Every finding on record at Schuyler County Nursing Home District

Based on observation and interview, the facility failed to ensure food service equipment/surfaces were appropriately cleaned under sanitary conditions in accordance with professional standards for food service safety, and failed to ensure trash cans were covered when not in use. The facility census was 41.Observations on 9/7/25 between 11:30 A.M. and 5:53 P.M., and on 9/8/25 between 9:27 A.M. and 9:42 A.M., in the kitchen showed the following:-The kitchen Heating Ventilation and Air-Conditioning System (HVAC) unit surfaces/supports above the upright refrigerator, two compartment food prep sink, and two spice/seasoning shelves, with a moderate to heavy buildup of dust and debris;-A two-bulb emergency light fixture above two spice/seasoning shelves, with a moderate buildup of dust and debris;-Between and above the food tray prep table and coffee maker/clean glassware areas, three ceiling light fixtures, connecting flex conduit and ceiling chain supports with a moderate to heavy buildup of dust and debris;-Under the hand washing sink beside the coffee machine, a trash can containing used paper towels with no cover (staff not working in the area); -At the end of a food prep table and beside a floor food mixer, a garbage can containing disposed of food items/paper items with no cover (staff not working in the area);-In the dishwashing area beside the dining room serving door, a garbage can containing disposed of food items/paper items with no cover (staff not working in the area). During an interview on 9/8/25 at 9:35 A.M, Dietary [NAME] (L) said trash cans in the kitchen and dishwasher areas should be covered when not in use. During an interview on 9/8/25 at 9:45 A.M., the Dietary Director said the following:-He was not aware of the identified areas;-The areas identified are to be monitored by all dietary staff, on an on-going basis;-He expected the identified HVAC unit, emergency light fixture and the ceiling lights, supports and conduits to be free of dust and debris;-He expects all trash/garbage cans in the kitchen/dishwasher areas to be covered when not in use.

Based on observation, interview, and record review, the facility failed to develop policies to monitor the water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to ensure staff performed hand hygiene when providing incontinence care to four residents (Resident #3, #6, #40, #28), failed to ensure the urinary catheter drainage system was maintained off the floor for two residents (Residents #3 and #40), and to follow enhanced barrier precautions (EBP) for one resident (Resident #3) who had a urinary catheter, in a review of 17 sampled residents. The facility census was 41. 1. Review of the facility policy, Legionella Surveillance and Detection, revised September 2022, showed the following:-Facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella;-Legionnaire's disease is included as part of our infection surveillance activities;-Legionella can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains), and certain devices can spread contaminated water droplets via aerosolization;-Legionellosis outbreaks are generally linked to locations where water is held or accumulates, and pathogens can reproduce. Transmission from these water systems to humans occurs when the water is aerosolized (i.e., converted into a spray/mist in the air);-Legionella is less commonly spread by aspiration of drinking water or ice;-As part of the infection prevention and control program, all cases of pneumonia that are diagnosed in residents> 48 hours after admission are investigated for possible Legionnaire's disease;-Clinical staff are trained on the following signs and symptoms associated with pneumonia and Legionnaire's:a. Cough;b. Shortness of breath;c. Fever;d. Muscle aches;e. Headache; andf. Diarrhea, nausea and confusion associated with Legionnaire's disease.-Risk factors for developing Legionnaire's Disease include:a. Age greater than (>) 50 years;b. Smoking (current or historical);c. Chronic lung disease, such as emphysema or COPD (chronic obstructive pulmonary disease);d. Immune system disorders due to disease or medication;e. Systemic malignancy; andf. Underlying illness, such as diabetes, renal failure, or hepatic failure;-If pneumonia or Legionnaire's disease is suspected, the nurse will notify the physician or practitioner immediately;-Residents who have signs and symptoms of pneumonia may be pl aced on transmission-based (droplet) precautions, although person-to-person transmission is rare;-Diagnosis of Legionnaire's disease is based on a culture of lower respiratory secretions and urinary antigen testing (concurrently);-Depending on the severity of illness, a hospital transfer may be initiated;-If Legionella is detected in one or more residents, the infection preventionist will:a. Initiate active surveillance for Legionnaire's diseases;b. Notify the water management team;c. Notify the local health department; andd. Notify the administrator and the director of nursing services. Review of the facility policy did not include monitoring water temperatures, dead legs, flushing unused areas, monitoring for scaling, sediment, or biofilm within the water system or guidance on what to monitor and what actions to take if any findings were outside facility established parameters. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs and decorative fountains;-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical and epidemiological considerations for healthcare facilities are described in this toolkit;-Surveyors will review policies, procedures and reports documenting water management implementation results to verify that facilities:-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. During an interview on 09/10/25 at 2:35 P.M., the Administrator said the facility had not developed a policy that included monitoring water temperatures, dead legs, flushing unused areas, monitoring for scaling, sediment, or biofilm within the water system or guidance on what to monitor and what actions to take if any findings were outside facility established parameters. 2. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Review of the facility's weekly water temperature log, dated 06/01/25-09/10/25, showed the following hot water temperatures below 108 degrees F.:-On 05/05/25, the water temperature in the shower was 105 degrees F;-On 05/19/25, the water temperature in the shower was 105 degrees F;-05/26/25, the water temperature in the shower was 105 degrees F;-06/02/25, the water temperature in the shower was 105 degrees F;-06/09/25, the water temperature in the shower was 104 degrees F;-06/16/25, the water temperature in the shower was 104 degrees F;-07/28/25, the water temperature in the shower was 102 degrees F;-08/11/25, the water temperature in the shower was 105 degrees F;-08/18/25, the water temperature in the shower was 106 degrees F;-08/25/25, the water temperature in the shower was 106 degrees F;-09/02/25, the water temperature in the shower was 106 degrees F;-The facility had two, in-use showers. This documentation did not indicate which shower was tested. The facility provided no documentation showing monitoring of cold water temperatures. 3. Review of Resident #20's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's Infection Tracker Report, dated 04/21/25, showed the resident went to the hospital on [DATE], and was diagnosed with pneumonia and admitted to the hospital for the pneumonia. The resident's record (including hospital records available at the facility and the facility records) did not show screening for legionella with a urine or sputum test as facility policy directed. 4.Review of Resident #6's face sheet showed he/she admitted to the facility 12/01/23. Review of the resident's diagnosis showed a diagnosis of active pneumonia, unspecified organism added on 05/13/25. The resident's record did not show screening for legionella with a urine or sputum test as facility policy directed. During an interview on 09/08/25 at 5:25 P.M., Registered Nurse (RN) M said the following:-She was the Infection Preventionists (IP);-She was not on the water management team;-She did not know what ASHRAE standards were;-She did not monitor residents with pneumonia for legionellosis;-She had not done any monitoring of any residents for legionellosis; she had not educated any staff on what to monitor for. 4. During an interview on 09/10/25 at 2:25 P.M., the Maintenance Director said the following:-He, the Director of Nursing, the Administrator and the Medical Director made up the water management team;-The water management team met once after the last survey, but had not met since;-He was not familiar with the ASHRAE standards;-He did not monitor the cold-water temperatures and did not know if cold water temperatures stayed below 77 degrees F;-He did not know about cold and hot water ranges to prevent the growth of legionella;-He made sure hot water temperatures were between 105 degrees F and 120 degrees F.;-He did not check for sediment, scaling, or biofilm. During an interview on 09/09/25 at 1:47 P.M., the Director of Nursing (DON) said the following:-She did not know what ASHRAE standards were;-She had not attended a water management meeting;-She did not know if the IP had done any monitoring of any residents for legionellosis and did not have a plan to monitor future residents with pneumonia, -She did not know how or who to screen for legionellosis; -She had not educated any staff on what symptoms of legionellosis to monitor for. During an interview on 09/10/25 at 2:35 P.M., the Administrator said the following:-The facility staff do not know what ASHRAE standards are;-The facility did not have an active water management team, but the Maintenance Supervisor checked water temperatures weekly;-The facility had not had a water management meeting;-Staff was to follow the facility's policies that were in place;-The facility's water flow map was not complete. They had entry and exit points of water and water heaters, but no other areas in the building;-The facility was not sure what all needed to be monitored to prevent Legionellosis. 5. Review of the facility policy, Handwashing and Hand Hygiene, last revised October 2023, showed the following:-Hand hygiene is indicated: a. Immediately before touching a resident; b. Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. After contact with blood, body fluids or contaminated surfaces; d. After touching a resident; e. After touching the resident's environment; f. Before moving from work on a soiled body site to a clean body site on the same resident; g. Immediately after gown removal;-Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations;-Wash hand with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea including but not limited to infections caused by norovirus, salmonella, shigella and Clostridioides difficile (C. Diff);-Single-use disposable gloves should be used: a. Before aseptic procedures; b. When anticipating contact with blood or body fluids; c. When in contact with a resident, or the equipment of a resident, who is on contact precautions;-The use of gloves does not replace hand washing/hand hygiene;-Applying and removing gloves: a. Perform hand hygiene before applying non-sterile gloves; e. Perform hand hygiene after removing gloves. Review of the facility policy, Urinary Catheter Care, last revised August 2022, showed the following:-Purpose of the procedure is to prevent urinary catheter-associated complications, including urinary tract infections;-Use aseptic technique when handling or manipulating the drainage system;-Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility policy, Enhanced Barrier Precautions, dated August 2022, showed the following:-Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents;-EBP employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply;-Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room);-Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), wound care;-EBP is indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization;-EBP will remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk;-Standard precautions apply to the care of all residents regardless of suspected or confined infection or colonization status;-Staff are trained prior to caring for residents on EBP;-Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. 6. Review of Resident #3's face sheet showed the resident's diagnoses included history of urinary tract infection (UTI). Review of resident's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 7/18/25, showed the following:-Severe cognitive impairment;-Dependent on staff for toileting and personal hygiene;-Indwelling urinary catheter. Review of the resident's Care Plan, dated 8/13/25, showed the following: -The resident had a urinary catheter;-Staff need to perform hand hygiene before entering and after leaving the resident's room;-Provide catheter care every shift;-Staff to wear gowns and gloves when assisting the resident with dressing, toileting or emptying the resident's urinary catheter;-The resident needed assistance from one staff for personal hygiene;-The resident needed assistance from two staff for transfers, toileting and ambulation. Review of the resident's Physician Orders, dated September 2025, showed the following:-Urinary catheter care every shift;-Change urinary catheter every month and as need if plugged or malfunctioning. Observation on 9/08/25 at 10:31 A.M., showed the following:-A sign indicating the resident was on EBP was posted on the resident's door; -The resident sat in his/her wheelchair and watched television in his/her room;-The resident's urinary catheter bag was in a privacy bag that was attached under the resident's wheelchair. The urinary catheter tubing lay on the floor under the resident's wheelchair;-Nurse Assistant (NA) H entered the room, did not wash his/her hands, and put on a gown and gloves; -NA H pushed the resident in the wheelchair into the bathroom. The urinary catheter tubing dragged on the floor under the resident's wheelchair; -NA H placed a gait belt on the resident; -Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) I entered the room;-CNA/CMT I washed his/her hands and donned gloves. CNA/CMT I did not put on a gown;-NA H and CNA/CMT I used the gait belt and assisted the resident to stand;-NA H pulled down the resident's pants and incontinence brief and assisted the resident to sit on the toilet. During interview on 9/08/25 at 11:44 A.M., NA H said he/she should wash his/her hands and put on gloves before he/she assisted a resident with peri care. During interview on 9/08/25 at 2:53 P.M., CNA/CMT I said the following:-The sign was on the resident's door because the resident had a catheter;-He/She did not wear a gown earlier when assisting the resident in the bathroom since he/she did not provide direct care, such as wiping the resident;-He/She was not sure if he/she should wear a gown when he/she assisted the resident to the bathroom. Observation on 9/08/25 at 11:27 A.M., showed the following:-NA H and NA J washed their hands and donned gloves. Neither staff put on a gown; -The resident sat on the toilet and had a bowel movement; -NA J placed a gait belt on the resident;-NA H and NA J assisted the resident to stand;-NA J provided peri care to the resident while the resident stood; -Without removing his/her gloves, NA J pulled up the resident's clean incontinence brief and pants, assisted NA H to transfer the resident to the wheelchair, removed the gait belt from the resident's waist, and placed the gait belt on his/her own waist. During interviews on 9/08/25 at 11:45 A.M. and 2:45 P.M., NA J said the following:-After he/she provided peri care, he/she should remove his/her gloves, sanitized or washed his/her hands, and put on clean gloves before putting a clean incontinence brief on the resident; -He/She should have removed his/her gloves and sanitized his/her hands before he/she took the gait belt off the resident and put it on himself/herself.