Every finding on record at Riverways Manor

Based on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect all residents. The facility census was 46.The facility did not provide a policy for equipment maintenance. The facility did not provide current invoices related to commercial electric range repairs. Review of the Electric Range Estimates showed:- On 07/09/25, an estimate for a replacement of the electric range was obtained, but no further action taken;- On 08/07/25, an estimate for a replacement of the electric range was obtained, but no further action taken. Observation on 01/19/26 at 10:30 A.M., of the kitchen showed:- One commercial electric range with no working burner elements. During an interview on 01/20/26 at 11:42 A.M., Dietary Aide (DA) F said the soup was warmed in the oven because the top burners did not work on the electric range. During an interview on 01/20/26 at 11:48 A.M., the Dietary Manager (DM) said the electric range stove top was not working properly. There were no other burners on the electric stove to warm food. The burners had not worked for approximately six months. There were three top burner elements cracked and deformed, and a pot or skillet would not sit evenly on top of the burners. He/She was told not to use burners. The other elements on the electric stove top did not work at all and did not heat. Repairs had been requested to be made to the range multiple times in the last six months and there was a new Maintenance Supervisor (MS). The past Administrator was aware of the concern with the range and tried to get it replaced. The new Administrator was aware of the concern and had called for repairs. The oven section of the range did not heat properly, and cakes and cornbread did not cook evenly. The staff left the steam table on low because it could over boil and might need repairs. Staff warmed up soup in the oven and placed it on the steam table. Foods would need to be reheated that had cooled down. During an interview on 01/21/26 at 1:10 P.M., the MS said the electric range in the kitchen had been looked at by an outside contractor but not serviced, and the elements needed to be replaced. There was one bad burner out of 10 on the stove and no other issues than the top burner. He/She was not aware of any other problems with the range and hadn't heard the oven wasn't warming properly. During an interview on 01/21/26 at 2:38 P.M., the Administrator said the electric range burners were out of service and there might be an issue with the oven. There was a contractor here last Friday, but she didn't have a copy of an estimate available for the repairs. There were copies of estimates available from the past Administrator who wanted the range replaced several months ago. The range should be repaired or replaced.

Based on observation, interview, and record review, the facility failed to ensure placement of the urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was maintained for one resident (Resident #10) out of two sampled residents. The facility census was 46.Review of the facility's policy titled, Catheter Care, Urinary, dated August 2022, showed:- Be sure the catheter tubing and drainage bag are kept off the floor. 1.Review of Resident #10's medical record showed:- admitted on [DATE];- Diagnosis of urinary retention. Review of the resident's Physician Order Sheet (POS), dated January 2026, showed:- An order to change the Foley (a type of indwelling catheter) catheter 16 French (size of the catheter) 30 millimeter (ml) balloon and bag, monthly on the 8th using sterile technique, dated 01/08/26. Review of the resident's Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 01/15/26, showed:- Used an indwelling catheter. Review of the resident's Care Plan, dated 01/08/26, showed:- Resident with an indwelling catheter;- Evaluate character of urine;- Provide Foley catheter care every shift and as needed;- Monitor urinary output every shift and document;- Assist the resident to the bathroom every two hours and as needed. Observations of the resident on 01/20/26 at 11:40 A.M., 2:05 P.M., and 3:27 P.M., showed:- The resident sat in a wheelchair, the catheter drainage bag hung from the wheelchair, a privacy cover covered the catheter drainage bag, and approximately eight inches of tubing lay on the floor. During an interview on 01/20/26 at 2:05 P.M., Resident #10 said staff hadn't given assistance with his/her catheter drainage bag or tubing since around lunch time. During an interview on 01/21/26 at 1:34 P.M., Nursing Assistant (NA) A said he/she had training and watched videos on catheter care. Catheter drainage bags should be placed on the side of the bed or on the wheelchair. The drainage bag should be in a dignity bag. The bag and tubing should not touch the floor. During an interview on 01/21/26 at 1:40 P.M., Licensed Practical Nurse (LPN) E said the catheter drainage bag should be in a dignity bag. The drainage bag should be hung from the side of the bed. The drainage bag and tubing should be kept off the floor completely. During an interview on 01/21/26 at 1:45 P.M., Certified Nursing Assistant (CNA) B said when checking on residents with a catheter, the drainage bag should be under the resident and hooked under the wheelchair or on the bed rail. It should be in a dignity bag and covered always. The drainage bag and tubing should be off the floor. During an interview on 01/21/26 at 1:49 P.M., CNA C said residents with a catheter should have the drainage bag placed under them between their knees and the tubing should not be on the floor. During an interview on 01/21/26 at 1:51 P.M., CNA D said residents with a catheter should have the catheter bag covered with a dignity bag and it should be completely off the floor. The tubing should also never touch the floor. During an interview on 01/21/26 at 2:00 P.M., the Director of Nursing (DON) said she expects the catheter drainage bag to be in a dignity bag and the drainage bag and tubing should not be in the floor. During an interview on 01/21/26 at 2:55 P.M., the Administrator said she would expect the staff to follow the facility's policy and procedure regarding keeping catheter drainage bags and tubing from touching the floor.

Based on interview and record review, the facility failed to limit the use of as needed (PRN) psychotropic (medication that affect a person's mental state) medication orders for 14 days for one resident (Resident #46) out of three sampled residents, and failed to ensure an appropriate diagnoses for the use of an antipsychotic (medication that treats mental disorders characterized by a disconnection from reality) medication for one resident (Resident #40) out of two sampled residents. The facility census was 46. Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction, dated February 2025, showed: -The practitioner and staff identify symptoms for which a resident is receiving medication and monitor the resident for changes in those symptoms; -Behavior interventions are used to support the resident during and after GDR of a psychotropic medication. Review of the facility's policy titled, Psychotropic Medication Use, dated February 2025, showed: -Adequate indication for use refers to the identified, documented clinical rationale for administering medication; -Diagnosis alone does not necessarily warrant the use of psychotropic medication; -If a psychiatric diagnosis is part of the rationale for the use of psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for that diagnosis; -PRN orders for psychotropic medications are limited to 14 days; -For psychotropic medications that are not antipsychotics if the prescriber believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. 1. Review of Resident #40's medical record showed: -Date of admission [DATE]; -Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with psychotic disturbance, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety disorder (persistent worry and fear about everyday situations), and insomnia (difficulty sleeping). Review of the resident's Physician's Order Sheet (POS), dated January 2026, showed: -An order for Seroquel (an antipsychotic medication) 100 milligram (mg) tablet, give 0.5 tablet by mouth once a day and 1 tablet by mouth once a day, related to unspecified dementia, with psychotic disturbance, dated 05/07/25. Review of the Seroquel manufacturer's safety information, the black box warning showed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for elderly patients with dementia-related psychosis. Review of the resident's Gradual Dosage Reduction (GDR), dated 01/17/26, showed: -Seroquel 50 mg in morning and 100 mg at bedtime; -No changes should be made regarding the above regimen due to resident not being stable enough to handle dose reductions; -Resident no longer trying to walk without assistance and falls decreased; -No mention of any discrepancies with the manufacturer's black box warning, diagnosis or behaviors. Review of the resident's care plan, dated 12/18/25, showed: -Resident takes an antipsychotic medication Seroquel for dementia with psych behaviors; -Interventions included administer medication as ordered, invite resident to activities of interest and take time to talk and visit with him/her, and monitor for adverse reactions to medication and record. Contact physician as needed; -No mention of any discrepancies with the manufacturer's black box warning. 2. Review of Resident #46's POS, dated January 2026, showed: -Date of admission [DATE]; -Date of hospice admission [DATE]; -Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with psychotic disturbance and hospice care (health care that focuses on the quality of life of a terminally ill person), started 12/18/25; - An order for lorazepam (an anti-anxiety medication) concentrate 2 milligram (mg)/milliliter (ml) 0.25, or 0.50, or 0.75, or 1 ml by mouth every one hour PRN for anxiety/terminal restlessness, dated 12/19/25; - The facility failed to provide a 14 day stop date order for the lorazepam. During an interview on 01/21/26 at 1:20 P.M., the Director of Nursing (DON) said PRN psychotropics should all have a 14 day stop date. The DON said Dementia isn't usually an acceptable diagnosis for Seroquel, but thought, in Resident #40's case, it would be since the resident's dementia diagnosis included psychotic disturbances. The DON said she was aware of the black box warning for Seroquel. During an interview on 01/21/26 at 1:50 P.M., the Administrator said she would expect policy and procedures to be followed to include 14 day stop date for PRN psychotropics and appropriate documentation for behaviors and correct diagnosis.

