ICN was to oversee the antibiotic stewardship program and implement education if there was an identified need. During an interview on 04/08/22 at 12:47 PM, the Consultant Pharmacist stated she does not track or trend and this would be the responsibility of the individual for the infection control program. The Consultant Pharmacist stated she provided the facility with a monthly report on laboratory results and cultures but will not direct the facility if they met criteria or not for antibiotic use.

Based on interview and policy review, the facility failed to establish a system of records of receipt and disposition of all controlled medications. This failure to ensure a system for the receipt of controlled medications and accurate reconciliation prohibits the prompt identification of loss or potential diversion of controlled medications. Findings include: The undated facility policy titled, Medication Destruction Of documents, .Purpose: The facility will destroy and dispose of medications in a safe manner and in accordance to applicable law. The following protocol will be followed for controlled medications: 1. When a medication has been discontinued, the Nurse/CMT [certified medication technician] will discontinue the controlled medication on the POS [physician order sheet] and the MAR [medication administration record]. 2. The Nurse/CMT will document the amount of controlled medication to be discontinued on the MAR. (e.g., DC 'ed 10 tabs on card or DC 'ed 40cc in bottle). 3. The Nurse/CMT will then log the controlled medication on the individual resident's destruction record to include the following information: a. Date medication discontinued b. Rx Number c. Amount left on card or cc left in bottle 4. The controlled medication will then be placed in the locked cabinet for destruction. 5. The controlled medication count sheet will be maintained in the narcotic book under the discontinued narcotic tab and will be counted until destroyed. 6. When narcotics are destroyed, the nurses will document on the destruction record and narcotic record the following information: a. Date destroyed b. How medication was destroyed c. Both nurses' names and titles. 7. Controlled medications will be destroyed at least weekly with DON supervision. In an interview on 04/05/22 at 04:50 PM, the Director of Nurses (DON) explained the controlled medication process in the facility. The DON stated the pharmacy delivers controlled medication to the facility. The medication comes with a yellow reconciliation sheet that is placed in the narcotic count book located on the medication cart and the medication is secured in the locked medication cart. The controlled medication also comes with a yellow receipt listing the controlled medication delivered. The DON further stated when controlled medications are no longer in use, the controlled medications are maintained in the medication cart and the reconciliation sheet put in the part of the narcotic book for discontinued mediations. The medications remain in the cart and are counted each shift until they are destroyed. Controlled medications are destroyed by two nurses and the destruction date and staff names documented on the yellow reconciliation sheet and included in the resident's paper medical record. The DON stated she conducts periodic reviews of controlled medication and the reconciliation sheets in the narcotic book on the medication carts. The DON further stated the receipts that accompany the yellow reconciliation sheet and controlled medication are not maintained for future cross reference when the medication is no longer in use or is completed. The DON stated she did not have a process to maintain the controlled medication receipts and disposition of controlled medications in the facility. In an interview on 04/08/22 at 9:00 AM, the Pharmacist Consultant stated, the DON is responsible to maintain the controlled medication receipts that come from the pharmacy when a controlled medication is delivered. The DON should be using the receipts to cross reference the medication cards when the medication is taken off the unit medication cart to safeguard against any diversion. The Pharmacist Consultant stated she was not aware the DON was not using the receipts to track controlled medication in the facility.

Based on record review, interview, and policy review, the facility failed to implement nonpharmacological interventions for behaviors before using a chemical restraint for one of five sampled residents (Resident (R) 11) reviewed for unnecessary medication in a total sample of 45 residents. This failure had the potential to negatively impact the resident's quality of life. Findings include: Review of the undated facility policy titled, Antipsychotic Medication Use indicated, .Antipsychotic medication therapy shall only be used when it is necessary to treat a specific condition .The symptoms are not due to preventable or treatable underlying causes .Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions . Review of the Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Note, dated 10/20/20 and located in the EMR under the Progress Note tab, documented R11 was accustomed to smoking and has been for a long time. Review of the Smoking Assessment, dated 10/20/20 and located in the EMR under the Observation tab, revealed the resident smoked cigarettes with a frequency less than hourly. Review of the Nurse's Note, dated 10/23/20 at 9:00 AM and located in the EMR under the Progress Note tab, documented . the resident is impatient at times to smoke . Review of the Nurse's Note, dated 10/25/20 at 11:29 AM and located in the EMR under the Progress Note tab documented, . the resident becomes agitated easily when wanting to go out to smoke . Review of the Nurse's Note, dated 10/26/2020 at 9:24 PM and located in the EMR under the Progress Note tab, documented . the resident is impatient at times to smoke . Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/20 located in the EMR under the RAI tab indicated the Staff Assessment of Mental Status completed revealed R11 had severe cognitive impairment and did not exhibit behaviors. Review of Orders, located in the EMR under the Resident tab, revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Note, dated 12/1/20 and located in the EMR under the Progress Note tab, documented New med [medication]: orders to begin [MEDICATION(S)] 5mg 1 daily @hs d/t [due to] witnessed agitation by Dr. [name] r/t smoke break. Resident became belligerent and loud. He could not understand why he had to wait to smoke. Resident was trying to communicate wanting to go outside by himself to smoke. Advised several times, he was not ok to go out on his own. This made resident upset. Dr. [name] spoke to resident regarding smoke breaks and having to wait. Smoke breaks are never denied to resident; however, resident often has to wait for an aide to take them outside. N.O. [new order] entered and faxed. Review of the EMR and paper medical record revealed the Care Plan, dated 10/28/20, did not include a care plan for R11's desire to smoke and no interventions for R11's agitation when not being able to smoke when he desired. In an interview on 04/07/22 at 2:40 PM, MDS Coordinator 1 stated R11's preferences for smoking were not included in his care plan dated 10/28/20. MDS Coordinator 1 further stated interventions were not implemented to defuse the effect of not being able to smoke had on R11. In an interview on 04/08/22 at 9:30 AM, Physician 1 stated R11 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician 1 stated the staff are busy and R11 does not want to wait to smoke. Physician 1 further stated he did not meet with the resident or the interdisciplinary team to develop a specific plan for R11's behaviors related to the inability to smoke when desired. Physician 1 stated, the staff try to go with the resident, but they can't go when he wants to go out. Physician 1 stated he did not try any less restrictive interventions prior to ordering [MEDICATION(S)] and stated, I don't want him out smoking its cold. In an interview on 04/08/22 at 12:53 PM, the Director of Nursing (DON) stated R11 was started on [MEDICATION(S)] because of behaviors exhibited when he wanted to go out to smoke other than the scheduled smoke times. The DON stated the facility did not assess R11 to understand his smoking practices or implement less restrictive interventions related to the agitation R11 exhibited due to the desire to smoke prior to [MEDICATION(S)] being ordered.

Based on observation, interview, and record review, the facility failed to provide bed hold policy information to two residents (R185, R86), reviewed for hospitalization . The facility failed to provide R185 or her representative with information regarding the facility bed hold policy, when R185 was hospitalized on [DATE]. Additionally, the facility failed to provide bed hold policy information to R86, who was hospitalized on [DATE]. Findings include: 1. Review of R185's electronic medical record documented that she was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Note, dated 2/2/22 at 6:05am, recorded that R185 had an oxygen saturation reading of 80% [percent] on RA [room air.] Facility staff provided R185 with supplemental oxygen, and notified R185's physician. The physician instructed facility staff to send R185 to the hospital for evaluation and treatment. Facility staff notified R185's family. The note lacked documentation that the facility bed hold policy was provided to R185 or her family. Further review of R185's electronic medical record lacked documentation that the facility bed hold policy was provided to R185 or her family. On 4/7/22 at 10:13am, Licensed Practical Nurse (LPN2) indicated that she had not received much training from the facility at the time of hire two weeks previously. LPN2 indicated that based on previous knowledge, the facility bed hold policy should be provided to residents or their representatives at the time of transfer to the hospital. LPN2 indicated that staff should document in the medical record that this information was provided to the resident or their representative as evidence it had been completed. On 4/7/22 at 4:10pm, the Director of Nursing (DON) indicated that the expectation of staff was to provide a copy of the facility bed hold policy to residents or their representatives at the time of transfer to the hospital. The DON indicated that the facility had no evidence that a bed hold policy was provided to R185 or her representative. Review of the 11/28/2021 admission MDS recorded that R86 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that she was cognitively intact. Review of R86's electronic health record (EHR) recorded the following diagnoses, but not limited to, fractured (broken) hip and chronic obstructive pulmonary disease ([CONDITION(S)]-restrictive lung disease characterized by difficulty breathing), and recorded that she was discharged from the facility to the hospital on 12/5/2021. Additional review of the EHR revealed the record lacked evidence the Bed Hold policy was sent with the resident upon transfer to the hospital. On 4/7/22 at 4:10pm, the Director of Nursing (DON) indicated that the expectation of staff was to provide a copy of the facility bed hold policy to residents or their representatives at the time of transfer to the hospital. The DON indicated that the facility had no evidence that a bed hold policy was provided to R86 or her representative.