-The PPE sign was on the resident's door for when staff assisted the resident because the resident had a catheter;-He/She did not wear a gown earlier when providing care and should have. During interview on 9/08/25 at 2:29 P.M., NA H said the following:-The resident had a urinary catheter;-Staff should wear a gown and gloves when they emptied the urinary catheter or took the resident to the bathroom;-He/She did not wear a gown earlier when providing care for the resident and should have. Observation on 9/08/25 at 1:58 P.M., showed the following:-The resident sat in his/her wheelchair by the door in his/her room. The resident's urinary catheter bag was in the privacy bag and hung under the resident's wheelchair. The urinary catheter tubing lay on the floor; -NA H and CNA/CMT I walked by resident's room without looking in the room. Observation on 9/08/25 at 2:17 P.M., showed the following:-The resident sat in his/her wheelchair in his/her room;-CNA K was in the resident's room talking to the resident;-The resident urinary catheter bag was in privacy bag that hung under the resident's wheelchair. The urinary catheter tubing lay on the floor under the wheelchair. Observation on 9/09/25 at 8:46 A.M., showed the following:-The resident sat in his/her wheelchair in his/her room;-The resident's urinary catheter bag was not in a privacy bag and was hooked to the underneath side of his/her wheelchair; -The urinary catheter tubing lay on the floor under his/her wheelchair. Observation on 9/10/25 at 8:30 A.M., showed the following: -The resident sat in his/her wheelchair in the doorway of his/her room;-The resident's urinary catheter bag was in a privacy bag on the floor below his/her wheelchair;-The resident self-propelled the wheelchair in the hallway and the catheter bag and tubing dragged on the floor under his/her wheelchair;-Two CNAs walked by the resident in the hallway and did not assist the resident. During interview on 9/10/25 at 6:25 P.M., CNA K said the following:-The urinary catheter bag and tubing should be kept off the floor;-The urinary catheter bag and tubing should hang on the bar underneath the wheelchair. 7. Review of Resident #6's hospital Discharge summary, dated [DATE], showed the following:-Chief complaint: hematuria;-Final diagnosis: Urinary tract infectious disease and blood in the urine;-Hospital course: Foley catheter was placed and the emergency room Physician contacted Urology at another hospital who stated the resident could be seen as an outpatient. Since admission, bladder irrigation (a procedure to flush out the bladder to remove mucus, sediment, blood clots or other debris) was performed;-Urine culture showed E coli (a bacteria commonly found in the intestines of humans and other animals). Review of the resident's Care Plan, updated 06/11/25, showed the following:-The resident had frequent episodes of incontinence;-Provide the resident with good peri-care with all incontinent episodes. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Requires partial/moderate assistance from staff for personal hygiene;-Requires substantial/maximal assistance from staff for upper body dressing, lower body dressing; -Dependent on staff for toileting hygiene, shower/bathe and to roll left and right; -Indwelling urinary catheter (tube inserted in bladder to drain urine);-Always incontinent of bowel. Observation on 09/10/25 at 9:50 A.M., showed the following:-The resident was in his/her bed;-The resident had Enhanced Barrier Precautions signage on his/her door;-CNA N, NA O and CNA P cleansed their hands with alcohol gel, donned gloves and gowns and entered the resident's room;-NA O cleaned the resident's front perineal area; -NA O picked up the resident's perineal rinse cleanser bottle and sprayed a cloth;-NA O cleaned the resident's catheter with the same gloves he/she wore to provide perineal care;-NA O assisted CNA N to roll the resident to his/her left side, touching the resident's skin and clothing with the same gloves;-CNA N said the resident had a small bowel movement and cleaned the resident's back peri area;-CNA N did not remove his/her gloves, then assisted NA O to roll the resident to the other side; both CNAs touched the resident's skin, bedding and new incontinence brief; -NA O removed items from the resident's drawers with the same gloves he/she wore to provide perineal care;-CNA N and NA O removed their gloves, did not perform hand hygiene, and rolled the resident to his/her back, pulled him/her up in bed, touched several pillows, and touched the resident's skin, clothing and blankets. During an interview on 09/10/25 at 10:11 A.M., NA O said it would make sense to clean his/her hands after providing perineal care and before he/she touched clean items. He/She didn't think about it before. During an interview on 09/10/25 at 10:11 A.M., CNA N said staff was to wash their hands before and after providing major cares for a resident, before putting on gloves, after removing gloves, and between touching dirty and clean areas. He/She and NA O did not wash their hands when they removed their gloves because they routinely didn't, but they should. 8. Review of Resident #40's face sheet, showed the resident's diagnoses included history of UTI. Review of the resident's Care Plan, dated 8/05/25, showed the following: -The resident had a urinary catheter;-Staff needed to perform hand hygiene before entering and after leaving the resident's room;-Staff was to provide catheter care every shift;-The resident needed assistance from one staff for transfers, personal hygiene, dressing and bed mobility. -The resident had a colostomy (surgical opening in the large intestine) and this put him/her at risk for developing multi-resistant organisms (MDROs) and spreading them to others. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Dependent on staff for toileting and personal hygiene;-Indwelling urinary catheter and ostomy (surgical opening in any part of the gastrointestinal tract). Review of resident's Physician Orders, dated September 2025, showed the following:-Provide urinary catheter care every shift.-Change urinary catheter every month. Observation on 9/07/25 at 5:26 P.M., showed the following:-The resident sat in his wheelchair at the dining room table;-The resident's urinary catheter bag was in a privacy bag that hung under the resident's wheelchair;-The urinary catheter tubing lay on the floor under the wheelchair. Observation on 9/08/25, at 2:37 P.M., showed the following:-The resident sat in his/her wheelchair at the nurse's station;-Certified Nurse Assistant (CNA) C talked to the resident;-The urinary catheter bag was in a privacy bag that hung under the resident's wheelchair;-The urinary catheter tubing lay on the floor under the wheelchair. During interview on 9/10/25, at 6:26 P.M., CNA C said the urinary catheter bag and tubing should be kept off the floor. Observation on 9/09/25, at 8:56 A.M., showed the following:-CNA G, did not wash his/her hands, and put on gloves and a gown; -The resident had a colostomy bag attached to his/her abdomen;-CNA G emptied the colostomy bag into a plastic bag in the trash can;-He/She cleaned the opening end of the bag with a wet wipe. Feces were observed on the wet wipe; -CNA G did not change his/her gloves, and placed the clip on the end of the colostomy bag with the same gloved hand he/she used to clean the feces from the bag; -He/She said he/she usually had a helper who put the clip on the bag with clean hands, but that person was busy;-CNA G removed his/her gloves, did not perform hand hygiene, and put on new gloves; -He/She emptied the resident's urinary catheter into a graduated cylinder and disposed of the urine in the toilet. 9. Review of Resident #28's face sheet showed the resident's diagnoses included history of UTI. Review of the resident's Care Plan, dated 4/04/25, showed the following: -The resident required assistance from one staff for personal hygiene;-He/She had frequent episodes of bladder and bowel incontinence;-Staff was to provide good peri care after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Partial/moderate assistance required for personal hygiene;-Always incontinent of bladder;-Frequently incontinent of bowel. Observation on 9/08/25, at 2:42 P.M., showed the following:-CNA C and CNA K entered the resident's room, did not perform hand hygiene, and put on gloves; -The resident lay in bed;-CNA K assisted the resident to roll towards him/her in the bed;-CNA C removed the resident's urine-soiled incontinence brief and provided peri care;-Without removing his/her gloves, CNA C placed a clean bed pad under the resident and clean incontinence brief on the resident. During interview on 9/08/25, at 2:50 P.M., CNA C said the following:-He/She should wash his/her hands when entering a resident's room;-He/She should remove his/her gloves and wash his/her hands after he/she provided peri care.-He/She did not change his/her gloves or wash his/her hands between dirty and clean care today, but he/she usually did. 10. During interview on 9/10/25 at 7:30 P.M., the Director of Nursing (DON) said the following:-Urinary catheter bag and tubing should be kept off the floor at all times;-Staff was to wear gowns and gloves when providing high contact care to a resident who was on EBP; -Staff was to perform hand hygiene and change their gloves between dirty and clean tasks;-Staff should perform hand hygiene between gloves changes; -Staff was to wash their hands if their hands were visibly soiled;-Staff could sanitize their hands if they were not visibly soiled.

Based on interview and record review, the facility failed to ensure staff training needs, as identified in the facility assessment and the annual in-servicing calendar, were met for five nurse assistants (NA)'s/ certified nurse assistants (CNA)'s (NA O , NA J, CNA T, CNA K and CNA/Certified Medication Technician (CMT) S), in a sample of five NA's/CNA's reviewed, who had been employed over a year by the facility. Further review showed no documentation of the required 12 hours of training per year were completed, including dementia management and resident abuse prevention training. The facility census was 41. Review of the facility Assessment, dated 04/17/25, showed the following education requirements:-Communication - effective communications for direct care staff;-Resident's rights and facility responsibilities - ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents;-Abuse, neglect, and exploitation - training that at a minimum educates staff on-(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention;-Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program;-Culture change (that is, person-centered and person-directed care);2. Required in-service training for nurse aides. In-service training must:-a. Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year;-b. Include dementia management training and resident abuse prevention training;-c. Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff;-d. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired;-Required training of feeding assistants - through a State-approved training program for feeding assistants;- Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life;-Cultural competency (ability of organizations to effectively deliver health careservices that meet the social, cultural, and linguistic needs of residents);** Training and competencies will also be performed on an individual and/or as needed (PRN) basis depending on need. Review of the facility's Education Calendar showed the following trainings were to be offered/completed during the following months:-January: Abuse and Neglect, Resident Rights, Safety Management;-February: Universal Precautions, Infection Control, Blood-borne Pathogens;-March: Fall Prevention, Safe Transfers, Workplace Violence;-April: Fire Safety, Fire watch policy and procedure;-May: Alzheimer's Disease, Behavioral Health, Dementia;-June: Antipsychotics, Geriatric Depression, UTI (urinary tract infection) Prevention, Peri-Cath Cares;-July: Hospice Care and Services, Pressure Wounds;-August: HIPAA (Health Insurance Portability and Accountability Act), Emergency Preparedness, Disasters;-September: MDS (Minimum Data Set)/Care Plan, Pain Management;-October: Nutrition & Hydration, Feeding, Oral Cares;-November: State Survey Prep;-December: Customer Relations, Corporate Compliance, Communication, Teamwork, Quality Assurance and Performance Improvement (QAPI).1. Review of NA O's employee file showed a hire date of 04/24/24. 1.Review of the NA's employee education record, dated 09/01/24 to 09/09/25, showed the following:-Attended 03/25/25, prevention violence;-Attended 05/20/25, Alzheimer's/dementia;-Attended 06/19/25, UTI and depression;-Attended 07/17/25, hospice/wounds;-Attended 08/26/25, HIPAA/emergency preparedness.The record did not include hours attended. The NA had been employed for over a year, did not have documentation of 12 hours of in-services/training and missed required topics identified in the Facility Assessment including Abuse and Neglect, Resident Rights, Infection Control, Communication and QAPI. 2. Review of NA J's employee file showed a hire date of 04/25/23 (over one year). Review of the NA's employee education record, dated 09/01/24 to 09/09/25, showed the following:-Attended 01/16/25, safety;-Attended 06/06/25, dementia/Alzheimer's;-Attended 06/19/25, UTI prevention.The record did not include hours attended. The NA had been employed for over a year, did not have documentation of 12 hours of in-services/training and missed required topics identified in the Facility Assessment including Infection Control, Behavioral Health, Communication and QAPI. 3. Review of CNA T's, employee file, showed a hire date of 04/30/24. Review of the CNA's employee education record, dated 09/01/24 to 09/09/25, showed the following:-Attended 09/18/24, MDS;-Attended 11/21/24, abuse;-Attended 01/16/25, workman's compensation;-Attended 04/18/25, fire safety;-Attended 06/20/25, UTI prevention;-Attended 08/26/25, HIPAA/emergency preparedness.The record did not include hours attended. The CNA had been employed for over a year, did not have documentation of 12 hours of in-services/training and missed required topics identified in the Facility Assessment including Communication, QAPI, Infection Control, Alzheimer's Disease, Behavioral Health and Dementia. 4. Review of CNA K's, employee file, showed a hire date of 02/25/24. Review of the CNA's employee education record, dated 09/01/24 to 09/09/25, showed the following:-Attended 09/15/24, emergency preparedness;-Attended 11/21/24, resident rights;-Attended 01/16/25, workman's compensation;-Attended 03/26/25, workplace violence;-Attended 04/18/25, fire safety;-Attended 05/19/25, Alzheimer's Dementia;-Attended 06/19/25, Hospice;-Attended 07/21/25, UTI and Depression;-Attended 08/26/25, HIPAA and emergency procedure.The record did not include hours attended. The CNA had been employed for over a year, did not have documentation of 12 hours of in-services/training and missed required topics identified in the Facility Assessment including Communication, QAPI and Infection Control. 5. Review of CNA/CMT S's, employee file, showed a hire date of 02/13/24. Review of the CNA/CMT's employee education record, dated 09/01/24 to 09/09/25, showed the following:-Attended 09/19/24, MDS/care plan;-Attended 11/21/24, resident rights;-Attended 01/16/25, workman's compensation;-Attended 03/20/25, workplace violence/fall prevention/safe transfers;-Attended 04/17/25, fire safety;-Attended 06/19/25, depression;-Attended 07/17/25, hospice;-Attended 08/21/25, HIPAA and emergency preparedness.The record did not include hours attended. The CNA/CMT had been employed for over a year, did not have documentation of 12 hours of in-services/training and missed required topics identified in the Facility Assessment including Communication, QAPI, Infection Control, Alzheimer's Disease, Behavioral Health and Dementia. 6. During an interview on 09/10/25 at 10:42 A.M., the Director of Nursing (DON) said the following:-She had an educational calendar she followed and provided monthly in-services on educational topics to the staff;-The educational calendar following the training section in the facility assessment;-She kept individual training records for staff. When they come to a staff meeting, they sign in for the meeting and sign in the individual record; -She does monthly in-services which are about an hour long every month to cover required trainings and meet the 12 hours per year requirement;-Staff often miss monthly meetings;-She will have a makeup in-service sometimes, but they do not attend that either;-NA, CNA's and CMT's are required to have 12 hours of annual training/year including required topics.