Based on observation, interview and record review, the facility failed to maintain infection control practices during disinfection of a facility glucometer (a device for measuring the concentration of glucose in the blood) used for glucose (the main type of sugar in the blood) monitoring for three residents (Residents #22, #25 and #31) out of three sampled residents. The facility failed to maintain proper infection control practices during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #39) out of one sampled resident. The facility census was 47. The facility did not provide a policy on cleaning and disinfecting the glucometer. Review of the PDI Super Sani Cloths Manufacturer's Disinfection Directions showed: - If present, use a wipe to remove visible soil prior to disinfecting; - Unfold a clean wipe and thoroughly wet the surface; - Allow the treated surface to remain wet for two minutes; - Allow to air dry; - Dispose of the wipe after a single use. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: - Hand hygiene is indicated: immediately before touching a resident; before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; immediately after glove removal; - The use of gloves does not replace hand washing/hand hygiene. The facility did not provide a catheter care policy. 1. Observation of the blood glucose monitoring on 09/26/24, showed: - At 11:17 A.M., Licensed Practical Nurse (LPN) C performed blood glucose monitoring with the facility glucometer for Resident #25; - At 11:19 A.M., LPN C wiped down the glucometer with a PDI Super Sani Cloth and placed it on a clean paper plate to air dry. The glucometer did not remain wet for two minutes; - At 11:30 A.M., LPN C wiped down the same facility glucometer with a PDI Super Sani Cloth and placed it on a clean paper plate to air dry. LPN C performed blood glucose monitoring for Resident #22; - At 11:33 A.M., LPN C wiped down the glucometer with a PDI Super Sani Cloth and placed it on a clean paper plate to air dry. The glucometer did not remain wet for two minutes; - At 11:37 A.M., LPN C performed blood glucose monitoring for Resident #31 using the same facility glucometer; - At 11:39 A.M., LPN C wiped down the glucometer with a PDI Super Sani Cloth and placed it on a clean paper plate to air dry; - LPN C failed to disinfect the facility glucometer by allowing it to remain wet for two minutes between each resident use. During an interview on 09/26/24 at 11:41 A.M., LPN C said he/she was told to wipe the glucometer down with the wipe and allow it to air dry for two minutes between each resident use. During an interview on 09/26/24 at 11:50 A.M., Registered Nurse (RN) A said the glucometer should be wiped down and remain wet for two minutes, then allowed to air dry between each resident use. He/She usually wiped it down, wrapped it in a clean PDI Sani Cloth, allowed it to sit for the two minutes, and then air dry. During an interview on 09/26/24 at 11:54 A.M., the Director of Nursing (DON) said she would expect staff to clean and disinfect the glucometer making sure it remained wet for two minutes and then let it air dry. 2. Observation of catheter care for Resident #39 on 09/26/24 at 9:12 A.M., showed: - Certified Nursing Assistant (CNA) D and CNA G performed hand hygiene and put on gloves; - CNA G cleaned the catheter tubing with a twisting motion approximately two inches down the tubing, folded the washcloth, cleaned the tubing up toward the insertion site with a twisting motion, and did not pull the foreskin on the penis back to access the insertion point; - CNA G did not perform hand hygiene and without changing gloves, CNA G touched the resident's blanket and the resident to assist him/her to turn to the side; - CNA D removed gloves, performed hand hygiene, exited the room to retrieve supplies, returned to the doorway, and handed CNA G an incontinent pad through the privacy curtain; - CNA G did not perform hand hygiene and without changing gloves, CNA G placed the incontinent pad under the resident, touched the resident to roll to the side, touched the blanket, touched the foot board of the bed; - CNA G changed gloves and without performing hand hygiene, CNA G retrieved a container from the shared bathroom, set the container on the floor, emptied the catheter drainage bag into the container, emptied the container into the toilet, placed the soiled container on the back of the toilet with two clean rolls of toilet paper, removed the gloves, did not perform hand hygiene, gathered bags of trash and soiled linens, touched the inside doorknob of the room, walked to the barrel in the hall, touched the barrel lid, placed the soiled linen in the barrel, replaced the lid, took the trash to the barrel on another hall, touched the barrel lid, and performed hand hygiene. During an interview on 09/27/24 at 8:35 A.M., CNA G said for catheter care on a male, clean the top of the catheter tube starting at the penis down the catheter. If the resident was uncircumcised, pull the foreskin back, clean the tube from the penis down the tube and then put the foreskin back in place. Change gloves and wash hands if gloves were soiled, and before touching anything else. Remove gloves and wash hands or sanitize when care was complete. During an interview on 09/27/24 at 10:45 A.M., LPN C said for incontinent care, perform hand hygiene before care, put on gloves, use one cloth per wipe, remove the dirty items, change gloves, and wash hands, put on clean items, remove gloves, and wash hands. For catheter care, clean from the top of the catheter and go down. Should clean the entire area of the tube and go straight down the tube. During an interview on 09/27/24 at 10:45 A.M., Registered Nurse (RN) A said if the resident was not circumcised, pull the foreskin back, clean down the catheter tube and put the foreskin back in place. During an interview on 09/27/24 at 11:15 A.M., the DON said for incontinent care, wash hands, go in the room, and put on gloves. Wash hands and change gloves between dirty and clean tasks, before handling personal effects and wash hands before exiting the room. For catheter care on an uncircumcised resident, pull back the foreskin, clean straight down the catheter, not back and forth, and put the foreskin back. 47445