Based on interview and record review, facility staff failed to call emergency personnel and failed to provide basic life support, including cardio-pulmonary resuscitation (CPR), an emergency procedure that is performed when a person's heartbeat or breathing has stopped, for one resident (Resident #1) of a sample of four residents. The facility census was 89. The Administrator was notified on [DATE] at 11:55 A.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE] . On [DATE], the Administrator became aware of the violation of the facility cardio-pulmonary resuscitation policy. The staff member was suspended pending investigation and later terminated. The facility inserviced the staff on the cardio-pulmonary resuscitation policy and procedures. The IJ was removed and corrected on [DATE]. Record review of the facility's policy for CPR, dated ,[DATE] , showed the following: -Purpose: To ventilate and establish circulation on a resident with absence of respirations and pulse; -Guidelines: Do not initiate CPR if a valid Do Not Resuscitate (DNR) order is in place; -The following guidelines are for a one-adult rescuer CPR: 1. Determine unresponsiveness by tapping or gently shaking resident and shouting, Are you okay?; 2. Call out for help; 3. Delegate a specific individual to check resident clinical record for CPR or no CPR orders; have individual call paramedics, attending physician and administrative personnel per facility guidelines and report back to you as soon as possible; 4. DO NOT START CPR IF RESIDENT IS BREATHING AND HAS A PULSE. Start emergency oxygen, and delegate a specific individual to stay with the resident and monitor vital signs. Notify the attending physician of the resident's condition and request further orders for care; 5. Position the resident by turning on back as a unit, supporting head and neck. -Continue CPR; 18. Ventilate twice, observe chest rise. 19. Resume compression/ventilation cycles; 20. Feel for carotid pulse every few minutes; 21. Once CPR is started do not discontinue until: a. Qualified help arrives (paramedics); b. A physician pronounces the resident dead and gives orders to discontinue CPR; 22. When arrangements are made for transportation, notify the ambulance company that CPR will be or may be necessary during transfer. Record review of the resident's face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident's code status was a full code. Record review of the resident's medical record showed no review of advanced directives upon and after admission. Record review of the resident's physician's orders [REDACTED]. -The resident's [DIAGNOSES REDACTED]. - an order for [REDACTED]. Record review of the nurses' notes showed the following information: dated [DATE] at 2:21 A.M., showed: - On [DATE] at 2:21 A.M., Licensed Practical Nurse (LPN) A documented that he/she was called to the resident's room by Certified Nurse Aide (CNA) B due to the resident was breathing funny. LPN A went to the resident's room and grabbed his/her hand and spoke his/her name. The resident opened his/her eyes and took one long final breath. LPN A yelled for help and initiated chest compressions. LPN A heard no heartbeat, or a pulse, did a sternal rub and had no response. LPN C came into the room and verified the resident had no heartbeat or pulse. The resident was ashen gray in color and started mottling on his/her back. LPN A notified the physician, spouse, Director of Nursing (DON) and Facility Director per protocol. LPN A faxed the coroner per facility protocol. Record review of a written statement completed by LPN A, dated [DATE], showed the following: -At 1:35 A.M., CNA B told LPN A the resident was breathing funny; -LPN A assessed the resident as ashen in color; -LPN A spoke the resident's name and he/she opened his/her eyes and gave a final gasp of air; -LPN A listened to the resident's heart and was unable to hear it beat; -LPN A pumped the resident's chest three or four times and yelled for help; -LPN C was at lunch and unavailable to assist the nurse, but the resident was gone at this point. Record review of a written statement completed by CNA B, dated [DATE], showed the following: -CNA B entered the resident's room and introduced self and placed hand on his/her chest and noticed the resident wasn't breathing. CNA B ran to get LPN A; -LPN A came into the resident's room and started chest compressions; -CNA B left the room to grab towels and LPN A was still doing chest compressions; -CNA B returned to the resident's room, LPN A was removing the oxygen tubing and disconnected the tube feeding; -CNA B said the resident felt really cold and looked extremely pale. During a phone interview on [DATE] at 11:05 A.M. and 1:25 P.M., LPN A said the following: -Staff should call 911 and start compressions if a resident is a full code; -He/she did not call 911 for the resident and he/she did not know the resident was a full code; -This was his/her first code and did not know what to do and no one had told him/her; -911 was not called; -LPN A said LPN C came fifteen minutes later to assist and no CPR was started; -LPN A started chest compressions, because it was the 'right thing to do'; -He/she assumed the resident was no code and stopped after three to four compressions, due to he/she did not feel it would do the resident justice; -He/she stopped the chest compressions on the resident at 1:35 A.M.; -LPN A said he/she did not call 911 after discovering the resident was full code at 1:45 A.M. LPN A said it had been ten minutes since he/she was with the resident. During a phone interview on [DATE], at 1:35 P.M., LPN C said the following: -Staff should find the residents' code status by looking at the red or green dot on the outside of the door or binder of the chart; -Staff should initiate CPR and someone call 911 if a resident is non-responsive and a full code status; -An aide informed him/her at approximately 1:30 A.M., that he/she was needed down the hall to confirm a resident's death. LPN C said when he/she entered the resident's room between 1:30 A.M. and 1:35 A.M., the aides were providing post mortem care; -LPN C said the resident did not have a heart beat and was mildly warm to the touch; -LPN C found LPN A at the nurses' station on the phone and did not state anything about code status. During an interview on [DATE], at 2:55 P.M., the Director of Nursing (DON) said: -She expected a resident who is full code to have CPR initiated once staff determine no heartbeat and someone to call 911; -She expected staff to continue CPR until relieved or paramedics arrive; -The DON said LPN A entered the resident's room, tried a sternal rub and the resident took his/her last breath; -The DON said LPN A performed four chest compressions. The DON asked why only four chest compressions had been attempted and LPN A said he/she did not know until after the fact what the resident's code status was; -The DON asked LPN A why he/she did not resume CPR and LPN A said the bed was too soft and the chest compressions were not effective; -The DON asked LPN A why he/she did not place the resident on the floor and LPN A said he/she panicked; -The DON said LPN A said she did not call 911 and called the morgue. During a phone interview on [DATE] at 10:55 A.M., Physician A said: -LPN A notified him/her of Resident #1's death on [DATE]; -He was aware staff performed three to four compressions and stopped; -Staff should initiate CPR and call 911 if a resident is full code; -Staff should continue CPR until emergency services arrives; -Staff should have went back and attempted again with CPR once it was determined on the chart that the resident was a full code and call 911. During an interview on [DATE] at 10:05 A.M., the Administrator said the facility does not keep copies of CPR certification cards for those employees who are CPR certified. She said the employee is responsible for making sure they are up to date on their CPR certification and the facility will place a CPR certification class list up if employees need to renew certification. She said the facility keeps a list of everyone who is CPR certified. During an interview on [DATE] at 1:30 P.M., the Administrator said the video timeline showed the incident occurred on [DATE] between 1:,[DATE]:50 A.M. LPN A entered, exited the resident's room and went to the nurses' station to make phone calls. The Administrator said she saw no emergency services arrive at the facility during the viewing of the video. Record review of LPN A's employee counseling notice dated [DATE], showed LPN A was terminated due to failing to notify and/or delegate staff to notify Emergency Medical Services (EMS) during a code situation. Record review of a CPR in-service sign in sheet dated [DATE], showed LPN A's signature as attending the in-service. MO 339

Based on observation, interview and record review, the facility failed to timely administer pain medication to provide adequate pain management during a wound treatment, failed to administer pain medication to effectively manage pain at the end of life, failed to document alternative interventions for pain and failed to document notifying the physician when pain medication was somewhat effective or not effective for one resident (Resident #2) who received hospice services and had a history of [REDACTED]. The facility's census was 107. Record review of the facility's pain management protocol dated February 2004, showed the following information: -It is the policy of this facility to reduce or eliminate discomfort in those patients with alteration in comfort; -The nurse will complete an assessment of pain on residents who are experiencing pain according to resident need and use of pain medications; -The documented assessment will include: The nature and location of the pain, onset, severity, duration, aggravating factors, impact on daily life and goal. -The nurse will also assess the resident's pain by using the pain scale to determine the level of pain the resident is experiencing. -Pain relief measures should be utilized before pain becomes severe. -A consistent pain rating greater than 4 on the 0-10 scale will elicit review of the current pain therapy. The nurse may contact the physician for modification in treatment and/or further instruct the resident/family in pain regime. Ongoing evaluation will occur to monitor the effectiveness of the new intervention. -Interventions for relief of pain are divided into two categories: Pharmacological and non-pharmacological. -For pain that is unrelieved or episodes of breakthrough, the nurse should consult with the physician. -The care plan is to be updated as indicated by resident need. According to painedu.com the numeric pain scale uses numbers 0-10 to rate the intensity of one's pain. Zero is no pain, 5 is moderate pain and 10 is the worst possible pain. 1. Record review of Resident #2's admission record showed the staff admitted the resident to the facility on [DATE]. His/her [DIAGNOSES REDACTED]. The resident admitted to hospice services on 07/18/15. Record review of the pain assessment and evaluation dated 07/07/15, showed the following: -Pain medication currently in use to control pain. -The resident had