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment (minimum data set, MDS) for three residents (Resident #5, #7, and #36)), in a review of 17 sampled residents. The facility census was 41. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised 2022, showed the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;- The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident;-The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission;-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment;-Each resident's comprehensive person-centered care plan is c0nsistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning process;b. Identify individuals or roles to be included;c. Request meetings;d. Request revisions to the plan of care;e. Participate in establishing the expected goals and outcomes of care;f. Participate in determining the type, amount, frequency and duration of care;g. Receive the services and/or items included in the plan of care and;h. See the care plan and sign it after significant changes are made;-The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences;-The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being, including: 1. Services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2. Any specialized services to be provided as a result of PASARR screening and its recommendations, and; 3. Which professional services are responsible for each element of care; c. Includes the resident's stated goals upon admission and desired outcomes; d. Builds on the resident's strengths and; e. Reflects currently recognized standards of practice for problem areas and conditions;-Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making;-When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers;-Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change;-The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. 1.Review of Resident #5's face sheet showed the following:-admitted on [DATE];-Diagnoses of edema (a condition where excess fluid builds up in the body's tissues, causing swelling), shortness of breath, and diastolic congestive heart failure (a condition where the heart is unable to relax and fill with blood adequately, leading to a buildup of fluid in parts of the body). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/14/25, showed the following:-Diagnoses of heart failure;-Medications included a diuretic. Review of the resident's physician orders, dated 7/8/25, showed the following:-Lasix (a diuretic) 40 milligram (mg) tablet once a morning;-Lasix 20 mg tablet daily, as needed, for a weight gain of greater than two pounds in 48 hours;-Monthly weights, once a morning on the 5th of the month. Review of the resident's physician orders, dated 7/10/25, showed an order for a fluid restriction of 1.5 liters a day. Review of the resident's care plan, revised 7/22/25, showed no documentation to address the resident's congestive heart failure, fluid restriction and weight monitoring. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Diagnoses of heart failure;-Medications included a diuretic. During an interview on 9/10/25 at 6:28 P.M., Licensed Practical Nurse (LPN) A said the following:-The resident had congestive heart failure, and his/her weight fluctuated;-The resident had orders to be weighed monthly;-The resident had an order for as needed Lasix, with directions to administer based on weight changes in 48 hours, indicating staff should check the resident's weight daily. During an interview on 9/10/25 at 5:14 P.M., the Director of Nursing (DON) said the following:-The resident had an order for a fluid restriction;-Staff should monitor and document the resident's fluid intake;-The resident had an order for monthly weights;-The resident had an order for as needed Lasix, based on weight changes, but did not have an order for daily weights, and should;-There is no way to know or to truly monitor the resident's weights without checking daily weights. 2. Review of Resident #7's undated face sheet, showed the following:-admitted on [DATE];-Diagnoses of fracture of femur (the bone of the thigh), and pain. Review of the resident's physician orders, dated 7/14/25, showed an order for pain assessment every shift. Review of the resident's pain scores on 7/14/25 showed the following:-7 out of 10 pain (on a scale of 1-10 with 10 being the worst pain possible) at 1:05 P.M.;-7 out of 10 pain at 1:53 P.M.;-7 out of 10 pain at 9:05 P.M. Review of the resident's physician orders, dated 7/15/25, showed an order for acetaminophen pain relief, 500 milligram (mg) tablet, two tablets as needed. Review of the resident's pain scores on 7/15/25 showed the following:-7 out of 10 pain at 9:20 A.M.;-4 out of 10 pain at 9:55 P.M. Review of the resident's pain score on 7/16/25 at 11:38 A.M. showed 3 out of 10 for pain. Review of the resident's physician orders dated 7/17/25 showed an order for oxycodone (narcotic pain medication) 5 mg, take two capsules every four hours as needed for pain. Review of the resident's pain scores on 7/17/25 showed pain rated 5 out of 10 pain at 7:15 A.M. Review of the resident's pain scores on 7/18/25 showed the following:-6 out of 10 pain at 2:04 A.M.;-5 out of 10 pain at 9:21 A.M. Review of the resident's annual MDS, dated [DATE], showed the following:-Received pain medication on a scheduled and as needed basis;-Pain experienced frequently;-Pain rarely effected sleep or therapy activities;-Pain frequently effected day-to-day activities. Review of the resident's pain score on 7/21/25 at 8:07 A.M. showed 6 out of 10 pain. Review of the resident's pain score on 7/22/25 at 8:00 A.M. showed 7 out of 10 pain. Review of the resident's pain scores on 7/23/25 showed the following:-6 out of 10 pain at 12:58 A.M.;-7 out of 10 pain at 7:56 A.M. Review of the resident's pain scores on 7/24/25 at 6:30 A.M. showed 8 out of 10 pain. Review of the resident's pain scores on 7/26/25 showed the following:-6 out of 10 pain at 1:40 A.M.;-5 out of 10 pain at 12:25 P.M. Review of the resident's pain scores on 7/27/25 showed the following:-6 out of 10 pain at 3:21 A.M.;-4 out of 10 pain at 9:32 A.M. Review of the resident's pain scores on 7/28/25 showed the following:-8 out of 10 pain at 2:15 A.M.;-4 out of 10 pain at 4:09 P.M. Review of the resident's pain scores on 7/31/25 at 2:00 A.M. showed 6 out of 10 pain. Review of the resident's August pain scores showed the following:-8/3/25 at 1:49 A.M. 6 out of 10 pain;-8/3/25 at 6:50 A.M. 8 out of 10 pain;-8/4/25 at 1:42 A.M. 6 out of 10 pain;-8/4/25 at 12:19 P.M. 5 out of 10 pain;-8/7/25 at 1:30 A.M. 6 out of 10 pain;-8/8/25 at 1:00 A.M. 6 out of 10 pain;-8/9/25 at 12:19 P.M 4 out of 10 pain;-8/11/25 at 8:20 P.M. 4 out of 10 pain;-8/12/25 at 6:43 A.M. 5 out of 10 pain;-8/12/25 at 11:38 P.M. 6 out of 10 pain;-8/14/25 at 1:11 A.M. 6 out of 10 pain;-8/14/25 at 9:12 A.M. 5 out of 10 pain;-8/15/25 at 1:16 A.M. 6 out of 10 pain;-8/19/25 at 1:20 A.M. 6 out of 10 pain;-8/20/25 at 2:07 A.M. 6 out of 10 pain. Review of the resident's August medication administration record (MAR) showed the following:-As needed acetaminophen only administered once;-As needed oxycodone administered 43 times;-Pain assessment completed each shift. Review of the resident's care plan, dated 8/27/25, showed nothing in the plan addressing the resident's pain or use of opioid pain medication. Review of the resident's care plan conference, dated 8/27/25, showed the resident was receiving as needed acetaminophen and oxycodone for pain. Review of the resident's progress notes showed no documentation of a care plan conference occurring prior to 8/27/25. 3. Review of Resident #36's face sheet showed the following:-admitted [DATE];-Diagnoses of dementia, and carcinoma in situ (cancer) of left breast. Review of the resident's census showed the following:-6/27/25: hospitalized ;-7/1/25: returned to the facility under the payer Hospice. Review of the resident's Hospice admission Note and Hospice Certification of Terminal Illness, dated 7/1/25, showed the resident was terminally ill with a life expectancy of six months or less if the disease followed its normal course, and was admitted to hospice. Review of Resident #36's physician notification fax, dated 7/1/25, showed the Director of Nursing faxed a notification to the physician, stating the resident would be returning from the hospital on hospice. Review of the resident's progress notes dated 7/1/25 at 12:42 P.M. showed the resident was readmitted to the facility. Review of the resident's progress notes dated 7/7/25 at 6:18 P.M. showed the resident continued hospice care. Review of the resident's significant change MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Has a chronic disease that may result in a life expectancy of less than 6 months;-No special treatments, not on hospice. Review of the resident's care plan, revised 7/10/25, did not address hospice care. Review of the resident's physician orders, dated 9/8/25, showed no orders for hospice. During an interview on 09/08/25 at 10:10 A.M., the Director of Nursing said the resident was on hospice. During an interview on 09/18/25, at 10:37 A.M., the MDS Coordinator said the following:-Comprehensive care plans should be updated at least every three months;-They should be updated with major care areas changes that changed the cares provided.

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for five residents (Resident's #5, #11, #28, #34, #40) in a sample of 17 residents. The facility failed to follow physician's orders related to daily weights and administering Lasix (a diuretic) according to parameters set by the physician to ensure the resident did not experience fluid overload for Resident #11. The facility failed to follow physician's orders related to fluid restrictions, administering Lasix according to parameters set by the physician, and to check daily weights, according to the parameters set on the Lasix order, to ensure the resident did not experience fluid overload for Resident #5. The facility failed to follow physician's orders related to weight loss and notifying the physician and/or dietician when a significant or severe weight loss occurred for Residents #40, #28 and #34. The facility census was 41. Review of the facility policy Medication Orders, dated November 2014, showed the following:-The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders;-Each resident must be under the care of a Licensed Physician authorized to practice medicine in this state;-A current list of orders must be maintained in the clinical record of each resident;-Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered;-PRN (as needed) Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration.-Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. Review of the facility policy Nutrition (Impaired)/Unplanned Weight Loss, last revised September 2017, showed the following:-Nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individuals with anorexia (lack or loss of appetite for food), weight loss or gain, and significant risk for impaired nutrition;-The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake;-The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions;-For individuals with recent or rapid weight gain or loss (more than a pound a day), the staff will review for possible fluid and electrolyte imbalance as a cause;-The physician will review carefully and rule out medical causes of oral or swallowing problems before authorizing other consults or interventions to modify diet consistency;-The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis and wishes;-The staff and physician will review and consider existing dietary restrictions and modified consistency of diets;-Physician and staff will monitor nutritional status, an individual's response to interventions and possible complications of such interventions. Review of the facility's policy Weight Assessment and Intervention, revised March 2022, showed the following:-Resident weights are monitored for undesirable or unintended weight loss or gain;-Residents are weighed upon admission and at intervals established by the interdisciplinary team;-Weights are recorded in each unit's weight record chart and in the individual's medical record;-A weight change of 5% or more since the last weight assessment is retaken the next day for confirmation;-If the weight is verified, nursing will immediately notify the dietician in writing;-Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time;-The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- 5% weight loss is significant, greater than 5% is severe; b. 3 months- 7.5% weight loss is significant, greater than 7.5% is severe; c. 6 months- 10% weight loss is significant; greater than 10% is severe;-The physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss;-Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietician, the Consultant Pharmacist and the resident's legal surrogate;-Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment;-Interventions for undesired weight gain consider resident preferences and rights, a weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. 1. 1. Review of Resident #11's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 04/21/25, showed the following:-Severe cognitive impairment;-Diagnoses of atrial fibrillation (irregular heart rhythm), high blood pressure, dementia, malnutrition and adult failure to thrive;-Weighed 184 pounds;-No diuretic use. Review of the resident's Care Plan, dated 04/23/25, showed the following:-The resident has diagnosis of acute kidney failure, edema (swelling in tissue), high blood pressure, atrial fibrillation (abnormal rapid heart rate), low blood pressure, dehydration, and fluid overload;-Monitor the resident's weight monthly;-Report the resident's weight to the charge nurse so they can report any abnormal change to the resident's physician; (The resident's fluid overload, Lasix PRN, and daily weight monitoring was not included in the resident's care plan.) Review of the resident's Physician Order Sheets (POS), dated July 2025, showed an order for Lasix 20 mg, administer one tablet PRN for weight gain of 3 pounds in one day or 5 pounds in one week. May also give for increased swelling in legs, diagnosis fluid overload, and daily weights (original order dated 04/14/25). Review of the resident's MAR, dated July 2025, showed the following:-07/02/25, no weight recorded; resident sleeping;-07/03/25, no weight recorded; no explanation;-07/04/25, no weight recorded; resident refused;-07/05/25, no weight recorded; resident didn't get up;-07/06/25, no weight recorded; resident asleep. Review of the resident's weight record, dated July 2025, showed the following:-07/07/25, 170.5 pounds;-07/08/25, 170.5 pounds;-07/09/25, 169 pounds;-07/10/25, 169.2 pounds;-07/11/25, 169.2 pounds;-07/12/25, 171 pounds;-07/13/25, 172 pounds. Review of the resident's MAR, dated 07/14/25, showed no weight recorded. The resident was asleep. Review of the resident's weight record, dated July 2025, showed the following:-07/15/25, 174.5 pounds;-07/16/25 175.5 pounds (a 6.5-pound weight gain since 07/09/25, one week). Review of the resident's MAR, dated 07/16/25, showed no documentation staff administered PRN Lasix as ordered for a 5-pound weight gain in one week. Review of the resident's Nurses Notes, dated 07/01/25-07/16/25, did not add any additional entries on why daily weights were not completed or why the Lasix was not administered as ordered on 07/16/25. The nurse's notes did not include any evidence staff notified the physician of missing weights or the resident's weight gain on 07/16/25. Review of the resident's MAR, dated July 2025, showed the following:-07/17/25, no weight recorded, no explanation;-07/18/25, no weight recorded, no explanation. Review of the resident's weight record, dated July 2025, showed on 07/19/25, the resident weighed 173.5 pounds. Review of the resident's MAR, dated 07/20/25, showed no weight recorded. The resident was asleep. Review of the resident's Nurses Notes, dated 07/17/25-07/21/25, showed no additional entries why daily weights were not completed or physician notification that the weights were unable to be obtained. Review of the resident's Weight Record, dated July 2025, showed the following:-On 07/21/25, the resident weighed 174 pounds;-On 07/22/25, the resident weighed 177 pounds (a 3-pound weight gain since 07/21/25, one day). Review of the resident's MAR, dated 07/22/25, showed no documentation staff administered Lasix as ordered for a 3-pound weight gain