Based on observation, interview, and record review, the facility to follow physician's orders for four residents (Residents #7, #16, #17 and #29) out of four sampled residents when the facility failed to ensure medications were available to administer to the residents. The facility also failed to ensure medications were administered within the prescribed time frame for two residents (Residents #25 and #41) out of nine sampled residents. The facility census was 47. Review of facility policy titled, Administering Medication, revised April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - Medications are administered within one hour of their prescribed time, unless otherwise specified or liberal medication passes; - The policy didn't address the time frame for ordering of medication refills. 1. Review of Resident #7's Physician Order Sheet (POS), dated September 2024, showed: - Diagnosis of anxiety (persistent worry and fear about everyday situations); - An order for buspirone (antianxiety medication) 7.5 milligram (mg) one via gastrostomy (g-tube - a tube placed in the stomach for nutrition and medication administration) two times a day, dated 06/04/24, with a hold date of 09/24/24 at 10:05 A.M., due to awaiting medication from the pharmacy. Review of the resident's Medication Administration Record (MAR), dated September 2024, showed: - Buspirone 7.5 mg two times a day related to anxiety disorder, dated 06/04/24, with a hold date of 09/24/24-09/26/24; - Five doses of the buspirone missed out of five opportunities on 09/24/24-09/26/24. Review of the resident's Nurse's Notes, dated 09/24/24 at 10:06 A.M., showed buspirone 7.5 mg placed on hold per the physician due to the facility not receiving the medication from the pharmacy. 2. Review of Resident #16's medical record showed: - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life) and glaucoma (a disease affecting eye pressure and causing gradual loss of vision). Review of the resident's POS, dated September 2024, showed: - An order for fluoxetine (an antidepressant) 5 milliliters (ml) by mouth one time a day, dated 06/04/24, on hold 09/24/24; - An order for Xalatan Ophthalmic Solution (medication used to treat glaucoma) 0.005% instill one drop in both eyes at bedtime for glaucoma, dated 06/03/24, on hold 09/25/24. Review of the resident's MAR, dated September 2024, showed: - Fluoxetine 5 ml by mouth one time a day, on hold awaiting from the pharmacy, dated 09/24/24; - Two doses of the fluoxetine missed out of two opportunities on 09/24/24-09/25/24; - Xalatan Ophthalmic Solution 0.005% instill one drop in both eyes at bedtime for glaucoma, on hold awaiting from pharmacy from 09/25/24-09/29/24, dated 09/25/24; - Two doses of the Xalatan missed out of two opportunities on 09/25/24-09/26/24. Review of the resident's Nurse's Note, dated 09/25/24, showed: - At 5:07 P.M., a new order per the physician to hold the eye drops until the Xalatan was received from the pharmacy. 3. Review of Resident #17's medical record showed: - Diagnosis of hemiplegia (loss of strength or paralysis on one side of the body). Review of the resident's POS, dated September 2024, showed: - An order for hydrocodone-acetaminophen (an opioid pain medication) 5-325 mg by mouth four times a day for pain, dated 06/18/24; - An order for hydrocodone-acetaminophen 5-325 mg by mouth four times a day for pain, on hold from 09/25/24 at 8:48 A.M.-09/30/24 at 8:47 A.M., awaiting from the pharmacy, dated 09/25/24 at 7:32 P.M.; - An order to resume hydrocodone-acetaminophen 5-325 mg by mouth four times a day for pain, dated 09/25/24 at 4:40 P.M., due to the medication was pulled from the emergency medication kit (E-Kit). Review of the resident's MAR, dated September 2024, showed: - Hydrocodone-acetaminophen 5-325 mg by mouth four times a day for pain, on hold date of 09/25/24 at 8:48 A.M.-09/25/24 at 04:20 P.M.; - Four doses of the hydrocodone-acetaminophen missed out of four opportunities on 09/24/24-09/25/24. Review of the resident's Nurses Notes showed: - On 09/24/2024 at 7:32 P.M., hydrocodone-acetaminophen 5-325 mg by mouth four times a day for pain. Medication on hold awaiting from the pharmacy; - On 09/24/2024 at 11:59 P.M., hydrocodone-acetaminophen 5-325 by mouth four times a day for pain. Medication out of stock, reorder had been sent to the pharmacy; - On 09/25/2024 at 5:05 A.M., hydrocodone-acetaminophen 5-325 mg by mouth four times a day for pain. Medication out of stock, request had been sent to the pharmacy, not filled as of 09/25/24 at 5:00 A.M.; - On 09/25/2024 at 8:46 A.M., new order from the physician to hold hydrocodone-acetaminophen 5-325 mg until received from the pharmacy. All parties made aware. During an interview on 09/26/24 at 4:09 P.M., Resident #17 said he/she had not been able to get his/her pain medicine for a couple of days. He/She had pain to his/her back and just all over, and was told by the staff that the physician was out and they were unable to get the medicine filled until he/she got back. 4. Review of Resident #25's medical record showed: - Diagnoses of diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), anxiety disorder, polyneuropathy (a sudden and severe kidney infection), and chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should). Review of the resident's POS, dated September 2024, showed: - An order for insulin glargine inject 30 units subcutaneously (an injection under the skin) at bedtime related to type two diabetes mellitus without complications, dated 09/12/24. Review of the resident's MAR, dated 09/16/24-09/23/24, showed: - Insulin glargine inject 30 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications, dated 09/12/24; - On 09/16/24, 8:00 P.M., scheduled insulin glargine administered on 09/16/24 at 11:19 P.M.; - On 09/20/24, 8:00 P.M., scheduled insulin glargine administered on 09/21/24 at 3:27 A.M.; - On 09/21/24, 8:00 P.M., scheduled insulin glargine administered on 09/22/24 at 4:23 A.M.; - On 09/22/24, 8:00 P.M., scheduled insulin glargine administered on 09/23/24 at 3:26 A.M.; - On 09/23/24, 8:00 P.M., scheduled insulin glargine administered on 09/24/24 at 3:55 A.M.; - Five doses of insulin glargine not administered as ordered out of eight opportunities on 09/16/24, and 09/20/24-09/23/24. During an interview on 09/26/24 at 3:40 P.M., Resident # 25 said the staff sometimes woke him/her up to give the insulin glargine after his/her bedtime. 5. Review of Resident #29's medical record showed: - Diagnoses of edema, atrial fibrillation (an irregular heart rate) and insomnia (difficulty sleeping). Review of the resident's POS, dated September 2024, showed: - An order for furosemide (a diuretic medication) 40 mg by mouth daily, dated 09/12/24, on hold 09/26/24-09/30/24, medication was out; - An order for trazodone (an antidepressant medication) 50 mg by mouth one time a day, dated 08/26/24, and hold on 09/23/24-09/25/24 due to awaiting from the pharmacy. Review of the resident's MAR, dated September 2024, showed: - Furosemide 40 mg by mouth daily, on hold 09/26/24-09/30/24, awaiting from the pharmacy; - One dose of furosemide missed out of one opportunity on 09/26/24, medication not in the building; - Two doses of trazodone missed out of two opportunities on 09/23/24-09/24/24. Review of the resident's Nurse's Notes, showed: - On 09/25/24, a new order per the physician to hold the furosemide until it was received from the pharmacy; - On 09/23/24, trazodone 50 mg unavailable from the pharmacy, placed on hold per the physician until it came in from the pharmacy. 6. Review of Resident #41's medical record showed: - Diagnoses of malignant neoplasm of esophagus (throat cancer), adult failure to thrive, unspecified severe protein-calorie malnutrition, and acute gastritis (inflammation of the lining of the stomach) with bleeding. Review of the resident's POS, dated September 2024, showed; - An order for TwoCal HN Oral Liquid (a nutritional supplement) give 237 ml via g-tube four times a day related to unspecified severe protein-calorie malnutrition. May use Osmolite 1.5 (a nutritional supplement) if TwoCal HN was unavailable, dated 09/16/24; - An order to flush the g-tube with 237 ml water one time a day related to unspecified severe protein-calorie malnutrition, dated 09/17/24; - An order to check the residual (the fluid remaining in the stomach) with each g-tube feeding. If residual greater than 250 ml, hold for two hours, recheck, and if less than 125 ml, resume feeding, four times a day related to unspecified severe protein-calorie malnutrition, dated 09/16/24; - An order to flush the g-tube with 237 ml water five times a day - four times a day with feedings and once in the morning, related to unspecified severe protein-calorie malnutrition, dated 09/16/24. Review of the resident's MAR, dated 09/16/24-09/24/24, showed: - TwoCal HN Oral Liquid give 237 ml via g-tube four times a day related to unspecified severe protein-calorie malnutrition, dated 09/16/24; - On 09/21/24 at 9:00 P.M., scheduled TwoCal HN Oral Liquid feeding administered on 09/22/24 at 4:24 A.M.; - On 09/22/24 at 9:00 P.M., scheduled TwoCal HN Oral Liquid feeding administered on 09/23/24 at 3:27 A.M.; - On 09/23/24 at 9:00 P.M., scheduled TwoCal HN Oral Liquid feeding administered on 09/24/24 at 5:51 A.M.; - Three doses of TwoCal HN not administered as ordered out of 36 opportunities on 09/22/24-09/24/24; - An order to check the residual with each g-tube feeding. If residual greater than 250 ml, hold for two hours, recheck, and if less than 125 ml, resume feeding, four times a day related to unspecified severe protein-calorie malnutrition, dated 09/16/24; - On 09/21/24 at 9:00 P.M., scheduled residual check completed on 09/22/24 at 4:24 A.M.; - On 09/22/24 at 9:00 P.M., scheduled residual check completed on 09/23/24 at 3:28 A.M.; - On 09/23/24 at 5:00 P.M., scheduled residual check showed no documentation of completion; - On 09/23/24 at 9:00 P.M., scheduled residual check completed on 09/24/24 at 1:44 A.M.; - Four residual checks not completed as ordered out of 36 opportunities on 09/21/24-09/23/24; - Flush the g-tube with 237 ml water five times a day - four times a day with feedings and once in the morning, related to unspecified severe protein-calorie malnutrition, dated 09/16/24; - On 09/20/24 at 9:00 P.M., scheduled flush administered on 09/21/24 at 2:48 AM; - On 09/21/24 at 9:00 P.M., scheduled flush administered on 09/22/24 at 4:26 A.M.; - On 09/22/24 at 6:00 A.M., scheduled flush no documentation of administration; - On 09/22/24 at 9:00 P.M., scheduled flush administered on 09/23/24 at 3:28 A.M.; - On 09/23/24 at 6:00 A.M., scheduled flush administered on 09/24/24 at 4:33 A.M.; - On 09/23/24 at 5:00 P.M., scheduled flush showed no documentation of completion; - On 09/23/24 at 9:00 P.M., scheduled flush administered on 09/24/24 at 1:44 A.M.; - On 09/24/24 at 6:00 A.M., scheduled flush administered on 09/24/24 at 9:24 A.M. - Eight g-tube flushes not completed as ordered out of 45 opportunities on 09/20/24-09/23/24. Observations and interview of the resident on 09/24/24, showed: - At 11:46 A.M., the resident said the nurses didn't give his/her g-tube feedings on time; - At 12:00 P.M.-1:05 P.M., the g-tube feeding, residual check, and the flush not offered or completed; - At 1:53 P.M., the resident lay in bed and said the noon g-tube feeding was never done for the 12:00 P.M., scheduled feeding. He/She said the staff needed to come on and do it because he/she was tired of waiting; - At 2:26 P.M., Licensed Practical Nurse (LPN) I stood with medication/treatment cart outside of the resident's room, pulled one carton of TwoCal HN from the cart, and put on an isolation gown and gloves from the Enhanced Barrier Precautions (EBP) container outside room. LPN I said the resident didn't want to get his/her feeding at noon, so nurses just held it and asked him/her again later, since he/she was already so skinny. LPN I placed the TwoCal HN carton back in the cart and walked down the hall toward the nurse's station; - At 2:29 P.M., LPN I returned to the cart outside the resident's room, said he/she had already administered the TwoCal HN g-tube feeding, the residual check, and the flush to the resident at 12:30 P.M., and forgot to complete the documentation. He/She documented the g-tube feeding about 10 minutes ago. LPN I entered the residents's room and told the resident his/her next feeding was at 5:00 P.M. During an interview of 09/25/24 at 9:59 A.M., Registered Nurse (RN) A said if a tube feeding was administered late, he/she would call the doctor and see if they wanted to go ahead and give it and write an order for that particular time. During an interview on 09/26/24 at 10:26 A.M., Certified Medication Technician CMT (H) said the A.M. medications should be given between 7 A.M.-10 A.M. If it was later, he/she would not give the medications until it was discussed with the charge nurse or the Director of Nursing (DON). During an Interview on 09/26/24 at 1:38 P.M., the DON said the A.M., medications should be given between 8 A.M.-10 A.M. During an interview on 09/27/24 at 10:30 A.M., LPN B said he/she passed medications on 09/24/24, due to both CMT's had called in. He/She did not generally pass medications and he/she was very slow since not familiar with the medication cart. The medications were late because of that and they should be administered within the correct time frame. During an interview on 09/27/24 at 10:43 A.M., RN A said the medication cards had a place on them that alerts staff when the medications should be reordered. It was the responsibility of the CMT's and the nursing staff passing the medications to reorder the medications. The residents should not run out of medications. During an interview on 09/27/24 at 10:30 A.M., LPN C said medications needed to be ordered by 2:00 P.M., each day to allow the pharmacy time to get the medication delivered. Residents should not go without their medications. Medications should be given at their scheduled times. During an interview on 09/27/24 at 11:15 A.M., the DON said medications should be administered within the ordered time frame. If they were late, the physician should be called and follow what was then ordered. During an interview on 09/27/24 at 11:15 P.M., the Administrator said he would expect resident medications to be available in the facility and be administered in the ordered time frame. During an interview on 10/02/24 at 11:35 A.M., the DON said when she was told about Resident #17 being out of his/her pain medication and not being able to get it filled until the physician returned, she had the staff to pull the medication from the E-Kit. The medications should be reordered when they were down to the last line on the medication card. Residents should not go out with their medications. 45693 47445

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident and/or the resident's representative in writing at least two days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected two residents (Residents #20 and #43) out of three sampled residents. The facility census was 47. The facility did not provide a policy regarding the SNF ABN. 1. Review of Resident #20's medical record showed: - Medicare Part A skilled services started on 05/07/24, and ended on 06/02/24; - The facility initiated the discharge from Medicare Part A Services with the resident's benefit days not exhausted and the resident remained in the facility; - Notice of Medicare Non-Coverage (NOMNC) form, dated 05/31/24, was provided; - No documentation of the SNF ABN form was issued to the resident and/or the resident's representative. 2. Review of Resident #43's medical record showed: - Medicare Part A skilled services started on 08/14/24, and ended on 08/30/24; - The facility initiated the discharge from Medicare Part A Services with the resident's benefit days not exhausted and the resident remained in the facility; - NOMNC form, dated 08/27/24, was provided; - No documentation of the SNF ABN form was issued to the resident and/or the resident's representative. During an interview on 09/25/24 at 4:48 P.M., the Social Services Director (SSD) said he/she never completed the SNF ABN and did not know when to use the form. During an interview on 09/27/24 at 11:45 A.M., the Administrator said he was not aware the SNF ABN form had to be completed if a Notice of Medicare Non-Coverage (NOMNC) was provided. He would expect the residents to be issued a NOMNC and SNF ABN prior to a Medicare Part A discharge.