occasional pain in his/her right lower leg within the last five days. -Over the past five days, pain had limited his/her day-to-day activities; -Unable to answer if the pain made it hard for the resident to sleep at night. -The resident rated his/her worst pain, in the last five days, as a 10. -The resident indicated, over the past five days, his/her worst pain was severe. -He/she described the pain as crushing and/or throbbing that comes and goes. -Per staff, the resident had vocal complaints of pain (that hurts, ouch, stop) and facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) that indicated pain, one to two days out of the past five days; -Measures to alleviate pain: Pain medication, exercise and heat; -Pain medication: [MEDICATION NAME] (medication used to relieve moderate to severe pain), as needed, the physician did not order the administration of pain medication routinely; -The pain medication is always effective. Record review of the admission Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 07/22/15, showed the following information: -Cognition moderately impaired; -Extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene; -Four Stage II pressure ulcers (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) present upon admit; -Had pain frequently; -The resident rated his/her worst pain, in the last five days, as a 10; -Over the past five days, pain made it hard for the resident to sleep at night and limited his/her day-to-day activities. Record review of the care plan dated 07/27/15, showed the following information: -The resident is at risk for pain related to [DIAGNOSES REDACTED]. -Administer pain medications as ordered; -Attempt non-pharmacological interventions as appropriate such as rest, diversion, positioning, ect. -Monitor effectiveness of pain medications and notify the physician as needed; -Monitor for other sources of pain such as infection, inflammation, positioning, ect. -Hospice care related to heart failure and [MEDICAL CONDITION]; -Coordinate the resident's care with his/her hospice team; -Coordinate with hospice to assure the resident experiences as little pain as possible. Record review a nurse's note dated 07/28/15 showed a nurse documented the resident complained of increased pain. Hospice notified and ordered to increase [MEDICATION NAME]-[MEDICATION NAME] 10 milligrams (mg)/325 mg to every four hours, as needed (PRN), for pain. Record review of the significant change MDS dated [DATE], showed the following results of the pain assessment interview: -Had pain almost constantly; -The resident rated his/her worst pain, in the last five days, as a 9; -Over the past five days, pain made it hard for the resident to sleep at night. Record review of nurses' notes showed on 08/02/15, at 11:05 A.M., a nurse documented the resident complained of increased pain with breakthrough pain between the PRN doses of [MEDICATION NAME]. The nurse obtained new orders for [MEDICATION NAME] concentrate 0.25 milliliters (ml)/5 mg, sublingual (SL) (under the tongue), every three hours PRN for pain/air hunger (the feeling of not being able to get a satisfying breath) and [MEDICATION NAME] 1 mg, SL, as needed, every four hours for anxiety/air hunger. Record review of the August 2015 physician's orders [REDACTED]. -An order dated 07/28/15 for [MEDICATION NAME]-[MEDICATION NAME] 10 mg-325 mg every four as needed for pain; -An order dated 08/02/15 for [MEDICATION NAME] 2 mg per ml, administer 1 mg (0.5 ml) every four hours as needed for pain; -An order dated 08/02/15 for [MEDICATION NAME] concentrate solution, 100 mg/5 ml, administer 5 mg (0.25 ml) SL every three hours as needed for pain/air hunger. Record review of the physician's history and physical dated 08/03/15, showed the following information: -When staff admitted the resident to the facility, he/she had multiple pressure ulcers. Due to his/her significant lack of appetite, the resident developed an extensive pressure ulcer on his/her sacrum (a large, triangular bone at the base of the spine) and significant pain. -The resident said he/she had significant pain. Staff had been administering [MEDICATION NAME] and [MEDICATION NAME]; -The resident said other than the sacral pain and discomfort; he/she had been relatively stable. -The resident appeared to be somewhat uncomfortable lying in his/her bed. -Start the resident on [MEDICATION NAME] extended release 15 mg, every 8 hours; -Continue to monitor the resident's pain. Record review of a nurses' note dated 08/03/15, at 10:10 P.M., showed a nurse documented the physician assessed the resident and wrote a new order for [MEDICATION NAME] extended release 15 mg, by mouth, every eight hours for pain. Record review of a physician's orders [REDACTED]. Record review of nurses' notes dated 08/04/15-08/17/15, showed the following information: -On 08/04/15, 9:37 P.M., a nurse documented when she performed the dressing change to the resident's sacral wound, the resident complained of pain. The nurse administered PRN [MEDICATION NAME] which was effective. -On 08/06/15, at 1:25 P.M., a nurse documented he/she administered pain medication, to the resident, prior to dressing changes. The resident tolerated the dressing changes well. -On 08/07/15, at 10:40 A.M., a nurse documented upon assessment and treatment of [REDACTED]. The nurse administered PRN [MEDICATION NAME] with relief. -On 08/10/15, at 4:03 P.M., a nurse documented he/she administered pain medication prior to performing the dressing change on the resident's pressure ulcer; the resident tolerated the procedure well; -On 08/15/15, at 1:04 P.M., a nurse documented he/she performed the resident's dressing changes per physician's orders [REDACTED]. -On 08/15/15, at 10:16 P.M., a nurse documented the resident complained of general discomfort while the nurse performed the dressing change to his/her pressure ulcer. The nurse administered PRN [MEDICATION NAME] with effectiveness. -On 08/16/15, at 1:00 P.M., a nurse documented he/she administered pain medication prior to performing the dressing change to the resident's pressure ulcer. The resident tolerated the treatment well. -On 08/17/15, at 12:28 A.M., a nurse documented the resident complained of pain at midnight but refused pain medication. The resident said he/she did not want that stuff; she/she did not want [MEDICATION NAME] or [MEDICATION NAME]. That stuff is not right; she did not want to pass out. The nurse attempted to reassure the resident the medication would not do this to him/her but he/she still refused over and over again. -On 08/17/15, at 1:36 A.M., a nurse documented the resident called his/her family member on his/her cell phone and said help, I need help quick. The daughter arrived at the facility and convinced the resident to take the [MEDICATION NAME] and [MEDICATION NAME] at the same time. Record review of the August 2015 medication administration record (MAR) and nurses' notes dated 08/22/15-08/24/15, showed the following information: -On 08/21/15 staff documented, on the MAR, administering [MEDICATION NAME] four times in 24 hours and [MEDICATION NAME] two times in 24 hours. At 7:16 A.M., staff administered [MEDICATION NAME] for a pain level of 7 and [MEDICATION NAME] for restlessness, calling out and trying to get out of bed; the medications were effective. At 10:47 A.M. staff administered [MEDICATION NAME] for a pain level of 7; the medication was somewhat effective. At 3:12 P.M. (four and a half hours since last dose of [MEDICATION NAME]), staff administered [MEDICATION NAME] for a pain level of 7; the medication was somewhat effective. At 10:55 P.M. (over seven hours since the last dose of [MEDICATION NAME]), staff documented administering [MEDICATION NAME] for a pain level of 8; the medication was somewhat effective. At 11:51 P.M., staff administered [MEDICATION NAME] for restlessness; the medication was effective. -Review of the nurses' notes dated 08/21/15 showed no documentation staff attempted other interventions or notified the physician the resident's medication was somewhat effective. -On 08/22/15, at staff documented, on the MAR, administering [MEDICATION NAME] five times and [MEDICATION NAME] four times. At 2:03 A.M., staff administered [MEDICATION NAME] for a pain level of 7; the medication was effective. At 5:36 A.M. staff administered [MEDICATION NAME] for a pain level of 7and [MEDICATION NAME] for restless; the medications were effective. At 3:20 P.M., staff administered [MEDICATION NAME] for a pain level of 8; the medication was effective. At 4:18 P.M., staff administered [MEDICATION NAME] for restlessness; the medication was effective. At 6:36 P.M., staff administered [MEDICATION NAME] for a pain level of 8; the medication was effective. At 9:36 P.M., staff administered [MEDICATION NAME] for restlessness; the medication was effective. -On 08/22/15, at 9:41 P.M., a nurse documented, in the nurses' notes, he/she administered PRN [MEDICATION NAME] and [MEDICATION NAME] when allowed for restlessness and per family request. -On 08/22/15, at 10:23 P.M., staff documented, on the MAR, administering [MEDICATION NAME] for a pain level of 8; the medication was effective. -On 08/23/15 staff documented, on the MAR, administering [MEDICATION NAME] two times and [MEDICATION NAME] two times. At 1:07 P.M., staff administered [MEDICATION NAME] for restlessness; the medication was effective. At 3:08 P.M. staff administered [MEDICATION NAME] for a pain level of 8; the medication was effective. At 5:06 P.M., staff administered [MEDICATION NAME] for restlessness; the medication was effective. At 8:55 P.M., staff administered [MEDICATION NAME] for a pain level of 10; the medication was effective. -On 08/24/15 staff documented, on the MAR, administering [MEDICATION NAME] four times and [MEDICATION NAME] four times. At 2:42 A.M., staff administered [MEDICATION NAME] for a pain level of 10; the medication was effective. At 3:46 A.M., staff administered [MEDICATION NAME] for pain and anxiety; the medication was effective. At 5:10 A.M., staff administered [MEDICATION NAME] for a pain level of 8; the medication was effective. At 5:10 A.M., a nurse documented he/she administered the [MEDICATION NAME] at 2:00 A.M., (not 2:42 A.M.) and 5:00 A.M., as ordered. At 9:05 A.M., staff administered [MEDICATION NAME] for a pain level of 6 and [MEDICATION NAME] for restlessness, flailing and thrashing; the medications were effective. At 12:10 P.M. staff administered [MEDICATION NAME] for a pain level of 6; the medication was effective. -On 08/24/15, at 4:55 P.M., a nurse documented, in the nurses' notes, the resident's hospice nurse assessed the resident. The nurse obtained an order to increase the frequency of the [MEDICATION NAME] from every three hours to every two hours as needed for pain/air hunger. Record review of a physician's orders [REDACTED]. Record review of the August 2015 MAR and nurses' notes, dated 08/24/15-08/25/15 showed the following information: -On 08/24/15 at 6:07 P.M., staff documented, on the MAR, administering [MEDICATION NAME] for pain and [MEDICATION NAME] for pain; the medications were not effective. At 11:45 P.M. (five and a half hours after the last dose of [MEDICATION