in one day. Review of the resident's Nurses Notes, dated 07/22/25, showed no additional entries why staff did not administer the resident's Lasix as ordered on 07/22/25. The nurse's notes did not include any evidence staff notified the physician of the resident's weight gain on 07/22/25. Review of the resident's Weight Record, dated July 2025, showed the following:-07/23/25, 176.5 pounds;-07/24/25, 177.5 pounds;-07/25/25, 178 pounds;-07/26/25, 181 pounds (a 3-pound weight gain since 07/25/25, one day; and a 7.5-pound weight gain since 07/19/25, one week). Review of the resident's MAR, dated 07/26/25, showed no documentation staff administered Lasix as ordered when the resident had 3-pound weight gain in one day and 7.5-pound weight gain in one week. Review of the resident's Nurses Notes, dated 07/26/25, showed no additional entries why staff did not administer the resident's Lasix as ordered on 07/26/25. The nurse's notes did not include any evidence staff notified the physician of the resident's weight gain on 07/26/25. Review of the resident's Weight Record, dated July 2025, showed the following:-07/27/25, 181 pounds;-07/28/25, 182 pounds (an 8-pound weight gain since 07/21/25, one week). Review of the resident's MAR, dated 07/28/25, showed no documentation staff administered Lasix as ordered when the resident had an 8-pound weight gain in one week. Review of the resident's Nurses Notes, dated 07/28/25, showed no additional entries why staff did not administer the resident's Lasix as ordered on 07/28/25. The nurse's notes did not include evidence staff notified the physician of the resident's weight gain on 07/28/25. Review of the resident's Weight Record, dated July 2025, showed the following:-07/29/25, 181 pounds; -07/30/25, 181.5 pounds (a 5-pound weight gain since 07/23/25, one week). Review of the resident's MAR, dated 07/30/25, showed no documentation staff administered Lasix as directed when the resident had a 5-pound weight gain in one week. Review of the resident's Nurses Notes, dated 07/30/25, showed no additional entries why staff did not administer the resident's Lasix as ordered on 07/30/25. The nurse's notes did not include evidence staff notified the resident's physician of the resident's weight gain on 07/30/25. Review of the resident's POS, dated August 2025, showed an order for Lasix 20 mg, administer one tablet PRN for weight gain of 3 pounds in one day or 5 pounds in one week. May also give for increased swelling in legs, diagnosis fluid overload, and daily weights. Review of the resident's Weight Record, dated August 2025, showed the following:-08/01/25, no weight recorded;-08/02/25, 183 pounds (a 5-pound weight gain since 07/25/25, one week). Review of the resident's MAR, dated August 2025, showed the following:-08/01/25, no weight recorded; no reason documented;-08/02/25, no documentation staff administered Lasix as ordered for a 5-pound weight gain in one week. Review of the resident's Nurses Notes, dated 08/01/25-08/02/25, showed no additional entries why staff did not complete daily weights, or why staff did not administer the resident's Lasix as ordered on 08/02/25. The nurse's notes did not include evidence staff notified the resident's physician of missing weights or the resident's weight gain on 08/02/25. Review of the resident's MAR, dated 08/02/25, showed no weight recorded. The resident was asleep. Review of the resident's Weight Record, dated 08/04/25, showed the resident weighed 187.5 lbs. (a 4.5-pound weight gain since 08/02/25 and a 6.5-pound weight gain since 07/27/25, one week). Review of the resident's MAR, dated 08/04/25, showed no documentation staff administered Lasix as ordered for 4.5-pound weight gain in one day and a 6.5-pound weight gain in one week. Review of the resident's Nurses Notes, dated 08/03/25-08/04/25, showed no additional entries why staff did not complete daily weights, or why staff did not administer the resident's Lasix as ordered on 08/04/25. The nurse's notes did not include staff notified the resident's physician of missing weights or the resident's weight gain on 08/04/25. Review of the resident's MAR, dated August 2025, showed the following:-08/06/25, no weight recorded; no reason recorded;-08/07/25, no weight recorded; did not obtain;-08/11/25, no weight recorded; asleep;-08/13/25, no weight recorded; no reason recorded;-08/16/25, no weight recorded; no reason recorded;-08/18 /25, no weight recorded; due to condition. Review of the resident's Weight Record, dated August 2025, showed the following:-08/21/25, 186.5 pounds;-08/22/25, 189.5 pounds (a 3-pound weight gain since 08/21/25, one day). Review of the resident's MAR, dated 08/22/25, showed no documentation staff administered Lasix as ordered for 3-pound weight gain in one day. Review of the resident's Nurses Notes, dated 08/05/25-08/22/25, showed no additional entries why staff did not complete daily weights, or why staff did not administer the resident's Lasix as ordered on 08/22/25. The nurse's notes did not include evidence staff notified the resident's physician of missing weights or the resident's weight gain on 08/22/25. Review of the resident's MAR, dated August 2025, showed the following:-08/24/25, no weight recorded; no reason documented;-08/25/25, no weight recorded; the resident was asleep. Review of the resident's Weight Record, dated August 2025, showed the following:-08/28/25, 188.5 lbs.;-08/29/25, 191.5 lbs. (3-pound weight gain since 08/28/25, one day); Review of the resident's MAR, dated 08/29/25, showed no documentation staff administered Lasix as ordered for a 3-pound weight gain in one day. Review of the resident's Nurses Notes, dated 08/23/025-08/30/25, showed no additional entries why staff did not complete why daily weights, or why staff did not administer the resident's Lasix as ordered on 08/29/25. The nurse's notes did not include evidence staff notified the resident's physician of missing weights or the resident's weight gain on 08/29/25. Review of the resident's POS, dated September 2025, showed an order for Lasix 20 mg, administer one tablet PRN for weight gain of 3 pounds in one day or 5 pounds in one week. May also give for increased swelling in legs, diagnosis fluid overload, and daily weights. Review of the resident's Weight Record, dated September 2025, showed the following:-09/04/25, 189.5 pounds;-09/05/25, 195 pounds (a 5.5-pound weight gain since 09/04/25, one day). Review of the resident's MAR, dated 09/05/25, showed no documentation staff administered Lasix as ordered for a 5.5-pound weight gain in one day. Review of the resident's Nurses Notes, dated 09/05/25, showed no additional entries why staff did not administer the resident's Lasix as ordered on 09/05/25. The nurse's notes did not include evidence staff notified the resident's physician of the resident's weight gain on 09/05/25. Review of the resident's MAR, dated 09/07/25, showed no weight recorded; staff documented due to condition. Review of the resident's Nurses Notes, dated 09/07/25, showed no additional entries why staff did not complete the daily weight on 09/07/25. Observation on 09/07/2025 at 1:30 P.M. showed the resident sat in the recliner in his/her room. The resident's ankles showed some edema (fluid accumulation in tissues). The resident had creases in his/her skin from socks making indentions due to fluid. During an interview on 09/10/25 at 6:28 P.M., Licensed Practical Nurse (LPN) A said the following: -He/She worked as a charge nurse primarily on evening shift;-Resident #11 had a physician's order for daily weights;-Evening shift nurses and/or Certified Nurse Assistants (CNAs) complete daily weights. The resident frequently refused to be weighed. He/She had never reported this to the physician and was not aware of anyone else reporting this to the physician;-Staff were to document on the MAR or Nurses Notes when the resident refused weights;-Nurses complete the charting, not the CNAs. I if a CNA gets the weight, they give it to the nurse to chart;-The nurse was to compare the weight to the previous day's weight to determine if there was an increase and if the resident should receive any as needed medications or the nursed needed to notify the physician. 2. Review of Resident #5's face sheet showed the following:-admitted [DATE];-Diagnoses of edema, chronic atrial fibrillation, shortness of breath, hypertension, and diastolic congestive heart failure (a condition when the left ventricle of the heart becomes stiff and cannot relax properly to fill with enough blood between beats, leading to symptoms of heart failure). Review of the resident's weight record, dated 07/02/25, showed the resident weighed 170.5 pounds. Review of the resident's physician orders, dated 07/08/25, showed the following:-Lasix 20 mg tablet daily, as needed (PRN), for a weight gain of greater than 2 pounds in 48 hours;-Monthly weights, once a morning on the 5th of the month. Review of the resident's physician orders, dated 7/10/25, showed an order for a fluid restriction of 1.5 liters a day. Review of the resident's medical record showed no documentation staff obtained the resident's weight in July 2025 as ordered to accurately monitor for a 2-pound weight gain in 48 hours as directed in the physician's order for administration of PRN Lasix. Review of the resident's fluid intake record showed the following:-On 7/13/25, no documentation of fluid intake to ensure the resident's fluid intake did not exceed 1.5 liters a day (as ordered);-On 7/18/25, no documentation of fluid intake. Review of the resident's care plan, revised 7/22/25, showed to monitor weight monthly. Report weight to charge nurse so they can report any changes to physician. (The care plan did not include the resident's fluid restriction, daily weights to monitor for greater than 2 pound weight gain in 48 hours or any additional interventions to address his/her congestive heart failure.) Review of the resident's fluid intake record showed on 7/25/25, staff did not document the resident's fluid intake. Review of the resident's physician orders, dated August 2025, showed the following:-Lasix 20 mg tablet daily PRN for a weight gain of greater than 2 pounds in 48 hours;-Monthly weights, once a morning on the 5th of the month;-Fluid restriction of 1.5 liters a day. Review of the resident's weight record, dated 08/02/25, showed he/she weighed 161.5 pounds. Review of the resident's fluid intake record showed on 08/10/25, staff did not document the resident's fluid intake. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Diagnoses of heart failure and hypertension;-Weight loss of 5% or more in the last month or 10% or more in the last six months;-No weight gain; -Weight 162 pounds;-Medications included a diuretic. Review of the resident's fluid intake record showed the following:-On 8/18/25, no documentation of the resident's fluid intake;-On 8/21/25, no documentation of the resident's fluid intake;-On 8/23/25, no documentation of the resident's fluid intake;-On 8/25/25, no documentation of the resident's fluid intake;-On 8/28/25, no documentation of the resident's fluid intake;-On 8/29/25, no documentation of the resident's fluid intake. Review of the resident's medical record showed no documentation staff obtained the resident's weight in August 2025 as ordered toaccurately monitor for a 2-pound weight gain in 48 hours as directed in the physician's order for administration of PRN Lasix. Review of the resident's August 2025 Medication Administration Record (MAR) showed no documentation staff administered Lasix 20 mg PRN, ordered for a weight gain of 2 pounds in 48 hours Review of the resident's physician orders, dated September 2025, showed the following:-Lasix 20 mg tablet daily PRN for a weight gain of greater than 2 pounds in 48 hours;-Monthly weights, once a morning on the 5th of the month;-Fluid restriction of 1.5 liters a day. Review of the resident's weight record showed on 09/01/25, the resident weighed 154.5 pounds. Review of the resident's fluid intake record showed the following:-On 9/3/25, no documentation of the resident's fluid intake;-On 9/7/25, no documentation of the resident's fluid intake. Review of the resident's medical record showed no documentation staff obtained the resident's weight in September 2025 as ordered to accurately monitor for a 2-pound weight gain in 48 hours as directed in the physician's order for administration of PRN Lasix. Review of the resident's September 2025 MAR showed no documentation staff administered Lasix 20 mg PRN, ordered for a weight gain of 2 pounds in 48 hours, from 9/1/25 through 9/8/25. During an interview on 9/10/25 at 6:28 P.M., Licensed Practical Nurse (LPN) A said the following:-The resident had congestive heart failure, and his/her weight fluctuated;-The resident had orders to be weighed monthly;-He/She would follow the physician's orders, but would expect the resident to be weighed, at minimum, weekly, due to his/her congestive heart failure;-The resident had an order for as needed Lasix, with directions based on weight changes, indicating the resident should be weighed daily, which was not reflected with the current orders. During an interview on 9/10/25 at 5:14 P.M., the Director of Nursing (DON) said the following:-The resident had a fluid restriction;-Staff should monitor and document the resident's fluid intake;-The resident had an order for as needed Lasix, based on weight changes, but did not have an order for daily weights;-There was no way to know or to truly monitor the resident's weights without checking the resident's weight daily. 3. Review of Resident #40's Care Plan, dated 8/05/25, showed the following: -Monitor weight weekly for significant weight changes;-Report his/her weight to the charge nurse so they can report any abnormal weights to the physician. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 8/08/25, showed the following: -Severe cognitive impairment;-Weight 272 pounds;-No weight loss. Review of the resident's Nutritional Quarterly Assessment, dated 8/08/25, showed the following:-Current weight 271.5 pounds;-Weight last quarter 268 pounds. Review of the resident's physician orders, dated August 2025, showed an order for weekly weights to monitor for weight loss. Review of the resident's weight record showed the following:-On 08/02/25, the resident weighed 271.5 pounds;-On 08/12/25, the resident weighed 265 pounds;-On 08/26/25, the resident weighed 269 pounds. Review of the resident's weight record, dated 9/01/25, showed the resident weighed 206.5 pounds (a weight loss of 23.23% in one week). Review of the resident's medical record showed no evidence staff re-weighed the resident to ensure the weight obtained on 9/01/25 was accurate to reflect the resident's current weight. During an interview on 9/10/25, at 9:32 A.M., Licensed Practical Nurse (LPN) D said the following:-He/She or the Certified Nurse Assistants (CNAs) weighed the residents;-He/She entered the weight into the electronic health record (EHR);-If he/she saw a discrepancy in the weight, staff re-weighed the resident;-If the re-weigh showed a discrepancy from the previous weights, he/she did a comparison in the EHR that included checking vital signs and checking for edema and notified the physician;-He/She missed this resident's weight on 9/01/25. He/She should have re-weighed the resident and looked at the resident's intake. During an interview on 9/10/25, at 7:30 P.M., the Director of Nursing (DON) said the following:-Aides documented the residents' weights in the Electronic Health Record (HER);-If a weight appeared inaccurate, the nurses are to re-weigh the resident and compare the weight to previous weights. 4. Review of the Resident #28's Care Plan, dated 4/04/25, showed the following: -The resident was on a low concentrated sweets diet and could feed himself/herself;-Monitor weight monthly for significant weight changes;-Report his/her weight to the charge nurse so they can report any abnormal weights to the physician. Review of resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Weight 116 pounds;-No weight loss of 5 percent (%) in one month or 10% in last six months;-Therapeutic diet. Review of the Nutritional Quarterly Assessment, dated 7/08/25, showed the following:-Current weight 115 pounds;-Weight last quarter 113 pounds. Review of the resident's physician orders, dated August 2025, showed an order for monthly weights. Review of the resident's weight record, dated 8/02/25, showed the resident weighed 155.5 pounds (a weight gain of 35% in one month). Review of the resident's medical record showed no evidence staff re-weighed the resident to ensure the weight obtained on 8/02/25 was accurate to reflect the resident's current weight. Review of the resident's weight record, dated 9/02/25, showed the resident weighed 119.5 pounds (a weight loss of 23.15% in one month). Review of the resident's medical record showed no evidence staff re-weighed the resident to ensure the weight obtained on 9/02/25 was accurate to reflect the resident's current weight. During an interview on 9/10/25, at 9:56 A.M., LPN E said he/she missed this resident's weight on 9/02/25. He/She should have re-weighed the resident. 