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect by leaving one resident (Residents #39) out of one sampled resident with his/her genitalia exposed to the public. The facility census was 47. Review of the facility's policy titled, Dignity, revised February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being. Level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures; - Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. Review of Resident #39's medical record showed: - admitted [DATE]; - Diagnoses of diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), acquired absence of left leg below knee, bladder-neck obstruction (a blockage that slows or stops urine flow out of the bladder), hydronephrosis (a condition of the urinary tract where one or both kidneys swell), peripheral vascular disease (PVD - a condition that causes partial or complete obstruction of blood flow), unspecified sequelae of cerebral infarction (unspecified condition result of a stroke), retention of urine, lack of coordination, muscle weakness and abnormal posture. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 07/16/24, showed: - Cognition intact; - No behaviors; - Indwelling catheter (a tube inserted into the bladder to drain urine), always incontinent of bowel; - Impairment on one side of the upper and lower extremity; - Substantial/maximal assistance for toileting hygiene; - Partial/Moderate assistance for shower/bathe self, upper and lower body dressing, and personal hygiene; - Supervision or touching assistance for roll left and right, sit to lying, lying to sitting on bedside. Observations of the resident on 09/26/24, showed: - At 12:58 P.M.-1:04 P.M., the resident lay in the bed closest to the door with his/her genitalia visible from the hall, the resident's privacy curtain open, and multiple residents walked in the hall past the room; - At 1:00 P.M., Certified Nursing Assistant (CNA) G entered the room, talked to the resident, and exited the room with the resident's genitalia visible from the hall and the resident's privacy curtain open; - At 1:02 P.M., CNA G walked past the resident's room, pointed at the resident, and said, I didn't forget about you. Resident's genitalia visible from the hall and the resident's privacy curtain open; - At 1:03 P.M., the Director of Nursing (DON) and an unidentified staff member walked past the resident's room with the resident's genitalia visible from the hall and the resident's privacy curtain open; - At 1:04 P.M., CNA G entered the room, exited the room, the resident covered him/herself with a gown so his/her genitalia was no longer exposed, and the resident's privacy curtain open; - At 1:18 P.M.-1:25 P.M., the resident lay in bed closest to the door with his/her genitalia visible from the hall and the resident's privacy curtain open; - At 1:22 P.M., CNA J walked past the resident's room with the resident's genitalia visible from the hall, the resident's privacy curtain open, turned his/her head towards the resident's room, and continued walking and entered the shower room; - At 1:25 P.M., CNA F entered the residents' room, pulled the privacy curtain around the end of the resident's bed, and educated the resident he/she needed to cover up his/her bottom area; - At 2:55 P.M.-2:59 P.M., the resident lay in bed with his/her genitalia visible from the hall, the resident's privacy curtain open, the resident's roommate in the room, and the window curtain was open with the room visible to the parking lot; - At 3:00 P.M.-3:15 P.M., the resident lay in bed with his/her genitalia and buttocks visible from the hall, the resident's privacy curtain open, and the window curtain was open with the room visible to the parking lot; - At 3:15 P.M., CNA F entered the resident's room, the resident lay in bed with his/her genitalia visible from the hall, and pulled the privacy curtains around the resident's bed. During an interview on 09/26/24 at 3:15 P.M., CNA F said if the resident was in bed with his/her private areas exposed, CNA F would pull the privacy curtain and ask the resident to cover up if they could. If the resident didn't want to cover up, he/she would make sure the resident had his/her call light, pull the privacy curtains closed, pull the window curtain closed if needed, and/or shut the door. If a resident is in the hall or public area, he/she would try to cover or block the exposed area, ask someone to get a towel or blanket to cover the resident, and ask the resident to cover up or see if they would go to his/her room for more privacy. During an interview on 09/27/24 at 10:45 A.M., the DON said staff should educate and assist residents in maintaining their privacy when they were found exposed. However, Resident #39 had lived alone and didn't like to wear clothes. She doesn't think the window was see through from the outside, but not for she wasn't for sure. She didn't always look into the resident rooms when she walked down the hall so she probably didn't always see if Resident #39 was exposed. During an interview on 09/27/24 at 11:00 A.M., the Administrator said the resident could be unclothed in his/her room, but staff should educate and try to ensure the resident wasn't visible to others. The resident liked the door open and didn't like the curtain pulled completely due to being in bed and wanted to see what was going on in the hall.

Based on observation, interview, and record review, the facility failed to assess, care plan and monitor for efficacy for the use of a wheelchair seatbelt for one resident (Resident #26) out of one sampled resident. The facility census was 47. The facility did not provide a seatbelt policy. 1. Review of Resident #26's medical record showed: - admitted [DATE]; - Diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development), muscle spasm, psychosis (a mental disorder characterized by disconnection from reality) not due to a substance or known physiological condition, and convulsions (sudden, irregular movement of a limb or of the body); - No documentation of an assessment for the use of a seatbelt. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 09/24/24, showed: - Cognition intact; - Impairment on both sides of upper and lower extremities; - Partial/Moderate assistance for eating; - Dependent for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, roll left and right, sit to lying, lying to sit on side of bed, chair/bed-to-chair transfer; - Not attempted due to medical condition or safety concerns: sit to stand, walk 10 feet; - Use of motorized wheelchair or scooter; - Always incontinent of bowel and bladder; - Physical restraints not used in bed; - Physical restraints not used in chair or out of bed. Review of the resident's Fall Risk evaluation, dated 09/23/24, showed: - Intermittent confusion; - Ambulation - chair bound, required restraints; - Elimination status - assistance with elimination; - Considered high risk for potential falls. Review of the resident's care plan, dated 08/20/24, showed: - Potential for falls related to poor safety awareness; - Required staff assistance with mobility. Resident able to operate own battery-operated wheelchair, but often fell asleep and needed assistance to destination point; - Did not address the use of the seatbelt. Observations of the resident showed: - On 09/24/24 at 11:23 P.M., the resident sat in a battery-operated wheelchair with the seatbelt buckled below the waist and attached to the wheelchair; - On 09/26/24 at 11:11 A.M., the resident was transferred from the bed to the battery-operated wheelchair via a Hoyer (a device used to transfer a resident from one surface to another) lift by Certified Nurse Assistant (CNA) G and CNA F. The seatbelt was buckled below the resident's waist by CNA F; - On 09/26/24 at 3:26 P.M., CNA E asked the resident if he/she could unbuckle the seatbelt on the battery-operated wheelchair. The resident unbuckled the seatbelt without difficulty. During an interview on 09/27/24 at 10:30 A.M., the MDS Coordinator said there should be an assessment completed for seatbelt use on an battery-operated wheelchair. The nurses were responsible for the assessments. He/She believed the assessments should be completed quarterly, and the care plan should reflect the use of a seatbelt. During an interview on 09/27/24 at 11:15 A.M., the Director of Nursing (DON) said she was responsible for screening the residents for seatbelt or restraint use quarterly. She didn't think about Resident #26's seatbelt because the resident could remove it. The care plan should reflect the use of a seatbelt. During an interview on 09/27/24 at 11:15 A.M., the Administrator said he would expect assessments for seatbelts to be completed. 45693

Based on observation, interview, and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for three residents (Residents #16, #29 and #39) out of 12 sampled residents. The facility's census was 47. Review of the facility's policy titled, Resident Assessments, revised October 2023, showed: - The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments; - Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. 1. Review of Resident #16's medical record showed: - admitted [DATE]; - Diagnoses of cerebral infarction (a stroke), tremor (involuntary, rhythmic shaking or trembling that can affect one or more parts of the body), and cognitive communication deficit; - No side rail assessment; - Nurse's notes, dated 02/01/24-09/27/24, showed no documentation of side rails. Review of the resident's quarterly MDS, dated [DATE], showed: - Resident used side rail restraint daily; - The facility failed to code the resident's MDS accurately. Observations on 09/25/24 at 8:35 A.M., and 09/27/24 at 9:45 A.M., showed the resident lay in bed with no side rails on the bed. During an interview on 09/25/24 at 1:20 P.M., Certified Nurse Assistant (CNA) F said Resident #16 never had side rails on his/her bed. 2. Review of Resident #29's medical record showed: - admitted [DATE]; - Diagnosis of atrial fibrillation (an irregular heart rate); - An order for Plavix (an antiplatelet medication) 75 milligram (mg) by mouth daily, dated 08/16/24; - No documentation of an anticoagulant medication received. Review of the resident's admission MDS, dated [DATE], showed: - An antiplatelet and anticoagulant indicated; - The facility failed to code the resident's MDS accurately. Review of the resident's care plan, dated 09/03/24, showed; - The resident received anticoagulant therapy, Plavix, related to atrial fibrillation; - The facility failed to care plan the Plavix accurately. 3. Review of Resident #39's medical record showed: - admitted [DATE]; - Diagnoses of unspecified sequelae (related to another disease) of cerebral infarction and diabetes mellitus (DM - a condition that affects the way the body processes the blood sugar); - No documentation for a diagnosis of anxiety (persistent worry and fear about everyday situations); - An order for paroxetine (an antidepressant medication) 20 mg by mouth daily for anxiety, dated 07/05/24; - An order for Humalog (a type of insulin) per sliding scale subcutaneously (SQ - injection under the skin) before meals for diabetes, dated 07/05/24; - An order for Lantus (a type of insulin) 10 units SQ at hours of sleep for diabetes, dated 07/05/24; - An order for Remeron (an antidepressant medication) 15 mg by mouth daily for depression, dated 07/16/24. Review of the Medication Administration Record, July 2024, showed: - Lantus 10 units SQ at bedtime administered 07/05/24-07/16/24; - Humalog per sliding scale before meals administered 07/05/24-07/16/24. Review of the admission MDS, dated [DATE], showed: - admitted [DATE]; - Zero injections received during the last seven days or since admission. - Insulin not administered during the last seven days or since admission; - Antianxiety administered; - No antidepressant administered; - No diagnosis of anxiety or depression; - The facility failed to code the resident's MDS accurately. The resident's care plan, revised 09/19/24, showed: - Antianxiety medication use addressed without non-pharmacological interventions; - Antidepressant medication use not addressed. During an interview on 09/27/24 at 10:30 A.M., the MDS Coordinator said whoever completed the admission, linked the diagnosis with the medications. The Director of Nursing (DON) looked behind to ensure the correct diagnosis was linked with the correct medications. The MDS should be accurate and reflect if a resident was on certain medications, had certain diagnosis, or had any restraints, which included side rails. Plavix should be documented as an antiplatelet on the MDS. During an interview on 09/27/24 at 11:15 A.M., the DON said MDS's should be accurate to include a resident's diagnosis, medications, and restraints. Plavix should be documented as an antiplatelet on the MDS. During an interview on 09/27/24 at 11:25 A.M., the Administrator said it was his expectation that MDS's would be documented with accurate information. 47445