NAME] and [MEDICATION NAME]), staff documented administering [MEDICATION NAME] for pain and [MEDICATION NAME] for pain; the medications were effective. -Review of the nurses' notes dated 08/24/15 showed no documentation staff attempted other interventions or notified the physician the resident's medication was not effective. -On 08/25/15 staff documented, on the MAR, administering [MEDICATION NAME] four times in 24 hours and [MEDICATION NAME] four times in 24 hours. At 7:25 A.M., staff administered [MEDICATION NAME] for pain (facial grimacing and restlessness) and [MEDICATION NAME] for restlessness and flailing; the medications were effective. At 9:44 A.M., staff documented administering [MEDICATION NAME] for pain (facial grimacing); the medication was effective; -On 08/25/15, at 1:06 P.M., a nurse documented, in the nurses' notes, the weekly skin assessment. The resident had a pressure ulcers to his/her left hip and sacrum. The nurse administered PRN pain and anxiety medications with good relief; An observation on 08/25/15, at 2:50 P.M., showed nurse assistant (NA) C and the director of nursing (DON) repositioned the resident in bed. As staff rolled the resident onto his/her side, the resident grimaced and moaned. The DON told the resident we are getting you a pain pill. Record review of the August 2015 MAR and nurses' notes dated 08/25/15-08/26/15, showed the following information: -On 08/25/15, at 2:55 P.M., staff documented, in the MAR, administering [MEDICATION NAME] for pain (facial grimacing and moaning) and [MEDICATION NAME] for restlessness and trying to get up on his/her own; the medications were not effective. At 5:40 P.M. (three hours since the last dose), staff administered [MEDICATION NAME] for pain (the nurse documented he/she administered the medication early due to condition); the medication was effective. At 7:43 P.M., staff documented administering [MEDICATION NAME] for anxiety (two hours since last dose, nurse documented early administration due to condition); the medication was effective. At 8:56 P.M. (six hours since his/her last dose), staff administered [MEDICATION NAME] for pain (increased blood pressure); the medication was effective. -Review of the nurses' notes dated 08/25/15 showed no documentation staff attempted other interventions or notified the physician the resident's medication was not effective. -On 08/26/15, at 8:32 A.M., staff administered [MEDICATION NAME] for pain (signs and symptoms of pain, facial grimacing) and [MEDICATION NAME] for calling out and grabbing; the medication was effective. At 11:32 A.M., (three hours since last dose of [MEDICATION NAME]) staff administered [MEDICATION NAME] for pain (signs and symptoms of pain, facial grimacing); the medication was somewhat effective. -Review of the nurses' notes dated 08/26/15 showed no documentation staff attempted other interventions or notified the physician the resident's medication was somewhat effective. Record review of the care plan dated 08/26/15, showed instructions for staff to assess the resident for pain related to pressure ulcer or it's treatment. An observation on 08/26/15, at 1:22 P.M., (10 minutes before the resident could have the [MEDICATION NAME], as needed every two hours) showed LPN D changing the dressing on the resident's sacrum. As the nurse cleaned the wound, the resident moaned loudly, cried out and attempted to move the nurse's hand from the wound, several times. The LPN told the resident he/she was sorry, and it would be over before he/she knew it. As the nurse packed the wound with gauze, the resident moaned loudly and cried out. The NA said I know, we are almost done. The nurse told the resident he/she needed to change the resident's dressing on his/her left hip. When the NA assisted the nurse and rolled the resident onto his/her right side, the resident cried out. NA C told the nurse he/she did not know how long the resident would lay on his/her right side. The NA said the resident had an old [MEDICAL CONDITION] with pins in his/her right hip; laying on his/her right side causes his/her excruciating pain. When LPN D finished the resident's treatments, he/she checked the resident's medication administration record (MAR) to confirm the resident could have pain and anxiety medication then administered the medication. Record review of the August 2015 MAR and nurses' notes dated 08/26/15-08/27/15, showed the following information: -On 08/26/15, at 1:56 P.M., staff documented, in the MAR, administering [MEDICATION NAME] for pain (facial grimacing and moaning) and [MEDICATION NAME] for restlessness and flailing; the medications were not effective. At 7:01 P.M., (five hours after the last dose of [MEDICATION NAME]) staff administered [MEDICATION NAME] for pain; the medication was not effective. At 11:36 P.M. (four and a half hours after the last dose of [MEDICATION NAME]), staff administered [MEDICATION NAME] and [MEDICATION NAME] for pain; the medication was effective. -Review of the nurses' notes dated 08/26/15 showed no documentation staff attempted other interventions or notified the physician the resident's medication was not effective. -On 08/27/15 staff documented, on the MAR, administering [MEDICATION NAME] three times and [MEDICATION NAME] two times. At 2:18 A.M., staff administered [MEDICATION NAME] for pain; the medication was effective. At 3:23 A.M., staff administered [MEDICATION NAME] for pain; the medication was effective. At 4:25 A.M., staff administered [MEDICATION NAME] for pain; the medication was effective. At 9:34 A.M., staff administered [MEDICATION NAME] and [MEDICATION NAME] for pain; the medications were effective. During an interview conducted on 08/27/15, at 10:35 A.M., LPN D said the following: -The resident indicates pain in his/her back area, and has chronic pain on his/her right side due to an old fracture. Due to the pain on his/her right side, the resident prefers to lay on his/her left side. -Before the resident's decline, he/she was able to rate his/her pain on a scale of 0-10 but now he/she mostly shows pain by grimacing. -His/her pain is worse now than it was. The nurse just spoke with the hospice nurse today because the resident has had more breakthrough pain and more indications of pain such as restlessness. -The physician ordered to increase the resident [MEDICATION NAME] concentrate to 10 mg every two hours, as needed and changed the [MEDICATION NAME] to 1 mg every two hours, as needed. -LPN D tries to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours; this seems to help his/her pain. He/she is able to relax and rest. -At this time the resident's pain seems to be getting better. Hopefully the new orders for medication are going to help him/her. -The resident does not always have signs of pain with cares. On Tuesday (08/25/15) the LPN repositioned the resident without the resident moaning. Record review of a physician's orders [REDACTED]. -[MEDICATION NAME] 2 mg/ ml, administer 1 mg (0.5 mg) every 2 hours as needed; -[MEDICATION NAME] concentrate 100 mg/5 mg, administer 10 mg (0.5 ml), every two hours as needed for pain/air hunger. Record review of nurses' notes dated 08/27/15 showed the following information: -At 12:37 P.M., a nurse documented he/she notified the hospice nurse that the resident was restless and had facial grimacing after administering PRN SL medications and obtained orders to increase [MEDICATION NAME] dosage to 10 mg SL every two hours as needed for pain/air hunger and change the [MEDICATION NAME] to 1 mg SL every two hours as needed for anxiety/air hunger. -At 1:10 P.M., a nurse documented notifying the hospice nurse of the resident's signs and symptoms of pain during dressing changes and his/her inability to swallow medications by mouth. The nurse obtained orders for staff to administer [MEDICATION NAME] 10 mg, one hour before scheduled and PRN dressing changes, and to discontinue all medications taken by mouth. During an interview conducted on 08/27/15, at 10:25 A.M., Certified Nurse Assistant (CNA) E said the resident's pain is bad when he/she is coherent; he/she makes faces and cries out. The resident normally has pain with cares. During an interview conducted on 08/27/15, at 10:25 A.M., CNA F said today (08/27/15) after breakfast, he/she assisted the nurse while the nurse completed the treatments on the resident's wounds. When he/she rolled the resident onto his/her side, the resident moaned. The resident has a pressure ulcer but the CNA was not sure if the resident's moaning was due to pain. When staff rolls the resident onto his/her right side, he/she fights; he/she tries to hold onto the side rail to keep from rolling. The CNA did not know why the resident did not want to lay on his/her right side. The resident cries out every now and then. He/she does not talk but will say ow with cares. During an interview conducted on 08/27/15, at 10:55 A.M., Certified Medication Technician (CMT) A said nonverbal signs and symptoms of pain include moaning, facial grimacing and/or hollering. If the CMT observes any of these indicators of pain, he/she notifies the charge nurse. CMTs cannot administer the PRN narcotic pain medication. When staff administers PRN pain medication, they ask the resident to rate his/her pain and document it in the computer. If the resident is unable to rate his/her pain, staff documents the signs of pain they observed. Staff does not ask everyone about their pain. The resident is on routine [MEDICATION NAME]. He/she is able to swallow the small pill, but it is becoming more difficult for him/her. The resident does express pain every now and then. When we turn or move him/her, the majority of the time, he/she cries out in pain. During an interview conducted on 08/27/185, at 11:10 A.M., LPN D said the nurses complete a pain assessment, and documents it in the treatment record, on most residents every shift. Depending on the type of medication, liquid or tablet, the nurses reassess a resident's pain 30 minutes to an hour after administration. If the pain medication was somewhat effective or not effective he/she would reposition the resident or take him/her to the bathroom. If the resident is still in pain, he/she would contact the physician. The LPN said he/she was going to administer, to the resident, some pain medication then he/she would perform the treatments on the resident's wounds. During an interview conducted on 08/27/15, at 11:25 A.M. and at 11:40 A.M., the DON said LPN D just repositioned the resident onto his/her right side. When the resident wakes up, his/her pain is bad. He/she sleeps a lot. An observation and interview on 08/27/15, at 11:45 A.M., showed LPN D, Registered Nurse (RN) G and the DON entered the resident's room to provide wound care. The resident, with his/her eyes closed, laid in bed on his/her right side. The resident did not respond when the nurse explained what he/she was going to do or while the nurse completed the treatment on the resident's right hip. As RN G positioned the resident further onto his/her right side, the resident, with his/her eyes closed, moaned quietly. LPN D removed the old dressing and as he/she began to clean the wound, the resident grimaced, moaned loudly