5. Review of Resident #34's Nutritional Quarterly Assessment, dated 6/24/25, showed the following:-Current weight 201 pounds;-Weight last quarter 206 pounds. Review of resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Weight 201 pounds;-Weight loss of 5% in one month or 10% in the last six months;-Not on physician-prescribed weight-loss regimen;-Therapeutic diet. Review of the resident's weight record, dated 7/01/25, showed the resident weighed 210 pounds. Review of the resident's care plan, dated 7/15/25, showed the following: -Monitor weight monthly for significant weight changes;-Report his/her weight to the charge nurse so they can report any abnormal weights to the physician. Review of the resident's weight record, dated 8/02/25, showed the resident weighed 228 pounds (a weight gain of 8.57% in one month). Review of the resident's medical record showed no evidence staff re-weighed the resident to ensure the weight obtained on 8/02/25 was accurate to reflect the resident's current weight. Review of the resident's weight record, dated 9/01/25, showed the resident weighed 209 pounds (a weight loss of 8.33% in one month). Review of the resident's medical record showed no evidence staff re-weighed the resident to ensure the weight obtained on 9/02/25 was accurate to reflect the resident's current weight. During an interview on 9/10/25, at 9:51 A.M., LPN E said he/she missed this resident's weight on 9/01/25. He/She should have re-weighed the resident. 6. During interview on 9/18/25, at 10:37 A.M., the MDS coordinator said the following:-She monitored resident weights weekly and monthly; the charge nurses are supposed to compare the daily weights to the weight the day and week before;-She had not noticed the lack of weights being documented for Resident #111;-The CNA's obtain the weights and give them to the charge nurse to put in, the MDS coordinator reviews them and gives updates in the clinical meeting to dietary and the rest of nursing staff. She lets the computer do the calculation and it will say if they are a significant weight loss/gain;-The electronic system automatically calculates if the resident has weight loss;-If the weight is way off, staff will re-weigh the resident. During an interview on 9/10/25, at 7:30 P.M., the DON said the following:-Aides chart the meal intakes and weights in care assist; -MDS and care plan coordinator notifies DON if the resident has lost weight/weight gain;-Nurses are expected to notify the physician if more than five pounds are gained or lost from last weight;-The nurse receiving a resident's daily weight should calculate weight gained or lost according to the parameters in the physician's orders.

Based on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed rails and failed to complete inspections of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #40, #5, #7, and #14), in a review of 17 sampled residents. The facility census was 41. During an interview on 09/09/10:15 A.M., the Director of Nursing (DON) said the facility did not have a policy for bed rails. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/08/25, showed the following:-Diagnoses of dementia and need for assistance with personal care; -Severe cognitive impairment;-Required substantial/maximal assistance for mobility and transfers. Review of the resident's Care Plan, dated 8/05/25, showed the following: -The resident was at risk for falls;-He/She required assistance from one staff for transfers and bed mobility;-Encourage the resident to ask for assistance;-No documentation related to bed rail use. Observation on 9/10/25, at 9:08 A.M., showed the resident lay asleep in bed. The halo rail (a circular grab/assist bar), located on the left side of the resident's bed, was in the raised position. Review of the resident's medical record showed no documentation staff obtained informed consent or assessed the resident's risk for entrapment prior to use of the halo rail. Review showed no documentation staff conducted a regular inspection of the resident's bed frame, mattress and the halo rail to identify areas of possible entrapment. 2. Review of Resident #5's undated face sheet, showed he/she admitted on [DATE]. Review of the resident's physician orders, dated 5/7/25, showed an order to have two quarter bed rails to assist with moving side to side in bed and to edge of bed for transfers, due to weakness and pain from recent abdominal surgery. Review of the resident's consent for use of side rails, dated 5/7/25, showed the following:-Left upper: quarter bed rail;-Right upper: quarter bed rail;-Bed rail or alternative interventions decision tree was not completed. Review of the resident's bed rail safety check, dated 5/20/25, showed the following:-Headboard measurement 0;-Footboard measurement 2;-Halo rail on the right side of the bed: -Zone 1: pass, measurement 3.5; -Zone 2: pass, no measurement; -Zone 3: pass, no measurement;(Staff completed the bed rail safety check for a halo rail, however, the resident had an order for two quarter bed rails. Review showed no documentation staff conducted a bed rail safety check to identify areas of possible entrapment between the bed frame, mattress and the quarter bed rails.) Review of the resident's side rails assessment and consent, completed 5/28/25, showed the following:-Medical symptoms requiring use of bed rails: new colostomy (an artificial opening in the abdominal wall to divert stool from the colon), abdominal pain, congestive heart failure, and atrial fibrillation;-Reason for bed rail usage: assist with transfer and bed mobility;-Types of rails to be used: top half, two sides;-Frequency of use: resident had two quarter bed rails to enable him/her to turn self and and reposition and to assist with sitting up on the edge of the bed.(Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Review of the resident's physician orders, dated 7/8/25, showed an order to have two quarter bed rails to assist with moving side to side in bed and to edge of bed for transfers, due to weakness and pain from recent abdominal surgery. Review of the resident's side rails assessment and consent, completed 7/23/25, showed the following:-Medical symptoms requiring use of bed rails: colostomy, atrial fibrillation, asthma, shortness of breath, and congestive heart failure;-Reason for bed rail usage: assist with transfer and bed mobility;-Types of rails to be used: top half, two sides;-Frequency of use: resident had two halo rails to assist with moving side to side in bed and sitting on edge of bed for transfers. (The assessment identified the resident had halo rails, however, the resident had a physician's order for quarter bed rails.)(Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/14/25, showed the following:-Moderate cognitive impairment;-Moderate assistance required for rolling left and right in bed, sitting on the side of the bed to lying flat on the bed, for sitting to standing, and chair/bed-to-chair transfers;-Set up assistance for lying flat on the back to sitting on the side of the bed with feet flat on the floor. Review of the resident's care plan, revised on 8/29/25, showed the following:-He/She required assistance from one staff with most activities of daily living (ADLs);-He/She was to have two quarter bedrails to assist with moving side to side in bed and to the edge of the bed for transfers since still weak from recent surgery. Observation on 9/10/25 at 8:49 A.M. showed the resident was asleep in bed. The resident had one quarter bed rail in the raised position on the left side of his/her bed. Review of the resident's medical record showed no documentation staff conducted a bed rail safety check to identify areas of possible entrapment between the bed frame, mattress and the quarter bed rail. 3. Review of Resident #7's undated face sheet, showed the resident was admitted on [DATE]. Review of the resident's physician orders, dated 7/14/25, showed an order to have two quarter bed rails to assist with moving side to side in bed and to edge of bed for transfers due to fracture of both femurs. Review of the resident's consent for use of side rails, dated 7/14/25, showed the following:-Left upper: quarter side rail;-Right upper: quarter side rail:-Bed rail or alternative intervention decision tree not completed. Review of the resident's admission MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Impairment in range of motion to both lower extremities;-Dependent on staff for rolling left and right in bed, sitting on the side of the bed to lying flat on the bed, lying flat on the back to sitting on the side of the bed with feet flat on the floor, sitting to standing and chair and bed-to-chair transfers. Review of the resident's care plan, revised 8/27/25, showed the following:-He/She required assistance with most ADLs;-He/She had two quarter bed rails to assist with moving side to side in bed and to edge of bed for therapy. Review of the resident's side rails assessment and consent, dated 8/27/25, showed the following:-Medical symptoms requiring use of bed rails: two fractured femurs, non-weight bearing, dementia, and pain;-Reason for use: assist with transfer and bed mobility;-Type of rails to be used: top half, two sides;-Frequency of use: resident had two quarter bed rails to enable him/her in self-turning and reposition and to assist in sitting up on the edge of bed;(Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Observation on 9/8/25 at 10:59 A.M. showed the resident was sleeping in bed. The resident had quarter bed rails in the raised position on both sides of his/her bed. Observation on 9/8/25 at 11:48 A.M. showed the resident was in bed. The quarter side rails on both sides of the resident's bed were in the raised position. The resident utilized the side rails to roll side to side in bed. Review of the resident's medical record showed no documentation staff conducted a regular inspection of the resident's bed frame, mattress and the quarter bed rails to identify areas of possible entrapment. 4. Review of Resident #14's undated face sheet showed he/she was admitted on [DATE]. Review of the resident's consent for use of side rails, dated 7/25/24, showed the following:-Left upper: halo rail;-Bed rail or alternative intervention decision tree not completed. Review of the resident's physician orders, dated 7/25/24, showed an order for one halo bed rail on the right side to assist with moving side to side in bed and to edge of bed for transfers. Review of the resident's side rails assessment and consent, dated 9/5/24, showed the following:-Medical symptoms requiring use of bed rails: coronary artery disease, osteoarthritis, angina pectoris (chest pain), gastroesophageal reflux disease (GERD);-Reason for use: assist with transfer and bed mobility;-Type of rails to be used: top half, one side;-Frequency of use: resident had a halo bed rail on upper left to enable him/her in self-turning and repositioning and to assist in setting on edge of bed.(Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Review of the resident's physician orders, dated 11/22/24, showed an order for one halo bed rail on the right side to assist with moving side to side in bed and to edge of bed for transfers due to unsteadiness on feet and weakness. Review of the resident's side rails assessment and consent, dated 12/4/24, showed the resident had a halo bed rail on the upper right to enable him/her in self-turning and repositioning and to assist in setting on edge of bed. (Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Review of the resident's side rails assessment and consent, dated 3/12/25, showed the resident had a halo bed rail on upper right to enable him/her in self-turning and repositioning and to assist in setting on edge of bed. (Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Review of the resident's bed rail safety check, dated 5/20/25, showed the following:-Quarter bed rail on the right side of the bed: -Zone 1 (within the rail): pass, measurement 3.5; -Zone 2 (under the rail between the mattress): pass, no measurement; -Zone 3 (between the rail and the mattress): pass, no measurement; -Zone 4 (under the rail at the ends of the rail): pass, no measurement;-Quarter bed rail on the left side of the bed: -Zone 1: pass, measurement 3.5; -Zone 2: pass, no measurement; -Zone 3: pass, no measurement; -Zone 4: pass, no measurement;(Review showed no documentation staff completed a thorough inspection to identify areas of possible entrapment between the bed rails and the resident's mattress and bed frame.) Review of the resident's side rails assessment and consent, dated 6/12/25, showed the resident had a halo bed rail on the upper right to enable him/her in self-turning and repositioning and to assist in setting on edge of bed. (Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Review of the resident's annual MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Maximum assistance required for rolling left and right in bed;-Dependent on staff for sitting on the side of the bed to lying flat on the bed, lying flat on the back to sitting on the side of the bed with feet flat, sitting to standing, and chair and bed-to-chair transfers. Review of the resident's side rails assessment and consent, dated 9/10/25, showed the following:-Reason for use: assist with transfer and bed mobility; -The resident had a halo bed rail on upper right to enable him/her in self-turning and repositioning and to assist in setting on edge of bed.(Review showed no documentation staff assessed the resident's risk for entrapment between the bed and the bed rails.) Review of the resident's care plan, revised 9/10/25, showed the resident had one halo rail on the left side to assist with moving side to side in bed and moving to edge of bed for transfers. Observation on 9/8/25 at 9:44 A.M. and 10:54 A.M. showed the quarter bed rails in the raised position on both sides of the resident's bed. 5. During an interview on 9/22/25 at 8:51 A.M., the Maintenance Director said the following:-The maintenance department was responsible for putting the bed rails on the residents' bed per physician orders;-He was not aware some residents were on beds with rails that did not match the physician order.-He evaluated the residents' beds and bed rails monthly. He conducted a visual check and quickly measured the zones. He kept a documentation to show he conducted the monthly inspection and measurements, but did not document the actual measurements;-He did not realize some residents with bed rails didn't have an inspection with measurements or that the most recent documented inspections with measurements did not match the bed rails the residents had on their beds.-He had a list of all residents and the types of rails they should have, but it was outdated and not correct. During interviews on 09/09/25 at 10:15 A.M. and on 09/10/25 at 7:30 P.M., the Director of Nursing (DON) said the following;-Staff was to complete the bed rail risk assessment prior to use of bed rails, including halo bed rails; -The MDS Coordinator monitored the bed rails on admission and quarterly;-Bed rail use should be on the resident's care plans.-The bed rail assessment did not assess the resident's risk for entrapment; -The facility did not have an assessment to evaluate the resident's risk or entrapment;-The facility did not have a system in place to know which residents with bed rails were at risk for entrapment. During an interview on 9/10/25 at 7:30 P.M., the Administrator said the following:-Staff should complete assessments prior to the use of all bed rails, including the halo rails. She did not know an entrapment risk assessment was required;-Maintenance staff was to measure the entrapment zones monthly.