Based on observation, interview and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was kept off the floor for two residents (Residents #29 and #39) out of two sampled residents. The facility census was 47. Review of the facility policy titled, Urinary Catheter Care, revised August 2022, showed; - Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #29's medical record showed: - admitted on [DATE]; - Diagnosis of neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem). Review of the resident's Physician Order Sheet (POS), dated September 2024, showed: - An order for Foley (a type of indwelling catheter) catheter care every shift, dated 08/16/24; - An order to change the Foley Catheter, 16 French (Fr - the measurement used to measure sizes of urinary catheters) 30 cubic centimeter (cc) balloon monthly on the 16th using sterile technique on night shift, dated 09/09/24. Review of the resident's care plan, dated 09/03/24, showed: - Resident had an indwelling catheter related to neurogenic bladder. Review of the resident's admission Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 08/22/24 showed: - The resident had an indwelling catheter. Observation on 09/24/25 at 11:30 A.M., showed the resident sat in a wheelchair with staff pushing the wheelchair from the hall and across the dining room to the table for lunch. The resident's catheter drainage bag hung from the wheelchair with the bottom of the bag touching the floor and drug the floor while pushed in the wheelchair. The catheter drainage bag was covered with a dignity bag with an open bottom and didn't cover the bag fully. Observation on 09/24/25 at 11:37 A.M., and 12:06 P.M., showed the resident sat in a wheelchair at the dining room table and the bottom of the catheter drainage bag touched the floor. The catheter drainage bag was covered with a dignity bag with an open bottom and didn't cover the bag fully. 2. Review of Resident #39's medical record showed: - Date of admission of 07/05/24; - Diagnoses of bladder neck obstruction (a blockage in the neck of the bladder) and unspecified hydronephorsis (a condition that occurs when urine builds up in the kidney, causing it to swell and stretch). Review of the resident's POS dated September 2024, showed: - An order to change the Foley catheter 16 Fr 30 cc balloon monthly on the 25th using sterile technique on night shift every month for urine retention, dated 09/25/24; - An order if catheter changed as needed (PRN), then not to be changed again until the following month on that date due to risk for infection, dated 09/25/24; - An order to may irrigate catheter with 60 milliliters (ml) of water as needed every 24 hours for Foley catheter care, dated 08/05/24; - An order for Foley catheter care every shift, dated 07/05/24. Review of the resident's care plan, revised 09/19/24, showed: - Need to irrigate the Foley catheter as needed due to obstruction not addressed; - Catheter care not addressed. Observation on 09/26/24 at 9:12 A.M., showed: - The resident lay in bed with the bed in the low position and the catheter drainage bag hooked on the bed frame. The bottom of catheter drainage bag touched the floor. During an interview on 09/27/24 at 10:45 A.M., Licensed Practical Nurse (LPN) C and Registered Nurse (RN) A said catheter drainage bags should never touch the floor. If they were found touching the floor, they should be immediately fixed. During an interview on 09/27/24 at 10:55 A.M., Certified Nurse Assistant (CNA) D said catheter drainage bags should not touch the floor. During an interview on 09/27/24 at 11:15 A.M., the Director of Nursing (DON) said a catheter, including the drainage bag and tubing, should not touch the bag. During an interview on 09/27/24 at 11:25 A.M. the Administrator said catheters should not touch the floor. 47445

Based on interview and record review, the facility failed to provide an appropriate facility-initiated discharge notice, failed to provide an appropriate discharge plan prior to providing the discharge notice, failed to reassess a resident's status after being discharged from an acute care hospital, and refused to allow the resident (Resident #1) to return to the facility out of three sampled residents. The facility census was 39. Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated October 2022, showed: - Each resident will be permitted to remain in the facility, and not be transferred or discharged unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; - Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; - Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected: - A facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; - When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the resident's return is generally expected; - Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility; - The notice of transfer or discharge is given as soon as it is practicable but before the transfer or discharge if the health and/or safety of individuals in the facility would be endangered due to the clinical or behavior status of the resident or an immediate transfer or discharge is required by the resident's urgent medical needs; - If a discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility, not at the time the resident was transferred to acute care; -If the facility does not permit a resident's return to the facility based on inability to meet the resident's needs, the facility will notify the resident, and/or his/her representative in writing of the discharge, including notification of appeal rights; - Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The basis for the transfer or discharge. If the resident is being transferred or discharged because his/her needs cannot be met at the facility, the documentation will include the specific resident needs that cannot be met, the facility's attempt to meet those needs, and the receiving facility's services that are available to meet those needs; - When a resident is transferred or discharged from the facility, the following information is documented in the medical record: The basis for the transfer or discharge. If the resident is being transferred or discharged because his/her needs cannot be met at the facility, the documentation will include the specific resident needs that cannot be met, the facility's attempt to meet those needs, and the receiving facility's services that are available to meet those needs; That an appropriate notice was provided to the resident and/or legal representative; The date and time of the transfer or discharge; The new location of the resident; The mode of transportation; A summary of the resident's overall medical, physical, and mental condition; Disposition of personal effects; Disposition of medications; Others as appropriate or as necessary; and the signature of the person recording the data in the medical record; - Should the resident be transferred or discharged , the basis for the transfer or discharge is documented in the resident's clinical record by the resident's attending physician: The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; - Should the resident be transferred or discharged , the basis for the transfer or discharge will be documented in the resident's clinical record by a physician: The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident or the health of individuals in the facility would otherwise be endangered; - If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: determine if the resident still requires the services of the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services; ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by facility staff to the hospital; find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications, and services needed, the facility may not be able to meet the resident's needs; and work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge. 1. Review of Resident #1's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (a mental disorder with periods of elevated moods and depression), obsessive-compulsive disorder (OCD) (a mental health disorder characterized by unreasonable thoughts and fears (obsessions) that lead to compulsive behaviors), anxiety (a mental health condition that causes excessive worry), and post-traumatic stress disorder (PTSD) (a person has difficulty recovering after experiencing or witnessing a terrifying event); - Had a legal guardian (a court appointed person who had the authority to make decisions for a person); - The resident alert, oriented, and cognitively intact; - On 06/21/23, untimed, the resident told nursing staff he/she was suicidal. The resident denied having a suicide plan and didn't want to be at the facility anymore; - On 06/21/23 at 5:50 P.M., The resident returned to the facility from the acute care hospital per the facility van. The resident told the staff at the hospital he/she never said anything about suicide at the facility. The resident returned and cleared by the emergency room (ER) physician with no new orders. A call was placed to the guardian with an update but received no answer and unable to leave a message; - On 06/22/23 at 4:20 P.M., the resident told staff he/she felt better and was sorry about yesterday. The resident was happy and smiling while interacting with staff and other residents. The resident said he/she was in a great mood today; - On 06/23/23, untimed, the resident was brought to the nurse by staff who showed him/her that the resident had cut his/her left wrist with scissors. An assessment and treatment was provided. The lacerations to the left wrist were not deep but did draw blood; - On 6/23/23, untimed, the resident was up in the facility in a good mood. He/She wandered around the halls without any signs or symptoms of what was happening in his/her thoughts. The resident came to staff and showed them he/she had gotten a pair of scissors off the nurse's desk, which were hidden, and proceeded to cut his/her left wrist with them. The resident then showed staff what he/she had done to his/her wrist. Staff spoke to the resident about his/her feelings and his/her attempt to hurt him/herself. The resident said he/she didn't want to be here anymore and didn't want to live anymore. The resident appeared to be sad after cutting his/her wrist, however showed no signs of suicide or hopelessness. The resident said after the event, he/she continued to feel sad. The police were called per the facility's protocol for an attempted suicide. Emergency Medical Services (EMS) was called to transfer the resident to an acute care hospital; - On 06/23/23 at 6:00 P.M., the resident's physician was notified of the resident's status with a new order received to send the resident to the acute care hospital for evaluation and treatment; - On 06/23/23 at 6:35 P.M., the resident left the facility via EMS transport; - On 06/23/23 at 7:00 P.M., the resident's guardian returned the nurse's call and was informed of the resident's status and where the res was transferred to; - On 06/23/23, untimed, the facility received a call from the acute care hospital staff and said resident was being discharged back to the facility from the ER. The hospital staff said the resident was seen by a physician and was not considered suicidal but was seeking attention. The hospital staff said the resident did not draw blood with the attempt of cutting his/her wrist. The facility staff explained that this was the second time this week that the resident had been sent out for suicide talk and an attempt. The resident had drawn blood with the attempt and the facility staff had cleaned him/her up. The hospital staff said the resident did not qualify to be held by psychiatry due to he/she was wanting attention and was not suicidal. The facility staff told the hospital staff that the facility could not accept the resident back due to his/her suicidal attempts and that the facility had sent an emergency discharge to the hospital; - No documentation from the physician regarding the resident being a safety risk to other residents; - No documentation from the physician regarding the specific needs or services the current facility cannot meet; - No documentation from the physician of the efforts the facility had attempted in meeting those needs; - No documentation from the physician of the specific services the receiving facility would provide that the current facility could not; - No documentation of a discharge plan prior to providing the discharge notice to the resident and/or the resident's legal guardian; - No documentation of the facility's reassessment of the resident's status after being discharged from the ER. Review of the resident's Pre-Admission Screening/Resident Review (PASRR) Level II Evaluation, dated 11/01/22, showed: - The resident's needs could be met in a nursing facility; - The resident did not need specialized services beyond those typically provided by a nursing facility; - The support services to be provided by the nursing facility were a behavioral support plan, a structured environment, crisis intervention services, medication therapy, an Activities of Daily Living (ADL) program, and a personal support network; - Diagnoses include anxiety, PTSD, attention-deficit/hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness) , schizoaffective disorder (a mental health condition where people experience psychosis as well as mood symptoms), major depression disorder, bipolar mood disorder, impulse control disorder (a chronic problem in which people lack the ability to maintain self-control), mild/moderate intellectual disability (limits to a person's ability to learn at an expected level and function in daily life), and severe mental retardation (presence of significantly subaverage general intellectual functioning as well as significant limitations in adaptive functioning); - Had a legal guardian; - History of attention seeking, tries to go to the ER numerous times, reports suicidal feelings and goes to the ER and reports medical concerns, aggression, anger, delusions (a false belief or judgement about external reality), hallucinations (an experience involving the apparent perception of something not present), manipulative, and non-compliant; - Crisis intervention plan should identify clear steps to be taken to support the resident during a crisis situation, specify who should be contacted for assistance, how staff should work together with the resident during the crisis, and identify when the physician/EMS/law enforcement should be contacted. Review of the resident's Notice of Discharge for Emergency Situation - Facility Unable to Meet Needs of Resident form, dated 06/23/23, showed: - The notice addressed to the resident and the resident's legal guardian; - This letter is a notice of discharge. After careful evaluation an in consultation with your attending physician, the facility can no longer meet your needs. The reason the facility can no longer meet your needs is evidenced by the resident inflicting self harm and suicide threats with actions. It is the responsibility of the facility to provide a safe environment for all residents in which to live; - The facility is prohibited from having residents in the facility whose needs cannot be met. Furthermore, when a resident's physical or mental condition changes such that the resident's needs can no longer be met by the facility, the facility is required to promptly transfer the resident. Based on the matters described above, the facility can no longer meet your needs and therefore, is required by law to transfer you. - The effective date of the discharge is 06/23/23. The facility deems this discharge to be an emergency. The location you will be discharged to is the acute care hospital; - You have the right to appeal this action; Any appeal must be made within 30 days of the date you receive this notice. Filing an appeal will allow you to remain in the facility until a hearing is held unless a hearing officer finds otherwise. During an interview on 06/28/23 at 10:20 A.M., the Director of Nursing (DON) said Resident #1 was no longer a resident at the facility. The last she knew, the resident was discharged from the facility to the hospital on 06/23/23 and would not be returning to the facility. She didn't know if the hospital had found placement for the resident or not but the last she knew, the resident was still in the ER. During an interview on 06/28/23 at 11:22 A.M., the Administrator said Resident #1 was emergency discharged from the facility to theER on [DATE] due to he/she said she felt suicidal and had taken a pair of scissors and scratched his/her wrist. He didn't feel the other residents were safe and that the facility could meet the needs of the resident due to these behaviors and feelings. He said the Emergency Discharge Notice was mailed to the resident's legal guardian. The hospital and the legal guardian had told him that an appeal to the discharge had been made but the facility hadn't received anything yet. The resident was not reassessed for readmittance to the facility after they were notified the resident was discharged from the ER. The resident did not have a discharge plan in place prior to or after the resident was discharged to the hospital. The resident was transferred to the hospital by EMS on 06/23/23, and the Emergency Discharge Notice was written by the Administrator and faxed to the hospital twice after the resident left. During an interview on 06/28/23 at 11:38 A.M., the resident's Public Administrator/Guardian said he/she had not received any paperwork from the facility which showed the resident had been discharged . He/she was told by the ER staff that the resident was transferred to the hospital on 06/23/23. An Emergency Discharge Notice was faxed to theER on [DATE] by the facility. The ER physician discharged the resident back to the facility and the facility refused to pick up the resident from the ER. The resident remained in the ER because he/she was not admitted to the hospital. The ER staff were caring for the resident. He/She and the hospital staff had been working on finding placement for the resident but had not found anywhere for the resident to be admitted to as of yet. During an interview on 06/28/23 at 12:28 P.M., the hospital's Manager for Care Coordination said the resident was transferred to the hospital'sER on [DATE] from the facility. An Emergency Discharge was faxed on 06/23/23 to the ER from the facility. The ER staff contacted the facility to let them know the resident would not be admitted to the hospital and would be discharged back to the facility. The facility refused to come pick up the resident and said the resident had been discharged to the hospital. The resident had nowhere to go so he/she had remained in the ER. The resident would remain in the ER until placement was found. The ER staff was caring for the resident. The resident had received his/her medications and meals. The resident was sleeping on a gurney and had one on one (1:1) care from hospital staff. He/She would continue to have 1:1 care until placement was found and he/she was sent out. The hospital had been boarding the resident for over five days now. During an interview on 06/28/23 at 2:45 P.M., the resident's Public Administrator/Guardian said another facility just now agreed to admit the resident and transportation was being arranged for him/her to leave theER on this date. The ER staff had been taking care of the resident since 06/23/23 to present even though they didn't admit him/her. He/She was very unhappy with the facility since they refused to take the resident back, but he/she was very relieved to find another facility for the resident to be admitted to for his/her care. Complaint #'s MO220491 & MO220495