and tried to move the nurse's hand away from the wound. When the nurse finished cleaning the wound, the resident sat up on the side of the bed. The nurses' encouraged the resident to lie down but he/she did not comply. After a few minutes, LPN D lifted the resident's legs into the bed and RN G assisted the resident into a lying position When the LPN and RN moved the resident up in bed, he/she grimaced and loudly moaned. The DON asked the LPN if the resident could have any pain medication. The LPN said the resident just had some [MEDICATION NAME]. The DON told the LPN to notify hospice and tell them the resident needed something additional for pain. While the LPN packed the wound, covered it with a dressing and repositioned the resident on his/her left side, the resident grimaced, moaned loudly and cried out. Record review of the August 2015 MAR and nurses' notes dated 08/27/15, showed the following information: -On 08/27/15 staff documented, on the MAR, administering [MEDICATION NAME] two times and [MEDICATION NAME] one time. At 11:13 A.M., staff administered [MEDICATION NAME] for restlessness and at 11:14 A.M., staff administered [MEDICATION NAME] for a pain level of 5; the medications were somewhat effective. -Review of the nurses' notes dated 08/27/15, showed no documentation staff attempted other interventions or notified the physician the resident's medication was somewhat effective. -At 4:49 P.M. (five and a half hours after the last dose of [MEDICATION NAME]), staff documented, on the MAR, administering [MEDICATION NAME] for a pain level of 7; the medication was not effective. -Review of the nurses' notes dated 08/27/15, showed no documentation staff attempted other interventions or notified the physician the resident's medication was not effective. Record review of a physician's orders [REDACTED]. -Discontinue all medications by mouth. -[MEDICATION NAME] concentrate 100 mg/5 ml, administer 10 mg one hour before scheduled dressing change for comfort/pain control; -[MEDICATION NAME] concentrate 100 mg/5 ml, administer 10 mg one hour before PRN dressing change for comfort/pain control. During an interview conducted on 08/27/15, at 5:15 P.M. and on 08/28/15, at 3:00 P.M., CNA H said the resident has a lot of pain. When the resident has pain he/she moves his/her arms and grabs at things, and sometimes calls out and/or moans. The resident's pain varies, but today his/her pain is worse than it was yesterday. Sometimes the resident's pain is worse, but usually has pain any time staff moves or touches him/her. The last time (a week or so ago) the CNA saw a nurse perform the treatments on the resident's wounds, the resident acted like it caused him/her pain; the resident attempted to remove the nurse's hand when the nurses performed the wound care and he/she attempted to remove the new dressing when the nurse completed the wound care. During an interview conducted on 08/27/15, at 6:00 P.M., LPN I said nonverbal signs and symptoms of pain include moaning, crying, behaviors, facial expressions. If the nurse observes any of these signs of pain, he/she administers pain medication and/or repositions the resident. About 45 minutes after administering a pain medication, the computer prompts the nurse to assess the effectiveness of the pain medication. The medication is either effective, somewhat effective or not effective. If a resident rated his/her pain as an 8 before taking the medication then rates his/her pain as a 3 or 4 (and is uncomfortable) after administering pain medication, the nurse would document the pain medication as somewhat effective. If a resident's pain medication was somewhat effective or not effective, the nurse would administer more pain medication, if ordered, notify the physician and document in the nurses' notes. The nurse just administered, to the resident, some [MEDICATION NAME]. A family member reported the resident was in pain; the nurse assessed the resident, and then administered the [MEDICATION NAME]. Record review of the August 2015 MAR showed on 08/28/15 (from midnight to 10:47 A.M.) staff documented administering [MEDICATION NAME] one time and [MEDICATION NAME] three times. At 1:34 A.M., staff administered [MEDICATION NAME] for anxiety; the medication was effective. At 4:59 A.M., staff administered [MEDICATION NAME] for writhing; the medication was effective. At 7:56 A.M., staff administered [MEDICATION NAME] for a pain level of 6 and [MEDICATION NAME] for restlessness. Staff did not document the effectiveness of either medication. During an interview with the DON and corporate nurse conducted on 08/28/15, at 10:30 A.M., showed the following information: -The DON said nonverbal signs and symptoms of pain include grimacing, restlessness, moaning, crying, yelling and increased behaviors. She did not know why some residents' TARS included a pain assessment every shift and other residents' TARs did not. Perhaps the every shift pain assessment is on those residents' TARs who trigger on the MDS for pain. -The DON said nurses' do not complete pain assessments, every shift, on all residents; only on those residents who are at risk for pain. All residents are at risk for pain. Staff completes a pain assessment upon admission and quarterly, when a resident asks for pain medications, when a resident has signs and symptoms of pain, when staff administers pain medication. The corporate nurse said staff also completes a pain assessment when a resident has a change in condition. -The corporate nurse said a nurse completes a pain assessment on admission. If the resident has chronic pain or if he/she scores high on the pain assessment, staff will assess his/her pain every shift. -The DON said if staff documents the pain medication was somewhat effective it means the medication partially worked, there are still some signs and symptoms of pain. If staff documents the pain medication was not effective then the nurse administers alternate medications and implements non-pharmacological interventions such as distractions. If these measures are not effective, the nurse contacts the physician and documents in the nurses' notes. -The DON said the resident has pain with treatments and with repositioning. The nurse obtained an order to administer pain medication prior performing the treatments on the resident's wounds. There is a fine line between sedation and quality of life. In recent past, the resident was able to verbalize his/her pain. He/she has had a change in his/her pain within the last few weeks. She did not know how often the nurses had administered pain medication to the resident. During an interview conducted on 08/28/15, at 2:45 P.M., LPN D said the following: -His/her pain is worse now than it was. The biggest change in his/her pain has been within the last couple of days. The resident was more alert then and did not have pain with during the treatment During an interview conducted on 08/28/15, at 3:30 P.M., LPN K said when the resident was first admitted to the facility, he/she did

Based on record review, interview, and observation the facility failed to ensure staff appropriately monitored, assessed and documented when staff were unable to obtain a physician-ordered urinalysis (UA-a laboratory test to check urine for the presence of bacteria) for one resident (Resident # 11), with a history of urinary tract infections, and failed to notify the physician of their inability in a timely manner when staff waited for five days. The facility failed to notify the physician when the resident developed behaviors such as expressing anxiety and pain and increased numbers of bowel movements, after starting on antibiotics, resulting in a hospitalization [MEDICAL CONDITION] (a bacterial infection in the bloodstream or body tissues) as a result of an infectious diarrhea Staff also failed to appropriately monitor, assess and document, as directed in the facility's fall management policy, on one resident (Resident#2) when the resident reported he/she had a fall and complained of pain. Staff failed to notify the physician and family in a timely manner; waiting 13 days. A sample of 17 residents was selected for review out of a census of 96. 1. Record review of Brunner and Suddarth's Textbook of Medical Surgical Nursing 9th edition, copyright 2000, regarding Urinary Tract Infections showed the following information: -The presence of bacteria in the urine increases with age and disability. UTIs are the most common cause of acute [MEDICAL CONDITION] (blood infection) in patients older than [AGE] years of age, in whom gram-[MEDICAL CONDITION] carries a mortality rate exceeding 50%; -In institutionalized elderly patients, such as those in nursing homes, infecting pathogens are often resistant to many antibiotics. Factors that may contribute to UTI in elderly nursing home patients include: high incidence of chronic illness; frequent use of antimicrobial agents, immobility and incomplete emptying of bladder; and use of bedpan rather than a commode; -Elderly patients often lack the typical symptoms of UTI [MEDICAL CONDITION]. Although frequency, urgency, and painful or difficult urination may occur, nonspecific symptoms such as altered sensorium, lethargy, loss of appetite, new incontinence, hyperventilation (rapid breathing), and low-grade fever, may be the only clues. -Frequent re-infections are common in the older adult. 1. Record review of Resident #11's admission history and physical to the facility dated 5/17/12, showed the following Diagnoses: [REDACTED]. Record review of the minimum data set (MDS), a federally mandated comprehensive assessment tool required to be completed by facility staff dated 5/21/12, showed:-Moderately impaired cognitive skills;-Rarely/never understands;-Rarely/never understood;-Extensive staff assistance transfers, dressing, toileting and personal hygiene;-Staff provides weight bearing support; with transfers, ambulation; -Occasionally incontinent of bowel;-Incontinent of bladder.-Staff did not identify that the resident had any behavioral issues. Record review of the admission care plan dated 5/11/12 showed the following information:-Pain: Monitor pain, non-drug interventions, establish causative factors and ways to alleviate them;-Infection alert: Type-urinary tract infection. Monitor signs and symptoms of infection. Vital signs every shift; -Cognitive loss. Anticipate needs and observe for non-verbal cues. Record review of the May and June 2012, physician orders [REDACTED]. -The resident needs continuous care due to inability to live independently and the need for 24 hour assistance, observation, and planning;- [MEDICATION NAME] (anti-[MEDICAL CONDITION] for pain and fever) 200 mg. Give 400 mg per [DEVICE] every 6 hours prn pain. -On 5/23/12, Straight catheter to obtain urinalysis for culture and sensitivity; Record review of nurse's notes (NN) and medication administration record (MAR) showed the following information: -(MAR) On 5/25/12 at 1:07 P.M., [MEDICATION NAME] 1 mg for anxiety ,calling out, grabbing staff and at 1:09 P.M., [MEDICATION NAME] 200 mg for pain, facial grimacing, calling out; -(NN) On 5/25/12 at 4:12 P.M., (two days after staff received the UA order) licensed practical nurse (LPN) M noted he/she attempted to catheterize the resident to obtain urine for the urinalysis. The resident "has two urethra openings" (tube that drains urine from the bladder). Urinates in the toilet, clear yellow urine, medication given to resident for signs and symptoms of pain and anxiety. Resident moaning, facial grimace, appetite poor. (Staff did not note they contacted the physician about these changes of behavior.) -(NN) On 5/26/12 at 1:04 P.M., Order for [MEDICATION NAME] (anti-anxiety medication) 1 milligram (mg); -(NN) On 5/26/12 at 2:26 P.M., the resident was groaning very loudly, staff redirected; - (MAR) On 5/26/12 at 2:39 P.M., [MEDICATION NAME] 1 mg restless and anxious; -(MAR) On 5/27/12 at 8:49 A.M., [MEDICATION NAME] for restless, denies pain and also at 7:31 P.M.-Staff did not document between 5/25/12 to 5/30/12, additional attempts to obtain the urine specimen; -(MAR) On 5/28/12 at 9:00 A.M., [MEDICATION NAME] 1 mg anxiety, moaning, restlessness and [MEDICATION NAME] 200 mg for signs symptoms of pain; -(MAR) On 5/28/12 at 2:46 P.M., [MEDICATION NAME] 200 mg for resident moaning and [MEDICATION NAME] 1 mg moaning; -(MAR) On 5/29/12 at 5:27 A.M., [MEDICATION NAME] 200 mg and at 1:25 P.M., [MEDICATION NAME] 1 mg; -(NN) On 5/30/12 at 12:44 P.M.,,(seven days after staff received the urinalysis order), staff notified the physician that they were unable to obtain urine for urinalysis. New order to discontinue order for urinalysis. No documentation that the nurse notified the physician that the resident continued with behaviors of moaning, anxiety and signs of continued pain; -(MAR) On 5/30/12 at 5:23 [MEDICATION NAME] 200 mg administered; -(MAR) On 5/30/12 at 5:23 A.M. [MEDICATION NAME] 200 mg administered and [MEDICATION NAME] at 4:36 A.M., and 9:20 A.M. for anxiety and calling out; -(NN) On 5/31/12 at 12:24 A.M., resident moaning, showing signs and symptoms of pain. [MEDICATION NAME] given; -(MAR) On 5/31/12 at 2:43 P.M., [MEDICATION NAME] 1 mg and [MEDICATION NAME] 200 mg; -(MAR) On 5/31/12 at 8:47 P.M., [MEDICATION NAME] 200 mg; Record review of physician's orders [REDACTED]. -On 6/1/12, [MEDICATION NAME] 400 mg (is used to treat certain infections such as pneumonia, [MEDICAL CONDITION], and sinus, skin, and abdominal infections caused by bacteria). Take one table by mouth daily for seven days. Record review of nurse's notes and MAR showed the following information: -(NN) On 6/1/12:-At 10:47 A.M., Weekly weight meeting. Resident current weight is 91 pounds, previous weight 91 pounds, diet order is pureed honey-thick liquid diet and [MEDICATION NAME] (protein supplement) 1.5 per [DEVICE]. Resident receives diet and tube feedings because of poor intake. -At 12:00 A.M., Therapeutic exercises held this day due to medical decline, nursing aware. -At 3:50 P.M., Resident continues on antibiotic for upper respiratory infection. Afebrile (no fever) at this time. Low-grade temperature this morning. Bilateral lungs are clear with diminished breath sounds. -On 6/2/12 at 11:04 A.M., Resident remained in bed for breakfast, declined to get up. Lungs are clear. Respirations unlabored and even. No signs of pain or anxiety noted. Family member called with condition report given this morning. (Record review of the bowel record showed staff noted on 6/2/12, the resident had two bowel movements,consistency unknown); -(MAR) On 6/3/12 at 11:06 P.M., [MEDICATION NAME] 200 mg and [MEDICATION NAME] 1 mg given for signs and symptoms of pain, restlessness, facial grimacing and moaning. (Record review of the bowel record showed staff noted on 6/3/12, the resident had two bowel movements,consistency unknown); - On 6/4/12 at 1:05 P.M., Resident continues to moan off and on as if in pain. Pain medication not effective because resident showing signs of symptoms of pain. Staff did not document they notified the physician of resident change of condition or the ineffectiveness of pain management. Resident started on antibiotic for upper respirator infection. Temperature 99.1 taken orally this shift. (Record review of the bowel record showed staff noted on 6/4/12, the resident had two bowel movements,consistency unknown); -On 6/5/12 at 11:36 A.M., administered [MEDICATION NAME] 1 mg for anxiety and [MEDICATION NAME] 200 mg for moaning; -Record review of MAR showed on 6/5/12 at 1:28 P.M., staff administered [MEDICATION NAME] 200 mg for pain; -On 6/6/12; -At 12:08 A.M., pulse ox symmetry 88% (normal 90-100%). Two liters of oxygen per nasal cannula ordered. Oral temperature this shift 100.2; -At 3:21 P.M., speech therapy reports that resident is not safe for nutrition by mouth. Resident has decreased ability to follow commands and decreased alertness. (Record review of the bowel record showed staff noted on 6/6/12, the resident had two bowel movements,consistency unknown); -On 6/7/12: -(Record review of MAR on 6/7/12 at 9:20 A.M., shows staff administered [MEDICATION NAME] 1 mg for anxiety and [MEDICATION NAME] 200 mg for signs and symptoms of pain, facial grimacing.) -At 12:00 A.M., the resident sat on edge of bed with maximal staff assistance, the resident only assisted slightly with head and trunk control. Transfer to bed to wheelchair using stand-pivot transfer with dependent assist (resident did not assist with transition); -At 3:58 P.M., Antibiotic therapy completed. Lungs clear, no cough or shortness of breath; Up in wheelchair for breakfast maximum assist. PRN (as needed) pain and anxiety medications given to resident due to restlessness, moaning, calling out and facial grimacing. (Record review of the bowel record showed staff noted on 6/7/12, the resident had two bowel movements,consistency unknown); -Between 5/30/12 to 6/7/12, staff did not document they notified the physician of the resident's change of condition that included his/her unrelieved pain, decreased in level of functioning and increase in episodes of bowel movements (possible diarrhea). -On 6/8/12:-At 3:24 P.M., No signs or symptoms of pain; -At 7:03 P.M., Resident sent by ambulance to local hospital. Staff not include an assessment of why they sent the resident to the hospital. Record review of hospital admission History and Physical dated 6/8/2012, showed [DIAGNOSES REDACTED]. Diff infection ([MEDICAL CONDITION] often called [DIAGNOSES REDACTED]icile or [DIAGNOSES REDACTED], is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from [DIAGNOSES REDACTED]icile most commonly affects older adults in hospitals or in long term care facilities and typically occurs after use of antibiotic medications) (Physician ordered antibiotic [MEDICATION NAME] on 6/1/12.)-UTI; -White blood count (indicates infection) of 22.5. Normal range is (4.03- 10.0). Record review of the re-admission facility History and Physical dated 6/20/12, showed the following Diagnoses: [REDACTED]. Difficile infection; -Severe debility;-Advanced [MEDICAL CONDITION];-Dysphagia with PEG tub feeding;-History of [MEDICAL CONDITION] bladder with chronic indwelling urinary catheter. Record review of the MDS dated [DATE], showed the following information:-Indwelling catheter;-Ambulation does not occur;-Requires extensive assistance from staff for all her needs. Record review of care plan dated 6/13/12, showed:-Dementia with Behavior: Monitor behavior and cognitive status. Report any change in cognitive status to physician; requires extensive assistance with eating, dressing, showering, turning in bed;-Problem onset 7/26/11, potential for UTI related to having a urinary catheter because the resident has a mass in his/her bladder and needs extensive assistance with fluids. Incontinent of bowel and bladder: Monitor for signs and symptoms of UTI such as elevated temperature, unusual frequency, burning, flank pain, communicate to physician as indicated;-[MEDICAL CONDITION]: Observe for change in mental status; notify physician. Monitor for decline in activity of daily living and notify charge nurse. -Staff did not indicate problems, goals and approaches to address care of the urinary catheter and the diagnose [MEDICAL CONDITION]. During the initial tour of the facility on 7/9/12 at 10:40 A.M., observation showed the resident sitting in wheelchair at bedside. He/she appeared thin and frail, feet resting on pillow,neck supported with pillow. A tube feeding pump was infusing supplement into the [DEVICE]. During an interview on 7/13/12 at 9:30 A.M., certified medication technician (CMT) P said the following:-Resident #11 did not have a urinary catheter prior to admission to hospital on [DATE];-The resident had one upon admission in May 2012, and then it was discontinued shortly after admission;-The resident came back from hospital with a urinary catheter. During an 7/13/12 at 9:35 A.M., LPN T said the following: -When receiving an order from physician, staff should document on the phone order sheet, and add it to the physician order [REDACTED]. -Staff should contact the physician about the order; -Staff should note the order and contact the lab to pick-up the specimen;-The lab pick-up for specimens are scheduled twice weekly and they will pick up on weekends;-Staff would be responsible to implement new orders for lab results from the physician;-The nurse should put a copy of the results on the call board for the physician to sign, and give a copy to the Director of nursing (DON), and put a copy in chart;-The nurse would be responsible to communicate to the oncoming nurse if labs needed to be obtained for a resident;-He/she said if a lab could not be obtained for whatever reason he/she would contact the physician within twenty-four hours. During an interview on 7/13/12 at 9:40 A.M., LPN W said the following information: -When staff received an order for [REDACTED]. He/she adds the order to the calendar so if he/she was not able to obtain it on his/her shift, the other shift would know to get the UA;-Staff should attempt to get the catheter UA. If not able to obtain, they should pass it on to the next shift to obtain.-If unable to obtain in two attempts, staff should contact the resident's physician for new orders;-LPN W said five days (between attempt to obtain and order to discontinue) was too long to wait before contacting the physician. LPN W said there was a reason why the UA was ordered. During an interview on 7/13/12 at 9:45 A.M., LPN U said the following: -He/she would write an order on the physician order [REDACTED]. LPN U said he/she would inform the physician if the specimen could not be obtained;-When results were received from lab, staff should page the physician, place a copy on physician's call board to sign, one copy to the DON and one copy goes into the chart;-On 5/30/12, he/she noted the order to discontinue the UA for the charge nurse on the hall because he/she was "swamped". During an interview on 7/13/12 at 1:00 P.M., the DON and nurse consultant said the following information:-When staff received orders for a UA they should note the order and enter the order into the computer;-Staff should document when they obtained the UA;-If staff were unable to obtain the UA they should contact the physician for further orders;-Staff should notify the physician if unable to obtain within the shift;-The DON said, "Five days was too long to wait to notify the physician". During an interview on 7/20/12 at 8:50 A.M., LPN M said the following information: -He/she obtained an order on 5/30/12, to discontinue the UA order;-Initially there was a physician's orders [REDACTED]. The physician wanted to rule out a UTI because of the resident's behavioral changes;-He/she called the physician (on 5/30/12) to discontinue the 5/23/12, UA order because staff could not obtain a urine specimen by catheterization on several attempts (record review showed staff only recorded one attempt to obtain the urine specimen); -Staff should obtain specimen within 24 hours of receiving order, if staff failed to do so, the physician should be contacted; -LPN M said "waiting seven days is too long to wait to contact the physician regarding an order". 