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 46. Record review of the facility's Kitchen Sanitization policy, revised November 2022, showed: - The food services area is maintained in a clean and sanitary manner; - All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions; - Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions; - All food will be labeled and dated. 1. Observations on 4/3/23 at 8:49 A.M., 4/3/23 at 3:49 P.M., and 4/4/23 at 8:27 A.M., of the kitchen showed: - The dish machine with a buildup of a white substance on the sides, the top and the front panel; - The Insinkerator waste disposal with exposed red, black and white wires and a missing protective covering under the sink; - The backsplash behind the waste disposal sink with water stains and a buildup of a white substance; - An isolation food tray cart with a buildup of stains and a white substance on the front, the sides and the back; - A five pound bag of imitation cheddar cheese, not dated and with no expiration date, located in the right-side of the True refrigerator; - A slice of pepperoni pizza in a zip lock bag, not dated or labeled, located in the left-side of the True refrigerator; - An opened bag of potato fries, with an expiration date of 11/18/22, located in the Artic Air freezer; - Four croissant rolls in a bag, not dated or labeled, located in the dry goods room; - A plastic tub container with four packages of country gravy mix with a large amount of a powdery substance on the bottom located in the dry goods room; - A large bag of red sauce, not labeled or dated, located in the can goods room. 2. Observations on 4/3/23 at 3:49 P.M., and 4/4/23 at 8:27 A.M., of the ice machine room located behind the nurse's station showed: - A buildup of stains, dirt and debris on the floor; - A loose dirty white sock, crumbled paper, dirt and debris on the floor under the ice machine; - A 12 inch (in.) x 18 in. x 3 in. pan with corrosion buildup located under the ice machine; - A buildup of a white substance and dirt on the top, the sides, and the front panel of the ice machine; - A buildup of dirt, grease and grime on the outside and inside of the microwave by the ice machine. Record review of the Kitchen Cleaning Schedule showed: - The dish machine not addressed; - The ice machine not addressed. Record review of the Maintenance Work Orders, dated 1/4/23 through 4/5/23, showed no current requests for areas of concern documented. During an interview on 4/3/23 at 9:48 A.M., Cook D said he/she verbally told maintenance of any repairs needed. He/she would expect the kitchen surfaces, equipment, and floors should be free of lime, grease, dirt, stains and debris buildup and would expect food to be labeled and dated. During an interview on 4/3/23 at 9:54 A.M., Dish Aide E said he/she verbally told maintenance of any repairs needed. He/she would expect the kitchen surfaces, equipment, and floors should be free of lime, grease, dirt, stains and debris buildup and would expect food to be labeled and dated. During and interview on 4/3/23 at 3:08 P.M., the Dietary Manager said he/she verbally told maintenance of any repairs needed. He/she would expect the kitchen surfaces, equipment, and floors should be free of lime, grease, dirt, stains and debris buildup and would expect food to be labeled and dated. During an interview on 4/4/23 at 8:34 A.M., Kitchen Aide F said he/she verbally told maintenance of any repairs needed. He/she would expect the kitchen surfaces, equipment, and floors should be free of lime, grease, dirt, stains and debris buildup and would expect food to be labeled and dated. During an interview on 4/5/23 at 10:26 A.M., the Maintenance Supervisor (MS) said staff mostly told him/her verbally if there was a needed repair or something needed to be addressed. There was a maintenance work order request that staff should be using as well to address any needed repairs or concerns. During an interview on 4/5/23 at 3:20 P.M., the Administrator said she would expect staff to write down any repairs or concerns needed rather than verbally tell the MS. She would expect the kitchen surfaces, equipment, and floors to be free of lime, grease, dirt, stains and debris buildup as well as foods labeled and dated accordingly.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 46. Observations on 4/3/23 at 10:46 A.M., 4/4/23 at 9:12 A.M., and 4/5/23 at 10:12 A.M., showed: - A three foot (ft.) baseboard missing behind the door next to the bathroom located in room [ROOM NUMBER]; - A figurine, a decorative plaque, and a ceramic figurine on top of the light fixture above the bed located by the window in room [ROOM NUMBER]; - A four ft. baseboard missing in front of the Direct Supply Attendant weight scale located in the room behind the nurse's station; - A seven inch (in.) x 12 in. area of paint and sheetrock peeled off in front of the Direct Supply Attendant weight scale located in the room behind the nurse's station. Observations on 4/3/23 at 3:18 P.M., of the shower room located next to the beauty shop showed: - A shower drain cover broken and not secured in place in the shower stall; - Several missing two in. x two in. floor tiles located in front of the shower spigot of the shower stall; - Several cracked two in. x two in. floor tiles located on the left and right side of the shower stall; - A buildup of black grime on the grout lines of the floor tiles located on the left and right side of the walls of the shower stall; - A central air and heat vent with buildup of dust and debris located on the ceiling; - Two exhaust fans with buildup of dust and debris located on the ceiling; - A one in. x 12 in. strip peeling off from the exhaust fan located on the ceiling. Observation on 4/3/23 at 10:52 A.M., showed: - Resident #10's right armrest cracked and coming apart at the seams; - The resident sat in his/her wheelchair in the hallway and his/her arm lay on the cracked armrest. Observation on 4/3/23 at 10:58 A.M., showed: - Resident #20's left and right armrest cracked and coming apart at the seams; - The resident sat in his/her wheelchair in his/her room and his/her arm lay on the cracked armrest. Observation on 4/4/23 at 9:24 A.M., showed: - Resident #28's left and right armrest cracked and coming apart at the seams; - The resident sat in his/her wheelchair near the nurse's station and his/her arm lay on the cracked armrest. Observation on 4/5/23 at 10:06 A.M., showed: - Resident #43's right armrest cracked and coming apart at the seam; - The resident sat in his/her wheelchair near the nurse's station and his/her arm lay on the cracked armrest. Observation on 4/6/23 at 9:45 A.M., of the shower room near room [ROOM NUMBER] showed: - Several cracked two in. x two in. floor tiles located on the left and right side of the shower stall; - A buildup of black grime on the grout lines of the floor tiles located on the left and right side of the walls of the shower stall. Record review of the Maintenance Work Orders, dated 1/4/23 through 4/5/23, showed no current requests for areas of concern documented. During an interview on 4/5/23 at 10:26 A.M., the Maintenance Supervisor (MS) said staff mostly told him/her verbally if there was a needed repair or something needed to be addressed. There was a maintenance work order request that staff should be using as well to address any needed repairs or concerns. During an interview on 4/5/23 at 10:34 A.M., Housekeeper A said if he/she noticed a baseboard missing, paint peeling, resident equipment or anything in need of repair, it was reported to the maintenance supervisor verbally. There was also a maintenance form that can be filled out addressing the needed repair. During an interview on 4/5/23 at 10:53 A.M., Certified Nursing Assistant (CNA) B said if he/she noticed a baseboard missing, paint peeling, resident equipment or anything in need of repair, it was reported to the maintenance supervisor verbally. There was also a maintenance form that can be filled out addressing the needed repair. During an interview on 4/5/23 at 11:05 A.M., Licensed Practical Nurse (LPN) C, said if he/she noticed a baseboard missing, or paint peeling, resident equipment anything in need of repair, it was reported to the maintenance supervisor verbally. There was also a maintenance form that can be filled out addressing the needed repair. During an interview on 4/5/23 at 3:35 P.M., the Administrator said she would expect staff to write down any repairs or concerns needed rather than verbally telling the MS in passing. She would expect staff to report any baseboards missing, paint peeling, resident equipment or anything in need of repair on the maintenance work order to be addressed. The facility did not provide a policy.