2. Record review of Resident #2's fall risk assessment dated [DATE], showed staff noted a score of 70. A score of greater than 10 indicated the resident was a high fall risk. Record review of the admission minimum data set (MDS) a federally mandated assessment tool required to be completed by facility staff dated 4/30/12 showed the following information: -Independent with cognitive decision-making skills;-No long or short-term memory problems; -No falls -Independent with transfers and personal hygiene;-Supervision with toileting; -[DIAGNOSES REDACTED]. Record review of the care plan dated 4/30/12, showed the resident at risk for falls due to weakness and decreased functional ability secondary to stroke leaving the resident with right-sided weakness. During observation and interview on 7/10/12 at 9:45 A.M., the resident sat in the wheelchair at the bedside. The resident was alert and oriented and answered questions appropriately. The resident said several weeks ago (6/8/12), he/she was transferring him/herself to the bed and twisted his/her ankle. He/she told the CMT, he/she had ankle and knee pain and asked for Tylenol. The CMT did not ask the resident why his/her knee and ankle hurt. Observation of the resident's right ankle showed it appeared slightly larger than the left. No visible bruising or redness was present. The resident said the nurse looked at his/her knee and ankle and he/she told the nurse he/she fell . The resident said it took over 10 days to get an x-ray and follow-up from staff and the physician notified. Record review of the physician's orders [REDACTED]. Record review of the medication record for 6/8/12 showed the following information: -At 6:05 P.M., staff noted they administered two 500 mg Tylenol tablets. Staff did not note why they administered the Tylenol;-At 9:20 P.M., staff noted "effective." Record review of the notes showed the following information: -Staff did not document between 5/24/12 to 6/9/12;-On 6/9/12, staff noted telephone orders for Tylenol 500 mg two tablets every four hours as needed for pain or increased temperature. Staff did not document about the resident's complaint of ankle/knee pain and/or about the fall;-Staff did not document between 6/9/12 to 6/20/12;-On 6/20/12 at 10:18 P.M., registered nurse (RN) A noted the resident had swelling in right foot this shift. Resident stated that he/she had fallen approximately two weeks ago and since his/her fall his/her foot has been swollen. The resident reported there was no pain in the foot and he/she could bear weight. No bruising, discoloration or warmth noted to the right foot at this time. Physician paged this shift, awaiting return phone call at this time. Reported to oncoming shift. Record review of the incident report showed the following information: -Narrative of incident: resident noted to have [MEDICAL CONDITION] (swelling from accumulation of fluid) in his/her right foot on 6/20/12. The resident stated that he/she had fallen on 6/8/12 and his/her foot has been swollen since the fall. The resident stated that he/she got him/herself off of the floor and reported it to the charge nurse on duty that night. [MEDICAL CONDITION] in right foot, no complaint of pain and is able to bear weight at this time;-Family and physician notified 6/21/12(13 days later). During an interview on 7/10/12 at 1:40 P.M., CMT D said he/she worked the evening of 6/20/12. He/she noticed the resident's leg was swollen. The resident said it had been like that a while. The resident said it was from a fall. CMT D reported it to the charge nurse RN A. CMT D said the charge nurse said he/she did not think the resident had fallen and there was nothing in the notes about a fall. Record review of the resident incident follow-up (undated) showed the following information: -Narrative of incident: resident noted to have [MEDICAL CONDITION] in right foot on 6/20/12. Resident stated that he/she had fallen on 6/8/12 and his/her foot has been swollen since the fall. Resident stated that he/she got him/herself off of the floor and reported it to the charge nurse on duty that night;-24 hour follow-up:-Mobility: wheelchair: -Mental: alert and oriented;-Vital signs: staff did not document the resident's vital signs;-New orders as a result of the incident: staff did not check the box to indicate any new orders. (staff received orders to obtain an x-ray). During an interview on 7/10/12 at 1:50 P.M., RN A said the following: -CMT D reported to him/her on 6/20/12, he/she completed an assessment and completed the incident report;-He/she paged the physician on 6/20/12, at the end of his/her shift and reported to the oncoming charge;-No further follow-up had been done until his/her next shift on 6/21/12;-He/she notified the nurse practitioner and received orders. Record review of the post-incident actions (undated) showed on the section for "Immediate post-incident action": resident educated to ask for assistance when needed. Record review of the incident investigation (undated) showed the assistant director of nursing (ADON) noted the following information: -Narrative of investigation: Resident can be uncooperative at times. Resident did not request help with transfer at time of fall. Staff unaware of fall until 6/20/12 (record review showed the resident reported the incident on 6/8/12, and staff received orders for Tylenol for the resident's complaints of pain). Resident educated to request assistance when needed. Record review of the notes showed the following information: -Staff did not document between 6/20/12 at 10:18 P.M., to 6/21/12 at 8:53 P.M., (approximately 23 hours);-On 6/21/12 at 8:53 P.M., RN A noted he/she notified the nurse practitioner of the resident's foot and statement of previous fall this day. New orders received for x-ray of right ankle and right foot on 6/22/12. X-ray notified and will be here on 6/22/12. Family notified. Resident notified. Will continue to monitor and report to oncoming shift;-On 6/22/12 at 11:43 A.M., x-ray was completed. Report faxed with no acute fracture or dislocation noted. Record review of the Nursing Home Visit dated 6/26/12, showed the nurse practitioner noted in part the following information: -Chief complaint: resident is being seen today for right ankle pain;-History of present illness: resident apparently twisted his/her ankle, a week or so ago (6/8/12). He/she was apparently ambulating to the bathroom and he/she describes an inversion-type injury (where the ankle is twisted inwards). X-rays were done of his/her foot and ankle which showed nothing acute. He/she states that his/her ankle was getting better, however it is somewhat swollen. He/she was requesting no different pain medication;-Impressions: right ankle sprain;-Plan: I will make no further changes at this time with the resident. He/she does not want any type of brace or anything else done with his/her ankle. We will continue to monitor. During an interview on 7/10/12 at 10:43 A.M., the restorative nurse assistant (RNA) E said he/she did not recall being told about the resident complaining of knee and/or ankle pain. During an interview on 7/10/12 at 10:44 A.M., CMT C said when staff administered an as needed medication, they should document why it was administered and ask the resident to rate their pain and the location. He/she had not received any reports about the resident having any knee and/or ankle pain. Record review of the fall management policy (undated) showed the following information: -In the event the resident does fall, investigate the cause of the fall with as much detail as possible and follow incident policy;-Nurses notes shall reflect all steps taken in the assessment process and interventions to be implemented. Record review of the incident reports on residents policy (undated) showed in part the following information: -An incident is any happening which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may be an incident, or a situation which might result in an incident;-When a resident has had an incident the person discovering the resident gets the charge nurse to evaluate;-Vital signs are taken for 24 hours or a ordered;-Notify the physician and family;-Incident reports are to filled out in detail, all spaces are to be completed. They are to be turned into the Director of nursing (DON) when completed but no later than 24 hours post accident;-Incident reports are to be turned in to the Administrator after reviewed by the DON;-Follow-up check of resident and documentation by DON in 72 hours and condition charted on the incident report. During record review and interview on 7/10/12 at 1:12 P.M., the ADON said the following: -She was responsible for completing fall investigations;-When a resident had a fall or incident, the charge nurse should complete an assessment, call the physician and notify the family;-Staff should complete an incident report and document in the notes;-The ADON reviewed the incident report and incident investigation report. She said staff was not aware of the fall until 6/20/12 (record review showed the resident reported the incident on 6/8/12, and staff received orders for Tylenol for the resident's complaints of pain).-When asked if the ADON had interviewed the staff on duty on 6/8/12, she said she had not done it yet;-She said her goal was to get the investigations done quicker but had gotten behind. During an interview on 7/10/12 at 2:20 P.M., LPN B said the following: -He/she was the charge nurse the evening of 6/8/12; -He/she did recall the resident's complaints of pain;-He/she did not complete a formal pain assessment;-The resident told him/her that he/she was able to bear weight and that it was his/her knee;-He/she asked the resident if he/she felt it needed to be x-rayed. The resident said he/she had a history of [REDACTED]. -He/she did not document in the notes and did not complete an incident report;-He/she should have completed an incident report, "Not sure why I didn't." During an interview on 7/11/12 at 2:37 P.M., the DON and nurse consultant said when a resident had a fall and/or incident, staff should complete an assessment and document in the notes and complete an incident report. The incident reports were brought to the morning meetings and discussed. The goal was to complete the incident investigation within 24 hours and to have appropriate interventions in place.

Based on record review and interviews with staff, the facility failed to monitor a resident (Resident #1) for a change in condition when staff first identified the resident with a change in condition on 1/12/11, when the resident began to limp and required more assistance with activities of daily living (ADLs) and showed increased signs and symptoms of pain. Staff continued to assist the resident and certified nursing assistants (CNAs) continued to report the resident's pain, limping and a bruise until 1/17/11, when an x-ray showed a right [MEDICAL CONDITION]. The licensed practical nurses (LPNs) continued to place calls to the resident's physician and when the physician did not return the calls staff did not follow up or notify the Director of Nursing (DON) or Administrator of the physician not responding. The resident walked on the right [MEDICAL CONDITION] for six days. The facility census was 91. 1. Record review of the undated current facility policy and procedure of suspected abuse and/or neglect showed the following: -The administrator and/or director of nursing (DON) are to be notified immediately of unknown injuries. -Notification of administrative staff must be immediate even outside of normal business hours and should be made through telephone communication. 2. Record review of the undated current facility policy and procedure for change in condition/abnormal vital signs directed staff to notify the resident's physician and family with any change in condition whether no apparent injury or injury is present. 3. Record review of Resident #1's medical record showed the resident admitted to the facility on [DATE], as a hospice patient with end-stage dementia and needed a special care unit. Record review of a history and physical dated 11/20/10, for the resident showed the following: -resident did not speak any English, does not communicate, says occasional words and is in constant motion. -[DIAGNOSES REDACTED]. Record review of the resident's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool required to be completed by facility staff, dated 11/27/10, showed the following: -Total dependence on staff for bed mobility, transfers, toilet use, personal hygiene and dressing. -Extensive assist when resident eats or walks. Record review of the resident's care plan dated 11/24/10, showed facility staff identified the resident as a fall risk related to cognitive status and the care plan directed staff to observe/document/report any functional decline. The care plan directed staff to monitor for actual/potential pain and to notify the charge nurse of signs and symptoms of pain, both verbal and non-verbal, administer pain medication per physician orders [REDACTED]. It directed staff to provide staff assistance for all ADL's. Record review of the CNA ADL form for the evening (2 to 10 shift) dated January 2011, showed the following: -On 1/12/11, staff documented the resident limped, seemed to have pain on the resident's right leg and the staff notified the nurse; -On 1/13/11, the resident limped with pain on his/her left leg and staff notified the nurse. The resident seemed to have pain which seemed to be more hip pain throughout the evening and the CNA notified the nurse again; -On 1/14/11, the resident had a hard time walking to the bathroom with two person assist, seemed extremely painful and the resident kept grabbing the right hip and staff notified the nurse; -On 1/15/11, staff documented the hip did not seem any better. The resident still seemed to be in a lot of pain, even when turning the resident in bed and staff notified the nurse; -On 1/16/11, the resident would not walk, limps in pain, and the resident had a bruise on the hip that the resident grabbed at and staff notified the nurse. Record review of the current January 2011, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review showed staff administered the as needed [MEDICATION NAME]/[MEDICATION NAME] twice on 1/14/11 and twice on 1/17/11. The PRN medication record showed staff administered as needed pain medication ([MEDICATION NAME]) at 7:00 A.M. and 4:40 P.M. on the 14th for right lower extremity pain with relief and again on the 17th at 2:00 A.M. and 12:45 P.M. for right hip pain. Record review of the nursing notes showed the following: -On 1/10/11, at 10:14 A.M., the resident was up ambulating with no signs and symptoms of pain, the resident wandered and pilfered and staff re-directed the resident. -On 1/13/11, at 8:29 P.M., LPN B documented the resident ambulated with a limp to his/her right foot, no swelling or bruising noted, tender to manipulation and staff placed a call to the physician on-call. An addendum added at 9:37 P.M. LPN B documented, upon further examination, the resident grimaced and moaned with right leg movement and no swelling or bruise noted. LPN B paged the physician on-call and staff did not receive a return call from the physician. Staff passed this information to the on-coming shift. -On 1/14/11, at 1:22 P.M., LPN C documented the resident exhibited facial grimace with movement of right lower extremity this A.M., and staff administered pain medication ([MEDICATION NAME]) and documented the resident showed relief. Staff assisted the resident up with no further signs and symptoms of pain, no bruises or abnormalities noted to right lower extremity or hip and both lower extremities were symmetrical. -On 1/15/11, at 10:36 A.M., LPN C documented the resident exhibited no signs or symptoms of pain, the resident remained resting in bed between meals, was sleepy this A.M. and did not eat his/her meal. -On 1/16/11, at 10:24 A.M., LPN C documented staff assisted the resident to his/her wheelchair and the resident had a fair appetite and showed no signs or symptoms of pain. -On 1/17/11, at 3:40 A.M., LPN D documented the resident with facial grimacing when staff moved the right lower extremity but the resident had no apparent bruise, staff administered an as needed pain medication and the resident showed some relief. The resident remained resting quietly in bed. -On 1/17/11, at 10:38 A.M., LPN A documented the resident had tenderness to the right leg with palpitation and ambulation but with no noted deformities or unexpected rotation upon assessment. LPN A noted yellow faint bruising to right outer hip approximately a half dollar size of unknown origin. LPN A called the family nurse practitioner (FNP) and the DON and the FNP gave an order for [REDACTED].M., hospice notified at 8:55 A.M. and family notified at 9:00 A.M. At 1:16 P.M., LPN A documented mobile x-ray was in to perform the x-ray at noon and the nurse assisted with the x-ray and at 12:52 via fax from the x-ray company, the resident did have a right [MEDICAL CONDITION]. LPN A left messages with hospice, family and the physician of the x-ray results. Staff received a return call from the resident's family at 2:22 P.M. and family requested the resident be sent to hospital for further evaluation and treatment. Staff called the FNP with the family's request to send resident to the hospital. The resident left the facility at 3:45 P.M. by ambulance. Record review showed on 1/17/11, facility staff LPN A completed an incident report and contacted the resident's physician, family member and hospice of the resident's condition. During an interview on 1/26/11 at 10:00 A.M., LPN C said the resident resided in the unit, was a fall risk, and was ambulatory before the [MEDICAL CONDITION]. He/she stated the resident started favoring the right hip but showed no signs or symptoms of pain. He/she did an assessment and found no bruising and no indication such as shortening of a leg or rotation outward or inward to indicate a fracture. He/she stated he/she gave the resident pain medication. He/she could not remember the exact date this occurred but it happened the week of January 10, 2011. LPN C stated the resident was a hospice patient and he/she called hospice and did not receive a call back. He/she did not call the resident's physician. During an interview on 1/26/11 at 10:10 A.M., Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) E said he/she worked in the unit and did know the resident. He/she said the resident normally ambulated all over the unit and fell a lot. He/she did not remember a specific fall but, the day he/she noticed the resident limped, it was about two days before staff sent the resident to the hospital. He/she first noticed the resident exhibited signs and symptoms of pain on the night shift and it was reported to LPN C. He/she did find a bruise on the resident's right hip. He/she said LPN C called the hospice nurse and did not know what happened after that, other than the resident walked less with the pain and limp in the right hip. During an interview on 1/26/11 at 10:30 A.M., the DON said LPN F who worked the night of 1/12/11, and to whom staff first reported the resident with signs and symptoms of pain and limping, was suspended on 1/17/11, when the DON began the investigation. The facility terminated LPN F's employment when they determined the nurse did not document assessing the resident. During an interview on 1/26/11 at 2:00 P.M., LPN A said on 1/17/11, he/she worked the evening shift and during breakfast that day the staff reported the resident limped over the weekend and the resident had a bruise on his/her right hip. LPN A said he/she did an assessment and found the resident had tenderness on the right hip/leg area but noted no shortening or rotation. He/she called the family and hospice and called the physician for an order for [REDACTED]. He/she said the resident was a two person assist that day and was normally a one person assist. LPN A said the x-ray showed a fracture and the FNP, family and hospice stated to send the resident to the hospital. During an interview on 1/26/11 at 2:05 P.M., CNA G and CNA H, both said they work the special care unit and on 1/12/11 they noticed the resident did not act like him/her self when they assisted the resident to the bathroom. The resident limped on the right side. Both CNA G and CNA H said they told LPN F they thought the resident may have hurt his/her foot. Both the CNAs stated they did not see the nurse assess the resident but knew the nurse had a hard time getting the resident to take his/her medication. On 1/13/11, they walked the resident to the bathroom and the resident showed signs and symptoms of pain and grabbed his/her hip. The last time the two CNAs did rounds they did not get the resident up due to the pain and when they rolled the resident in bed to change him/her they both realized the resident's hip hurt and not his/her foot. Both CNAs notified the LPN B who assessed the resident and called the on-call physician, but the physician never called back. On 1/15/11, both CNAs said they saw bruising on the resident's hip. They were told by nursing they called the physician who did not return their calls and the CNAs kept reporting the pain to the nurses. On 1/17/11, both CNAs said they went to the DON who said he/she was aware of the problem with the resident and the resident did have a fracture and had been sent to the hospital. During an interview on 1/26/11 at 2:11 P.M., LPN B said he/she worked on the unit on 1/13/11 and 1/14/11, and the two CNAs reported the resident limped. He/she assessed the resident and the resident showed signs and symptoms of pain and he/she paged the physician. He/she stated when the CNAs cleaned the resident up later that shift the resident grabbed his/her hip and reported to him/her again. LPN B said he/she again called the physician with no response. LPN B said he/she gave the resident pain medication and told staff to keep the resident off the hip and passed the information to the on-coming nurse. During a telephone interview on 1/27/11, at 2:50 P.M., LPN I said that on 1/13/11, during the night shift, during shift change from evening to nights that the aides reported the resident limped. He/she said he/she assessed the resident and found no bruising but did notice the resident grimace during range of motion assessment. He/she did not call the resident's physician because he/she had been told the evening shift nurse had called but received no call back. He/she passed the information on to the day shift nurse and did not work with the resident again. LPN I also stated the resident had chronic pain and when the resident showed signs and symptoms of pain he/she did not know if this was new or just the continuing pain, although the resident did not limp prior to this date. During an interview on 1/27/11 at 3:05 P.M., CNA J said he/she worked the evening shifts from Thursday to Sunday in the special care unit. He/she worked with another aide on 1/13/11 and it was obvious the resident was in pain. He/she said the resident would not put weight on the right side and staff usually assisted the resident with one staff member but this night the resident required two staff. He/she said when staff turned the resident in bed the resident flinched. He/she reported to the nurse who stated he/she would administer pain medication and report it. He/she said the resident usually walked around but this evening the resident sat in a wheelchair and did not act him/her self, toileting the resident was difficult. CNA J stated he/she did not report it again but thought the other aides reported to nursing staff each night. During an interview on 1/27/11, at 11:15 A.M., graduate practical nurse (GPN) D said he/she had worked at the facility about a month and just completed his/her nursing training. He/she worked the evening shift most times and nights a few times. He/she could not remember the exact date he/she worked but thought it was 1/13/11. The resident had not shown signs and symptoms of pain prior and had been ambulatory. GPN D said on 1/13/11, he/she thought the resident showed signs and symptoms of pain. He/she gave pain medication and assessed the resident and found no bruising but the resident did have tenderness to the right hip area. He/she did not call the resident's physician and had not worked with this resident again until after the resident had the x-ray and was sent out to the hospital. He/she said he/she stilled received training since he/she was new. He/she thought the facility thought he/she should have contacted the physician and asked for an x-ray to the right hip. Complaint Number MO 935