Based on observation, interview, and record review, the facility failed to ensure an order for code status was consistently documented throughout the medical record for two residents (Resident #30 and #48) out of three sampled residents. The facility census was 46. Record review of the facility's Advanced Directives policy, revised [DATE], showed: - If the resident or the resident's representative has executed one or more advance directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff; - The Director of Nursing (DON) services or designee notifies the attending physician of the advance directives (or changes in the advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care; - The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings; - The plan of care for each resident is consistent with his/her documented treatment preferences and or advance directive; - Changes or revocations of a directive must be submitted in writing to the administrator, the administrator may require new documents if changes are extensive; - The interdisciplinary team (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. 1. Record review of Resident #30's medical record showed: - An admitted [DATE]; - A do not resuscitate (DNR) (does not want cardiopulmonary resuscitation) (CPR) (an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) code status indicated on the Outside The Hospital Do Not Resuscitate Order (OHDNR) form signed by the resident representative and the physician, dated [DATE]; - The Physician Order Sheet (POS), dated [DATE], with a full code status (wants CPR if the heart stops beating or the person stops breathing) order, dated [DATE]. 2. Record review of Resident #48's medical record showed: - An admitted [DATE]; - A DNR code status indicated on the OHDNR form signed by the resident representative and the physician, dated [DATE]; - The POS, dated [DATE], with a a full code status order, undated. During an interview on [DATE] at 8:32 A.M., Licensed Practical Nurse (LPN) G said he/she would expect a resident's code status to be consistently documented throughout the resident's medical record. During an interview on [DATE] at 8:37 A.M., the DON said she would expect a resident's code status to be consistently documented throughout the resident's medical record. During an interview on [DATE] at 8:41 A.M., the Administrator said she would expect a resident's code status to be consistently documented throughout the resident's medical record. A DNR order should show that it was discussed with the resident and/or representative, and signed by the resident and/or representative and the attending physician. 45872

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility) assessment for one resident (Resident #48) out of three sampled residents. The facility's census was 46. Record review of the facility's Resident Assessments policy, Revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring that the appropriate resident assessments and reviews are completed; - A required MDS assessment is a significant change in status assessment; - A significant change in status assessment is a comprehensive assessment; - A comprehensive assessment includes the completion of the MDS, completion of the care area assessment (CAA) process, and the development of the comprehensive care plan; - The RAI provides detailed information on timing and submission of the MDS assessments. 1. Record review of Resident #48's medical record showed: - An admitted [DATE]; - admitted to hospice (health care focused on the quality of life of a terminally ill person) care on 2/14/23; - The facility failed to complete a significant change MDS within 14 days after the election of the resident's hospice benefit. During an interview on 4/6/23 at 10:30 A.M., the MDS Coordinator said the resident did not have two changes in status when he/she went on hospice services so he/she did not think the resident would need a significant change MDS. He/he was new to the job and was still learning and will get the significant change MDS started on the resident. During an interview on 4/6/23 at 12:35 P.M., the Administrator said she would expect a significant change MDS to be completed on any resident that was admitted to hospice services.

Based on interview and record review, the facility failed to send copies of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (a program that advocates for residents, provide information and help resolve problems) for four residents (Resident #13, #30, #35, and #37) out of four sampled residents. The facility's census was 46. 1. Record review of Resident #13's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital for evaluation on 12/5/22, 12/11/22, and 1/4/23; - No documentation of the notice of transfers or discharge provided to the representative of the LTC Ombudsman. 2. Record review of Resident #30's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on 3/29/23; - No documentation of the notice of transfer or discharge provided to the representative of the LTC Ombudsman. 3. Record review of Resident #35's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on 2/9/23; - No documentation of the notice of transfer or discharge provided to the representative of the LTC Ombudsman. 4. Record review of Resident #37's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital for evaluation on 2/2/23; - No documentation of the notice of transfer or discharge provided to the representative of the LTC Ombudsman. During an interview on 4/6/23 at 8:30 A.M., the Administrator said she did not realize the discharge notices had not been sent monthly to the Ombudsman, they have had a few new employees in the position that sends those out over the past year, and it just got overlooked. She will make sure they are sent out monthly from now on. The facility did not provide a policy regarding notices to the Ombudsman. 39201

Based on interview and record review, the facility failed to complete and notify in the proper timeframe, at least two calendar days before services were to end, the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two residents (Resident #1 and #38) out of three sampled residents. The facility census was 46. 1. Record review of Resident #1's NOMNC and SNF ABN forms showed: - The resident admitted to skilled Medicare services on 2/21/23; - The facility electronically signed the forms with the resident's name on 2/21/23, date of admission to skilled Medicare services; - The resident discharged from skilled Medicare services on 3/2/23, and remained in the facility; - The facility failed to provide the NOMNC and the SNF ABN forms to the resident at least two calendar days before the skilled Medicare services ended and not on day of admission to the skilled Medicare services. 2. Record review of Resident #38's NOMNC and SNF ABN forms showed: - The resident admitted to skilled Medicare services on 2/23/23; - The facility electronically signed the forms with the resident's name on 2/23/23, date of admission to skilled Medicare services; - The resident discharged from skilled Medicare services on 3/4/2023, and remained in the facility; - The facility failed to provide the NOMNC and the SNF ABN forms to the resident at least two calendar days before the skilled Medicare services ended and not on day of admission to the skilled Medicare services. During an interview on 4/6/2023 at 3:45 P.M., the Administrator said the previous Social Service Director had marked the forms wrong and the residents should receive the notices 48 hours prior to coming off of skilled services. The facility did not provide a policy.

Based on interview and closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's legal guardian and the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) in developing a discharge plan for one resident (Resident #50) out of two sampled discharged residents. The facility census was 46. Record review of the facility's Discharge Summary and Plan policy, revised October 2022, showed: - The post-discharge plan is developed by the care planning/interdisciplinary team with assistance of the resident and his or her family; - The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan; - A copy of the evaluation of discharge needs, the post-discharge plan and discharge summary will be filed in the resident's medical record. 1. Record review of Resident #50's closed medical record showed: - An admitted [DATE]; - Diagnoses of type II diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), stage four chronic kidney disease (unable to filter waste from the blood), hyperkalemia (increased blood level of potassium), and left below the knee amputee (BKA) (removal of the foot and lower leg) ; - The resident to be his/her own responsible party; - No documentation which addressed the resident's preference and potential for a future discharge; - No documentation of an assessment for the resident's continued care needs; - No documentation of an IDT discharge plan of care for the resident and/or the resident's legal guardian. During an interview on 4/6/23 at 10:32 A.M., the Director of Nursing (DON) said she would expect discharge planning to begin upon admission. The facility's IDT should assist the resident and/or the resident's representative in developing a discharge plan that reflected the resident's discharge needs, goals and treatment preferences. A social service designee (SSD) had recently been hired. During an interview on 4/6/23 at 10:42 A.M., the Administrator said she would expect the facility's IDT to assist the resident and/or the resident's representative in developing a discharge plan that reflected the resident's discharge needs, goals and treatment preferences upon admission. The SSD was still new and in the process of being trained in this role.

Based on interview and record review, the facility failed to complete and transmit Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) tracking records within the required timeframe for four residents (Resident #4, #18, #19 and #46) outside the sample The facility's census was 46. Record review of the facility's Resident Assessments policy, dated March 2022, showed: - Required assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes; - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: admission assessments (comprehensive) and discharge assessment (return anticipated and return not anticipated); - The Resident Assessment Instrument (RAI) provides detailed information on timing and submission of assessments. 1. Record review of Resident #4's medical record showed: - An admitted [DATE]; - discharged home on 11/17/2022, with no return anticipated; - The facility did not complete a discharge tracking record. 2. Record review of Resident #18's medical record showed: - An admitted [DATE]; - discharged home on 12/10/22, with no return anticipated; - The facility did not complete a discharge tracking record. 3. Record review of Resident #19's medical record showed: - An admitted [DATE]; - The resident discharged to the hospital on 9/30/22, with a return anticipated to the facility; - The facility did not complete a discharge with a return anticipated tracking record; - The resident readmitted to the facility on [DATE]; - Death in the facility on 11/18/2022; - The facility did not complete a death in the facility tracking record. 4. Record review of Resident #46's medical record showed: - An admitted [DATE]; - discharged to the hospital on 11/8/2022, with no return anticipated; - The facility did not complete a discharge tracking record. During an interview on 4/5/23 at 10:46 A.M., the MDS Coordinator said this was a new position for him/her and if the MDS was left open from the previous MDS Coordinator, the staff were able to go in and complete the MDS, however if the MDS's were closed, staff cannot complete them this late. She said the MDS's should be done upon admission, quarterly, annually, with a significant change, and discharge. During an interview on 4/6/23 at 8:45 A.M., the Administrator said she knew there were problems with the MDS's. She said she knew the previous MDS Coordinator had resigned in October 2022 and the MDS's were a mess. She said the MDS Coordinator was new to this position and the facility had brought back a retired employee to help the MDS Coordinator get the MDS's straightened up and corrected.

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframe) for one resident (Resident #12) outside the sample The facility's census was 46. Record review of the facility's Resident Assessments policy, Revised March 2022, showed: - Required Assessments are federally mandated, and therefore must be performed for all residents of Medicare and/or Medicaid certified nursing homes; - The resident assessment coordinator is responsible for ensuring that the appropriate resident assessments and reviews are completed; - The Resident Assessment Instrument (RAI) provides detailed information on timing and submission of the MDS assessments. 1. Record review of Resident #12's medical record showed: - An admitted [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. During an interview on 4/5/23 at 10:46 A.M., the MDS Coordinator said this was a new position for him/her and if the MDS was left open from the previous MDS Coordinator, the staff were able to go in and complete the MDS, however if the MDS's were closed, staff cannot complete them this late. She said the MDS's should be done upon admission, quarterly, annually, with a significant change, and discharge. During an interview on 4/6/23 at 8:45 A.M., the Administrator said the MDS Coordinator was new to the position and the facility had brought back a retired employee to help the MDS Coordinator get these MDS's straightened up and corrected. She said the previous MDS Coordinator had resigned in October 2022.

Based on observation, interview, and record review, the facility failed to assess and identify the potential risk factors for developing a pressure ulcer (PU) for one Resident (Resident #31) after readmission to the facility following a hospitalization . The facility failed to promote prevention of a Stage 3 (full-thickness skin and tissue loss) PU and monitor and evaluate interventions to promote healing. The facility also failed to prevent the development of additional pressure injuries. The facility census was 34. Record review of the facility's Skin and Wound Care Protocol policy, revised on 1/2012, showed: - Always assess wound etiology (the cause) and the resident's overall condition; - A complete wound assessment and documentation will be done weekly on all pressure ulcers until healed; - The complete wound assessment and documentation criteria will include the site/location, the stage, the size, the appearance of the wound bed, the undermining/tunneling, the surrounding skin, and the drainage. 1. Record review of Resident #31's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by the facility staff, dated 2/15/19, showed: - Severely impaired cognitive skills; - At risk of pressure ulcers; - No skin breakdown; - No [MEDICAL CONDITION] (break in the bone). Record review of the resident's nurse progress notes, dated 3/1/19 - 3/29/19, showed: - On 3/1/19, the resident readmitted to the facility from the hospital due to right [MEDICAL CONDITION] with surgical repair. The resident had two surgical incisions to right hip, one laceration to right elbow, and six staples to right side of the forehead. No documentation of skin breakdown noted; - On 3/2/19 - 3/29/19, no documentation of skin breakdown noted; - The facility failed to complete a readmission evaluation to identify potential risk factors for developing a pressure injury. Record review of the resident's (MONTH) 2019 physician's orders [REDACTED]. - An order dated 3/6/19, for the left heel to be cleansed with wound cleanser, apply a Vaseline gauze (non-adherent protective covering for wounds), cover with an abdominal (ABD) (a highly absorbent dressing) pad, secure with gauze wrap and tape daily and as needed; - An order dated 3/27/19, for the left heel to be cleansed with wound cleanser, apply [MEDICATION NAME] gel (a wound care dressing) to the wound bed, cover with a foam dressing (a type of wound dressing), and secure with gauze wrap and tape daily and as needed; - An order dated 3/27/19, for skin prep (a liquid applied to the skin that forms a protective barrier) to be applied to the right heel and the left plantar (sole of the foot) foot daily; - An order to float the heels at all times, dated 3/27/19. Record review of the front side of the (MONTH) 2019 Treatment Administration record (TAR), showed: - A treatment for [REDACTED]. - The treatment initialed by staff as provided to the resident 16 opportunities out of 22 opportunities; - No documentation by the staff for explanations of the six missed wound treatment opportunities; - The facility failed to complete the left heel treatment daily. Record review of the resident's weekly skin summary on the back side of the (MONTH) 2019 TAR, showed: - On 3/9/19, the facility failed to complete the weekly skin assessment; - On 3/16/19, the skin to be warm, dry, and intact with a dressing applied to the heel; - On 3/23/19, the facility failed to complete the weekly skin assessment; - No documentation of wound measurements of the skin breakdown; - The facility failed to complete wound assessment and documentation weekly. Record review of the resident's wound care consultation note showed: - On 3/6/19 initial evaluation of the wound showed one left heel Stage 3 (full-thickness skin and tissue loss) pressure injury that measured 5 centimeters (cm) for the length, 7.5 cm for the width, and 0.1 cm for the depth of the wound; - No additional wound care consultation visits for two weeks between 3/6/19 and 3/27/19. Record review of the resident's wound care consultation note, dated 3/27/19, showed: - Initial wound encounter for Wound #1- One right heel deep tissue pressure injury (a pressure-related injury to the subcutaneous tissues under intact skin) that measured 2.3 cm for the length, and 1.2 cm for the width of the wound; - Wound #2- One left heel Stage 3 pressure injury that measured 3.5 cm for the length, 5 cm for the width, and 0.1 cm for the depth of the wound; - Initial wound encounter for Wound #3- One left plantar foot deep tissue pressure injury that measured 2 cm for the length and 1.7 cm for the width of the wound. Record review of the resident's monthly nursing summary, dated 3/18/19, showed: - Pressure injury to both heels but no further documentation of the resident's skin breakdown. Observation of the resident's wounds on 3/28/19 at 3:25 P.M., showed: - An open pressure injury to the resident's left heel; - A dark purple discolored area to the resident's right heel; - A dark purple discolored area to the resident's left plantar foot. During an interview on 3/27/19 at 4:10 P.M., the Director of Nursing (DON) said the resident was seen by the wound care specialist today, 3/27/19. The resident was found to have pressure wounds on his/her left heel, his/her right heel, and his/her left lateral plantar foot by the wound care specialist. No investigation of the pressure wounds by the facility staff were found in the medical record. She said she didn't know the resident had any skin breakdown so she was unsure when the resident's wounds were found but that the nursing staff should have investigated how the wounds occurred and documented all pertinent information in the resident's medical record. During an interview on 3/28/19 at 1:49 P.M., Licensed Practical Nurse (LPN) D said the staff should document in a resident's medical record all pertinent information regarding a resident's pressure ulcer when it is found. The physician should be notified of the pressure wound and an order should be received for the treatment. He/she didn't know if the resident's pressure wounds were documented on due to he/she wasn't working the day they were found. He/she said the nurses are responsible to document weekly skin assessments that are on the back of the monthly TAR's. During an interview on 3/29/19 at 2:15 P.M., the facility Quality Assurance (QA) nurse said that the facility staff are to complete and document weekly resident skin assessments, but this was not done on this resident since a couple of the assessments were missed. She reviewed the resident's medical record and would have expected to see documentation on the investigation of the cause and the assessment of the resident's wounds, but unfortunately that was not done on this resident. It is the responsibility of the nursing staff to do a head to toe assessment when a resident returns to the facility from a hospitalization . He/she would have expected the DON to be aware of the conditions of the residents. During an interview on 3/29/19 at 2:28 P.M., the DON said she would expect a resident not to acquire any pressure ulcers. She would expect the nursing staff to document on any wounds when first assessed, and then routinely. She would also expect a wound to be investigated as to how it happened. During an interview on 4/5/19 at 10:02 A.M., the Wound Care Consultant F said that he/she goes to the facility weekly. When a resident needs a consultation, the staff verbally notify him/her. On 3/6/19, a facility staff member asked him/her to see Resident #31 for a wound care consultation. He/she failed to add the resident to his/her electronic system after the 3/6/19 visit, so the resident wasn't seen during the following weekly visits. On the 3/27/19 weekly visit, the facility staff again asked him/her to see Resident #31 for a wound care consultation. He/she doesn't know how the skin breakdown occurred for this resident.