Based on interview and record review, the facility failed to ensure seven nurse aides (NAs) completed a state-approved training program within four months of hire. The facility census was 41. Review of the facility policy, Nurse Aid Qualifications and Training Requirements, revised August 2022, showed the following:-Nurse aides must undergo a state-approved training program;-The facility will not employ any individual as a nurse aide for more than four months, full-time, temporary, per diem, or otherwise, unless: a. That individual is competent to provide designated nursing care and nursing related services, and; b. That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state or that individual has been deemed competent as provided in S483. IS0(a) and (b) of the requirements of participation;-Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. 1. Review of NA J's employee file showed a hire date of 4/25/23. During an interview on 09/08/25, at 10:14 A.M., NA J said he/she worked at the facility as an NA for a couple of years. He/She was enrolled in a training program. During an interview on 9/10/25 at 5:14 P.M., the Director of Nursing (DON) said NA J was currently enrolled in an online training program. 2. Review of NA O's employee file showed a hire date of 4/24/24. During an interview on 9/10/25 at 5:14 P.M., the DON said the following:-NA O had a delayed start into his/her classes;-NA O started part time. He/She tried to enroll into a different program and had problems with the program not accepting the facility's form of payment, and then he/she was off for a while.-NA O was scheduled to test on 9/15/25. 3. Review of NA U's employee file showed a hire date of 8/23/24. During an interview on 9/10/25 at 5:14 P.M., the DON said the following:-NA U failed a portion of his/her test and had not retested;-NA U was still working as an NA. 4. Review of NA V's employee file showed a hire date of 10/14/24. During an interview on 9/10/25 at 5:14 P.M., the DON said the following:-NA V failed a portion of his/her test and had not retested;-NA V was still working as an NA. During an interview on 09/09/25, at 1:14 P.M., NA V said he/she started at the facility last Fall and worked full time as an NA on the day shift. 5. Review of NA H's employee file showed a hire date of 12/2/24. During an interview on 9/10/25 at 5:14 P.M., the DON said the following:-NA H had a delayed start for his/her classes. He/She worked evenings, and then was off work for a while; -NA H was scheduled to test on 9/15/25. 6. Review of NA W's employee file showed a hire date of 3/4/25. During an interview on 9/10/25 at 5:14 P.M., the DON said NA W was scheduled to test on 9/15/25. 7. Review of NA X's employee file showed a hire date of 5/12/25. During an interview on 9/10/25 at 5:14 P.M., the DON said NA X started classes on 9/8/25. The program the facility used only have one class every 12 weeks. NA X was hired after the start of the previous class, so he/she had to wait to start the class. 8. During an interview on 9/10/25 at 5:14 P.M., the Director of Nursing (DON) said the following:-NAs must be certified within four months of hire;-The facility usually had NAs enrolled in class prior to their four months, but they do not always have their classes completed and test taken within the four months; -The facility typically held off enrolling NAs because the facility paid for classes and testing and the NAs did not always stay; -The training program the facility used only had one class every 12 weeks, so depending on when the NA was hired, they may be delayed getting into a course; -It did not matter if the NA was full time, part time or as needed, they were supposed to be certified within four months; -If the NA was not certified within four months, they were supposed to be terminated or moved to a non-direct care position.

Based on interview and record review, the facility failed to obtain a 14 day stop date on as needed (PRN) psychotropic medication for two residents (Residents #11 and #28), in a review of 17 sampled residents, and did not provide documentation of a clinical reason to extend the PRN medication beyond 14 days. Resident #11's PRN antipsychotic medication was administered for reasons that were not approved and lacked documentation of why the medication was administered. The facility census was 41. Review of drugs.com showed the following:-Seroquel is an antipsychotic medication that may increase the risk of death in older adults with mental health problems related to dementia.-Seroquel can cause a serious heart problem. Your risk may be higher if you also use certain other medicines for infections, asthma, heart problems, high blood pressure, depression, mental illness, and cancer.-Seroquel is approved for use for:-Schizophrenia in adults and children who are at least [AGE] years old.-Used alone or with divalproex or lithium to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods).-To prevent episodes of depression in patients with bipolar disorder.-Seroquel extended release is used in combination with antidepressant medications to treat major depressive disorder in adults. Review of the facility's policy, Antipsychotic Medication Use, last revised July 2022, showed the following: -Residents will not receive medications that are not clinically indicated to treat a specific condition;-Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review;-Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective;-The attending physician will identify, evaluate and document symptoms that may warrant the use of antipsychotic medications;-Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders: a. Schizophrenia; b. schizoaffective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders; f. Psychosis in the absence of dementia; g. medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania; h. Tourette's Disorder; I. Huntington Disease; j. Hiccups; k. Nausea and vomiting associated with cancer or chemotherapy;-Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident and others; AND; 1. The symptoms are identified as being due to mania or psychosis or; 2. Behavioral interventions have been attempted and included in the plan of care, except in an emergency;-Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness or crying along that is not related to depression or other psychiatric disorders; i. Fidgeting; j. Nervousness; k. Uncooperativeness;-Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record;-PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use;-The duration of the PRN order will be indicated in the order;-Staff will observe, document and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications;-The physician shall respond appropriately by stopping problematic doses or medications or clearly documenting why the benefits of the medication outweigh the risks or suspected confirmed adverse consequences. 1. Review of Resident #11's Nurses Notes, dated 04/14/25 at 8:37 P.M., showed the resident admitted to the facility at 11:50 A.M. on 4/14/25. The resident was restless, forgets to ask for help, and gets up and starts to walk without his/her walker. The resident wanted to go home. Review of the resident's undated Baseline Care Plan showed the resident was alert, confused, moody and wandered. The resident was an elopement risk and had a Wanderguard (electronic alert worn on the body). The baseline care plan did not include any other specific behaviors or interventions for behaviors. Review of the resident's Physician's Orders Sheet (POS), dated 04/14/25, showed Seroquel (quetiapine) 25 milligrams (mg), 1/2 tab (dose of 12.5 mg) daily PRN (as needed) for agitation. The order did not include a stop date of 14 days or less. Review of the resident's Medication Administration Record (MAR), dated 04/14/25 at 9:11 P.M., showed staff administered Seroquel 12.5 mg, for behavior issues, with a follow up entry noted as effective. (Behavior issues were not an approved use for the PRN Seroquel as directed in the physician's orders. The resident's record included no documentation to describe the resident's noted behavior issues or staff interventions prior to administration of Seroquel.) Review of the resident's MAR, dated 04/15/25 at 7:08 P.M., showed the resident received Seroquel 12.5 mg, for other, and a follow up entry effective. (Other is not an approved use for Seroquel). Review of the resident's Nurses Notes, dated 04/15/25, did not show any additional behaviors or documentation why staff administered Seroquel at 7:08 P.M. or staff interventions prior to administration of Seroquel. Review of the resident's MAR, dated 04/17/25 at 7:24 P.M., showed staff administered Seroquel 12.5 mg, for sleep. There was no follow up entry documented. (The resident's physician orders directed use for agitation). Review of the resident's Nurses Notes, dated 04/17/25, did not show any additional behaviors for the evening shift or documentation why staff administered Seroquel at 7:24 P.M or staff interventions prior to administration of Seroquel. Review of the resident's MAR, dated 04/18/25 at 5:09 P.M., showed staff administered Seroquel 12.5 mg, for other. There was no follow up entry regarding effectiveness. (Other is not an approved use for Seroquel). Review of the resident's Nurses Notes, dated 04/18/25, did not show any additional behaviors or documentation why staff administered Seroquel at 5:09 P.M. or staff interventions prior to administration of Seroquel. Review of the resident's MAR, dated 04/19/25 at 5:44 P.M., showed staff administered Seroquel 12.5 mg, for behavioral issue. A follow up entry noted somewhat effective. Review of the resident's Nurses Notes, dated 04/19/25, did not show any additional behaviors or documentation why staff administered Seroquel at 5:44 P.M or staff interventions prior to administration of Seroquel. At 8:36 P.M., staff documented family visit one on one with resident until just before the supper meal service. Resident prowling the hallways and forgetting his/her walker. The resident was cooperative and enjoyed talking to others. Will sit briefly in his/her recliner to watch television. Review of the resident's MAR, dated 04/20/25 at 7:18 P.M., showed staff administered Seroquel 12.5 mg, for behavioral issue. A follow up entry noted somewhat effective. Review of the resident's Nurses Notes, dated 04/20/25, did not show any additional behaviors or documentation why staff administered Seroquel at 7:18 P.M. or staff interventions prior to administration of Seroquel. At 9:26 P.M., staff documented for this shift (2 P.M to 10 P.M.), family at bedside and resident asleep in bedside recliner. Family left at 4:45 P.M., and then resident was fully awake. The resident ambulated in his/her room, then returned to his/her recliner watching westerns on television. No aggressive behaviors this shift. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 04/21/25, showed the following:-Severe cognitive impairment;-Diagnoses included Alzheimer's dementia, metabolic encephalopathy (neurological syndrome where brain function is impaired due to systemic illnesses), atrial fibrillation (irregular heartbeat), high blood pressure, pain, adult failure to thrive, and history of falling;- Usually understands-misses some part/intent of message but comprehends most conversation;-Wandering occurred one to three days;-Antipsychotic used on a PRN basis. Review of the resident's MAR, dated 04/22/25 at 8:24 P.M., showed staff administered Seroquel 12.5 mg, for other, restlessness. A follow up entry noted somewhat effective. (Restlessness and other is not an approved use for Seroquel). Review of the resident's Nurses Notes, dated 04/22/25, at 8:45 P.M., showed staff documented the resident was resting in bed watching television. Alert and oriented to self, pleasant and cooperative. Resident has been up several times this evening walking into the hallway but was easily redirected to room. No violent or aggressive behaviors noted this shift. Review of the resident's Nurses Notes, dated 04/22/25, did not show any additional behaviors or documentation why staff administered Seroquel at 8:24 P.M. or staff interventions prior to administration of Seroquel. Review of the resident's Care Plan, dated 04/23/25, showed the following:-Psychotropic Drug Use: The resident has a diagnosis of dementia and sometimeshas aggressive behaviors towards staff when they are trying to help him/her;-Resident to have less aggressive behaviors by next review date;-Resident has Seroquel PRN if he/she has aggressive behaviors;-Monitor the resident after administering Seroquel for side effects such as orthostatic hypotension (low blood pressure), lethargy, headache, weight gain, weakness, insomnia, dizziness and drowsiness. The resident's care plan did not include specific behaviors other than wandering, or interventions for specific behaviors other than wandering. The resident wore a Wanderguard. Review of the resident's Nurses Notes, dated 04/23/25, at 4:16 P.M., showed the resident sat in the dining room. The resident was calm and had not displayed any behaviors. Review of the resident's MAR, dated 04/23/25 at 8:27 P.M., showed staff administered Seroquel 12.5 mg, for other, restlessness. A follow up entry noted effective. (Restlessness is not an approved use for Seroquel). Review of the resident's Nurses Notes, dated 04/23/25, did not show any additional behaviors or documentation why staff administered Seroquel at 8:27 P.M. or staff interventions prior to administration of Seroquel. Review of the resident's Nurses Notes, dated 04/23/25, at 10:31 P.M., showed staff documented the resident was cooperative and had not tried to leave or talk about leaving. Review of the resident's MAR, dated 04/25/25 at 6:47 P.M., showed staff administered Seroquel 12.5 mg, for other, restlessness. A follow up entry noted effective. (Restlessness is not an approved use for Seroquel). Review of the resident's Nurses Notes, dated 04/25/25, did not show any additional behaviors or documentation why staff administered Seroquel at 6:47 P.M. or staff interventions prior to administration of Seroquel. Review of the resident's Nurses Notes, dated 04/25/25, at 7:22 P.M., showed the resident had been roaming the hall or sitting in front of the nurses desk. The resident required repeated reminders to use his/her rolling walker when ambulating. The resident had been calm. Review of the resident's Nurses Notes, dated 04/30/25, at 6:41 P.M., showed the resident wandered in the hallway. The resident forgets to use his/her walker. Review of the resident's MAR, dated 04/30/25 at 7:33 P.M., showed staff administered Seroquel 12.5 mg, for other, restlessness. A follow up entry noted effective. Review of the resident's Nurses Notes, dated 04/30/25, did not show any additional behaviors or documentation why staff administered Seroquel at 7:33 P.M. or staff interventions prior to administration of Seroquel. Review of the resident's MAR, dated 05/04/25 at 8:57 A.M., showed staff administered Seroquel 12.5 mg, for behavioral issue. A follow up entry noted somewhat effective. Review of the resident's Nurses Notes, dated 05/04/25, did not show any additional behaviors or documentation why staff administered Seroquel at 8:57 A.M. or staff interventions prior to administration of Seroquel. Review of the resident's MAR, dated 05/06/25 at 5:43 P.M., showed staff administered Seroquel 12.5 mg, for behavioral issue. A follow up entry noted effective. Review of the resident's Nurses Notes, dated 05/06/25, did not show any additional behaviors or documentation why staff administered Seroquel at 5:43 P.M., or staff interventions prior to administration of Seroquel. Review of the resident's MAR, dated 05/31/25 at 1:24 A.M., showed staff administered Seroquel 12.5 mg, for behavioral issue, exit seeking and resistance. A follow up entry noted effective. Review of the resident's Nurses Notes, dated 05/31/25, at 01:30 A.M., showed the resident was wandered in the hallway. He/She came to the nurses station and fixated on a chair by the fish tank. The resident picked up and walked around with the chair. The resident said he/she wanted to find his/her truck and go home. The resident put the chair in front of the dining room doors and sat, then went into the dining room. All attempts to redirect were unsuccessful. Resident agreed to take PRN Seroquel. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognition impairment;-Physical behavioral symptoms directed toward others occurred one to three days;-Wandering one to three days;- Usually understands-misses some part/intent of message but comprehends most conversation. Review of the resident's MAR, dated 08/31/25 at 8:19 P.M., showed staff administered Seroquel for sleep. Follow up documentation noted effective. Review of the resident's Nurses Notes, dated 08/31/25, showed no behaviors or documentation why staff administered Seroquel at 8:18 P.M., or staff interventions prior to administration of Seroquel. Review of the resident's medical record showed no documentation of a rationale from the resident's physician to indicate why it was appropriate to provide no indication for duration of the resident's Seroquel. 2. Review of Resident #28's care plan, dated 4/4/25, showed the following:-The resident had a diagnosis of anxiety and depression;-Monitor for signs and symptoms of depression and anxiety; -If the resident showed any signs, notify the charge nurse. Review of resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-No physical or verbal behaviors or rejection of cares;-Diagnoses of anxiety and depression;-Received an antidepressant medication. Review of the resident's Physician Orders, dated August 2025, showed an order for clorazepate dipotassium (a psychotropic medication used to treat anxiety) 7.5 milligrams (mg) twice daily PRN for anxiety (original order dated 4/17/25). (The PRN order did not include a stop date.) Review of the resident's Physician's Orders, dated September 2025, showed an order for clorazepate dipotassium 7.5 mg twice daily PRN for anxiety (original order dated 4/17/25). (The PRN order did not include a stop date.) Review of the resident's MAR, dated September 2025, showed the resident received four doses of clorazepate dipotassium. Review of the resident's medical record showed no documentation of a rationale from the resident's physician to indicate why it was appropriate to extend the PRN order for clorazepate dipotassium beyond 14 days and no indication for the duration of the PRN order. 3. During an interview on 9/10/25, at 7:30 P.M., the Director of Nursing (DON) said the following:-Staff should obtain stop dates of 14 days or less for PRN psychotropic medications;-Staff should inform the physician on how a resident responded to psychotropic medication and obtain an order to discontinue or continue the PRN psychotropic medication for 14 days at a time;-Staff should administer PRN medications for the indications for which they are approved.

Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #4 and #6), in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 41. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that:-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and is not self-limiting;-Impacts more than one area of the resident's health status;-Requires interdisciplinary review and/or revision the care plan.-The manual also showed a SCSA was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of activities of daily living (ADL) decline or improvement).1. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/29/25, showed the following:-Cognitively intact;-Diagnosis of chronic pain, sepsis (infection leading to bacteria in the blood), sacral (tailbone) fracture on admission; -Pain Management: Scheduled pain meds, PRN (as needed) pain medications, frequent pain, pain occasionally effects sleep, worst pain last five days the resident rated at a 10 on a 1-10 scale (10 being worst pain);-Walker use;-Set up or clean up assistance from staff for oral hygiene and personal hygiene;-Requires supervision/touching assistance from staff members for upper body dressing,;-Requires partial/moderate assistance from staff for toileting hygiene;-Requires substantial/maximal assistance from staff for lower body dressing, to roll right and left and for lying to sitting on bed side; -Dependent on staff for sit to stand, chair/bed-to-chair, toilet transfer and tub/shower transfer.Review of the resident's quarterly MDS, dated [DATE], showed the following:-New use of a wheelchair;-Independent with wheelchair mobility 50 feet with two turns (improvement); -Requires partial/moderate assistance from staff for oral hygiene (decline), personal hygiene (decline), to roll right and left (improvement), from lying to sitting on bed side (improvement), sit to stand (improvement), chair/bed-to-chair (improvement) and tub/toilet transfer (improvement);-Dependent on staff for toilet hygiene (decline), upper body dressing (decline), lower body dressing (decline), wheeling 150 feet (improvement); -No use of PRN (as needed) pain medication and no pain on interview (improvement).Observation on 09/07/25, at 12:30 and 1:25, showed the following:-The resident sat up in his/her wheelchair at lunch;-The resident fed himself/herself without any difficulty;-After lunch, the resident propelled his/her own wheelchair down the hall.The facility did not complete a SCSA when the resident had new wheelchair use and mobility, increased ability for bed mobility, increased ability for transfers, a decrease in ADLs such as oral hygiene, personal hygiene, toileting hygiene, dressing, and a decrease in pain and PRN pain medication use. 2. Review of Resident #6's annual MDS, dated [DATE], showed the following:-Minimal visual and hearing difficulties; has hearing aid and glasses;-Cognitively intact;-Diagnosis include sepsis, dysrhythmia (irregular heartbeat), heart failure, chronic pulmonary (respiratory) disease, tremor, convulsions unspecified, pain and edema;-Impairment of functional ROM (range of motion) in one lower extremity;-Wheelchair use;-Independent with eating;-Requires partial/moderate assistance from staff for oral hygiene and personal hygiene;-Requires substantial/maximal assistance from staff for upper body dressing, lower body dressing, footwear, and wheeling 50 feet with 2 turns;-Dependent on staff for toileting hygiene, to shower/bathe, to roll left and right, from sitting to lying and lying to sitting on bed side, and sit to stand;Could not attempt due to safety chair/bed-to-chair transfer or toilet transfer and walking;-Frequently incontinent of bowel and bladder; constipation present;-Scheduled pain meds, no PRN pain medications;-No weight loss. The facility did not complete a quarterly MDS for the resident in December 2024. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No limitations in functional ROM (improvement);-Set up or clean up assistance from staff for eating (decline);-Dependent on staff for oral hygiene (decline), upper body dressing (decline), lower body dressing (decline), footwear (decline), personal hygiene(decline) and wheeling 50 feet with two turns (decline);-New indwelling urinary catheter (tube inserted in bladder to drain urine);-The addition of PRN medications for pain;-Occasionally has moderate pain. The facility did not complete a SCSA when the resident had decline in the ability to eat, perform oral/personal hygiene, dressing, wheelchair mobility, a new indwelling urinary catheter, and increased pain requiring PRN medications to ensure the resident received proper care.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Requires substantial/maximal assistance from staff for toilet transfer (improvement);-Always incontinent of bowel (decline);-No PRN medication for pain (improvement);-Significant weight loss, not prescribed by a physician (decline);-Started on a therapeutic diet (decline). The facility did not complete a SCSA when the resident had decline in incontinence of bowel, weight loss with a new diet, and improvement in toilet transfer and pain. Review of the resident's Nurses Notes, dated 07/18/25 at 9:52 A.M., 2:09 P.M. and 3:21 P.M., showed the following:-The resident sat in his/her power electric recliner when his/her elbow became pressed against the remote;-Due to resident's general weakness, he/she was unable to move his/her elbow in time before it bucked him/her out of the recliner onto the floor;-The resident landed on the left side of his/her body and tangled himself/herself up into the bedside table;-The resident immediately began complaining of pain in his/her right lower extremity;-Noted swelling present in the resident's right knee;-After assessments and notifications, the resident was sent to the emergency room for evaluation;-2:09 P.M. update: hospital reported the resident will be admitted for two separate fractures in bilateral (both) legs. First fracture is a right distal femur (the lower end of the femur, or thigh bone above the knee) fracture and the second fracture is a left proximal tibial (the upper portion of the tibia, or shinbone, located at the top of the bone and forming part of the knee joint) fracture;-3:21 P.M., updated from resident's family member, the resident will have surgery on Monday, 07/21/25, to repair the left tibial fracture. Resident does not need surgical intervention on the right femur fracture and will have it soft casted. Review of the resident's Nurses Notes, dated 07/25/25 at 4:00 A.M., showed the hospital called and said the resident will be coming back to this facility but will have to be transferred by ambulance related to his/her fractured legs and non-weight bearing (NWB) status. Observation on 09/10/25 at 9:50 A.M., showed the following:-The resident was in bed;-Certified Nurse Assistant (CAN) N, Nurse Aide (NA) O and CNA P provided perineal and catheter care;-The resident was unable to move his/her legs (decrease in functional ROM);-Both legs were wrapped with bandages;-The resident had pain with movement. During an interview on 9/08/25 at 10:47 A.M., NA V said the following:-The resident only gets up when he/she wants to;-Since the resident fractured his/her legs in July, he/she requires a mechanical lift to transfer;-Now (since the fractures) staff turn him/her every two hours and he/she does not get out of bed as often;-The resident had pain at his/her surgical site because it had not healed well;-The resident was not up and about as much as he/she used to be and has a lot more pain when staff work with him/her. The facility staff did not complete a SCSA assessment after the resident had a fall with major fractures requiring surgery. The injuries decreased the resident's ability to transfer (now required a mechanical lift to get out of bed), the resident does not leave his/her room, has more pain and has dressings with a surgical incision. 3. During an interview on 09/18/25 at 10:37 A.M., the MDS Coordinator said the following:-She was responsible to complete SCSAs;-SCSAs are done when the resident has had a significant weight loss, decline in ADL's (activities of daily living) and was needing more help, starting hospice or palliative care for example;-Staff have 14 days to complete the SCSAs after the decline was identified;-She compared the MDS to the last assessment to see if there was a significant change (she was not aware that she should compare to the last comprehensive assessment);-SCSAs are expected to be completed with two or more changes in two care areas or two changes in section GG of the MDS. During an interview on 9/10/25 at 7:30 P.M., the Director of Nursing said the following:-The MDS coordinator was responsible to initiate and complete SCSAs according to the RAI manual;-SCSAs are required to be completed when there are two or more areas of decline in a resident's condition. During an interview on 9/10/25 at 7:30 P.M., the Administrator said the following:-The MDS coordinator was responsible to initiate and complete SCSAs according to the RAI manual;-SCSAs are required to be completed when a resident has a decline or has a significant change, such as incontinence or they cannot feed themselves.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident (Resident #20), in a review of 17 sampled residents. The resident experienced multiple falls and was high risk for falls. The facility failed to plan and reevaluate interventions to address the resident's falls. The facility did not have a consistent system to identify residents at risk for falls. The facility census was 41. Review of the undated facility policy, Resident Safety and Fall Management, showed the following:-The facility will implement comprehensive fall prevention and post fall management;-All residents will undergo a fall risk assessment upon admission and periodically thereafter;-An event checklist will be utilized that includes evaluation of environmental hazards, mobility status, medication review and individualized care needs;-Staff are responsible for implementing appropriate interventions such as ensure proper lighting, nonslip footwear, assistive devices and scheduled toileting to reduce fall risks;-After a fall, staff must complete the following steps: a. Complete the event in the matrix; b. Notify the doctor; c. Notify the family; d. Update care plan; e. Add a progress note; f. Print the event report from the reports section; g. Obtain witness statement from staff who observed the event; h. Complete a fall huddle; i. Conduct and print a fall risk assessment.;-Submit completed packet to the Director of Nursing (DON);-The facility will ensure ongoing staff training on fall prevention strategies, regular environmental safety checks and resident education to promote a safe, secure environment for all residents. 1. Review of Resident #20's Baseline Care Plan, dated 12/31/24, showed the following:-The resident has some confusion;-The resident is a fall risk;-Requires assist of one and a gait belt for activities of daily living (ADL's). Review of the resident's event history page of the resident's electronic medical record showed the resident had a fall on 01/03/25. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 01/07/25, showed the following:-Diagnosis include pneumonia, dementia, seizure disorder and COPD (chronic obstructive pulmonary disease);-Moderate cognitive impairment;-Understands but misses some part/intent of message;-No behaviors;-Uses a walker;-Resident had one fall prior to admission;-One, no injury fall, since admission to the facility;-Requires supervision/touching assistance from staff members for walking 10 feet, picking up an object from the floor and sit to stand;-Requires partial/moderate assistance from staff for chair/bed-to-chair transfer and ambulating 50 feet with two turns. Review of the resident's Care Plan, dated 01/09/25, showed the following:-The resident had a fall at home on [DATE] prior to admission;-The resident was weak and unsteady on his/her feet;-He/She ambulates with a walker and assist of one;-Goal to have no falls through next review;-Remind resident to have staff assist him/her and to use his/her walker;-Encourage the resident to use his/her call light;-Ensure the resident has shoes or gripper socks on while up. Review of the resident's event history page, of the resident's electronic medical record, showed the resident had falls on 01/12/25 (non-injury) and 01/19/25 (witnessed). Review of the resident's care plan showed no additional interventions or updates after the resident's falls on 01/12/25 or 01/19/25. Review of the resident's Safety Event Fall, dated 01/26/25 at 9:37 A.M., showed the following:-Resident fell in his/her room;-Resident was lying in bed prior to the fall;-Fall was unwitnessed;-No injuries. Review of the resident's care plan showed no additional interventions or updates after the resident's on 01/26/25. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No walker or wheelchair use;-One, non-injury fall, since last assessment (there had been two falls since the last assessment);-Independent with sit to stand, chair/bed-to-chair transfer, toilet transfer and walking 150 feet. Review of the resident's Safety Event Fall, dated 04/15/25 at 10:42 A.M., showed the following:-Resident fell in his/her room;-Using bathroom prior to fall;-Resident had regular socks on (not gripper socks like the care plan directed);-The resident said he/she came out of the bathroom, fell and slid down the wall;-No injury. Review of the resident's care plan showed no additional interventions or updates after the fall on 04/15/25. Review of the resident's Safety Event Fall, dated 04/19/25 at 8:15 A.M., showed the following:-Resident fell in his/her room;-Resident carrying cards prior to the fall;-Resident was found on his/her back holding the back of his/her head;-Resident states that he/she hit his/her head on the door trim;-Denies pain, except for some mild tenderness where he/she hit head;-Resident assisted into bed at this time per his/her request and educated oncall light use;-At 0840, resident found on the floor in his/her room again. This time he/she was lying on his/her right side on the floor at the end of his/her bed;-Resident said he/she hit his/her head again and also his/her right elbow;-Some mild redness present over right elbow but no other abnormalities;-Resident also appears much more confused compared to baseline;-Per nursing judgement, resident to be sent to the emergency room at this time related to increased confusion and repeated falls. Review of the resident's nurses notes, dated 04/19/25, showed the resident was admitted to the hospital with diagnosis of pneumonia. Review of the resident's care plan showed no additional interventions or updates after the resident's two falls on 04/19/25. Review of the resident's nurses notes showed the resident returned from the hospital on [DATE]. Review of the resident's Safety Event Fall, dated 4/22/25 at 6:34 A.M., showed the following:-The resident fell at the nurses station;-Prior to the fall, the resident was sitting in a chair;-The fall was not witnessed;-A nurse sitting behind the nurses station, heard a noise and witnessed the resident face down on the floor with his/her hand under his/her head;-The resident had a bruise above his/her left eyebrow and mid-forehead; ice pack applied;-The resident said, I was just leaning over and fell. Resident said he/she was tired. The night shift nurse reported the resident did not sleep much last night and the resident tends to be up most nights and sleep late;-The resident was sent to the emergency room for evaluation. Review of the resident's care plan updated 4/24/25, showed the resident has had several falls since admission to the facility and was in the hospital from [DATE] to 4/21/25 for a fall and COPD exacerbation with pneumonia. The care plan had no new interventions to address the resident's multiple falls. Review of the resident's Safety Event Fall, dated 4/28/25 at 1:52 P.M., showed the following:-Resident fell in his/her room;-He/She was lying in bed prior to the fall;-Facility was having a fire drill. Writer walked by the resident's room and saw the resident getting out of bed;-Writer looked in the resident's room again and saw the resident sitting on the floor, on his/her buttocks, with his/her feet straight out in front of him/her;-The resident asked what the noise was and that it scared him/her;-Resident wore non-skid socks and only one slipper. Review of the resident's care plan showed no additional interventions or updates after the resident's fall on 04/28/25, including interventions to address the resident's reaction to and fall resulting from the activation of the fire alarm. Review of the resident's Nursing Progress Notes, dated 06/09/25 at 12:53 P.M., showed the following:-CNA witnessed the resident fall;-The resident fell forward, landing on his/her knees, elbows, then hands and stomach;-The resident's elbows were red; his/her knees were red and beginning to bruise;-Left knee has a small linear open area;-Resident was wearing his/her slippers, which were too big;-These slippers were thrown away and new slippers with non-skid soles put on the resident at this time. Review of the resident's care plan showed no additional interventions or updates after the resident's fall on 06/09/25. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Two or more non injury falls since last assessment;-Two or more falls with injury since last assessment. Observation on 09/10/25 at 10:15 A.M., showed the facility announced a fire drill. The resident was stood outside of his/her door. The resident said, Fire drill, it's going to be loud. The resident started pacing and showed signs of distress. No staff came to ensure the resident was safe and not at risk for falling. During an interview on 09/18/25 at 10:37 A.M., the MDS Coordinator said she completes updates to the care plans with new falls, weight loss, bed alarms, hourly checks, anything that changed care. She tried to update the care plan as those events occurred, but she missed things sometimes. During interviews on 9/10/25 at 2:30 P.M and 7:30 P.M., the Director of Nursing (DON) said the following:-She expected the MDS coordinator to evaluate and update a resident's care plan interventions after each fall; -Care plans are expected to be specific to the resident and give guidance to staff on how to care for them and keep them safe; -Resident #20 should have updates to his/her care plan with each fall. During interview on 9/10/25 at 7:30 P.M., the administrator said she expected staff to follow care planned interventions to prevent falls. Care plans should be updated after a fall with evaluation and any new or revised interventions on the next business day (24 to 48 hours depending on if it is a weekend).

Based on observation, interview and record review, the facility failed to identify and reevaluate indications for use of indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) to prevent complications including urinary tract infections (UTI) for two residents (Resident #4 and #6), of 17 sampled residents. The facility failed to ensure that catheters were secured to the resident's leg with a device to reduce friction and movement at the site (also decreasing the chance of accidental removal and infection). The facility census was 41. Review of the facility policy, Urinary Catheter Care, revised October 2010, showed the following:-The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections;-Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site;-Review and document the clinical indications for catheter use prior to inserting;-Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use;-Remove the catheter as soon as it is no longer needed. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 09/27/24, showed the following:-Diagnosis of sepsis (when bacteria enter the blood from an infection) and urinary tract infection in the last 30 days;-Dependent on staff for toileting hygiene;-Frequently incontinent of bowel and bladder;-Antibiotic use. Review of the resident's Nurses Notes, dated 12/15/24 at 1:00 A.M., showed staff reported hematuria (blood in the urine) with moderate amounts of clots and increased incontinence. Review of the resident's Nurses Notes, dated 12/15/2024 at 10:17 A.M., showed bright red blood noted in the resident's brief, no clotting noted. Physician ordered to send the resident to the emergency room. Review of the resident's census showed the resident went to the hospital on [DATE] and then returned to the facility on [DATE]. Review of the resident's hospital Discharge summary, dated [DATE], showed the following:-Chief complaint: hematuria;-Final diagnosis: Urinary tract infectious disease and blood in the urine;-Computerized tomography (CT) scan (a type of imaging that uses X-ray techniques to create detailed images of the body) from 12/15/24 showed no hydronephrosis (excess fluid in a kidney due to a backup of urine), no urinary tract calcification (deposits of calcium and other minerals within the kidneys, bladder or other parts of the urinary tract) or obstruction;-Irregular increased density (abnormality) is present in the posterior bladder (the back or lower portion of the urinary bladder) measuring 2.5 centimeters (cm) in diameter, consistent with soft tissue mass versus blood clot;-Thickened urinary bladder wall, suspicious for cystitis (inflammation of the bladder), correlate with urine analysis (UA);-Posterior bladder soft tissue mass due to hematoma (a localized collection of blood outside the circulatory system that forms when blood vessels are damaged) less likely represents bladder neoplasm (an abnormal growth, or tumor, in the bladder that can be either benign (non-cancerous) or malignant (cancerous));-Consider cystoscopy (a medical procedure that allows a healthcare professional to examine the bladder and urethra using a thin, flexible tube called a cystoscope);-Hospital course: Urinary catheter was placed. Since admission, bladder irrigation (a procedure to flush out the bladder to remove mucus, sediment, blood clots or other debris) was performed;-Urine culture showed E coli (a bacteria commonly found in the intestines of humans and other animals);-Recommend follow up with urology on an outpatient basis. Review of the resident's Progress Notes dated 12/18/24 - 03/25/25, including Nursing, Social Services, and Physician notes, showed no information about follow up with urology or when to discontinue or continue using the urinary catheter with an indication for use. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Primary diagnosis of chronic heart failure;-Dependent on staff for toileting and personal hygiene, -New use of an indwelling urinary catheter; The MDS does not list a diagnosis that would be an appropriate indication for a urinary catheter. Review of the resident's Progress Notes dated 03/26/25-06/11/25, including Nursing, Social Services, and Physician notes, showed no information about follow up with urology or when to discontinue or continue using the urinary catheter with an indication for use. Review of resident's diagnosis list, in the electronic medical record, did not show a diagnosis that indicated a need for a urinary catheter. Review of the resident's Care Plan, dated 06/11/25, showed the following:-Resident has an indwelling urinary catheter;-Urinary catheter puts the resident at risk for developing multidrug-resistant organisms (MDROS) and spreading them to others;-Monitor the resident for signs and symptoms of a MDRO infection such as fever, chills, fatigue, lethargy, headache, cough, pain, pus discharge and wound breakdown. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Requires substantial/maximal assistance from staff for toilet transfer;-Urinary catheter present;-Always incontinent of bowel.The MDS did not list diagnosis that would be an appropriate indication for a urinary catheter. Review of the resident's Progress Notes dated 06/26/25-09/08/25, including Nursing, Social Services, and Physician notes, showed they did not include any information about follow up with urology or when to discontinue or continue using the urinary catheter with an indication for use. Observation on 09/08/25 at 3:12 P.M., showed the resident in bed, his/her urinary catheter bag was under the bed and sat in a bath basin. Observation on 09/10/25 at 9:50 A.M., showed the following:-The resident was in bed;-Certified Nurse Assistant (CNA) N, Nurse Aide (NA) O and CNA P entered the resident's room;-NA O cleansed the resident's front perineal area;-Visualization of the resident's catheter showed it was not secured to the resident's leg with a device;-When the staff turned the resident during cares the catheter tubing moved freely and would pull and then go slack repeatedly. During an interview on 09/10/25 at 10:11 A.M., CNA N said he/she was not sure if the facility had devices to secure the resident's catheter to his/her leg. During an interview on 09/08/25 at 5:25 P.M., Registered Nurse (RN) M, said the following:-She thought the resident had a urinary catheter for urinary retention, but was not sure; -She did know if the resident's catheter was permanent or if he/she was to have follow up with urology. 2. Review of Resident #4's Baseline Care Plan, dated 05/22/25, showed the following:-Resident admitted to the facility on [DATE];-Alert and oriented;-Resident has a catheter and requires catheter care. Review of the resident's Physician Order's Sheet, dated 05/25/25, showed an order for a urinary catheter with a 30 cubic centimeter (cc) bulb (amount of fluid held in the device to keep the catheter in place), change monthly on the 15th of the month. The order did not include an indication for use.Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnosis of urinary tract infection (UTI) in the last 30 days, chronic pain, sepsis and sacral (tailbone) fracture;-Pain Management: Scheduled pain meds, as needed (PRN) pain medications, frequent pain that occasionally effects sleep, the worst pain last 5 days the resident rated a 10 (on a one to ten scale with 10 being the worst pain ever felt);-Requires partial/moderate assistance from staff for toileting hygiene; -Requires substantial/maximal assistance from staff for lower body dressing, roll right and left; -Dependent on staff for sit to stand, toilet transfer;-Indwelling catheter present;-Daily opioid (pain medication) use;-Physical and occupational therapy. Review of the resident's Physician Order's Sheet, dated 07/22/25, showed a new order to change the urinary catheter bag every two weeks. The catheter order did not have an indication for catheter use. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Catheter use;-Diagnosis did not include an indication for catheter use. Review of the resident's Care Plan, dated 09/02/25, showed the following:-Resident has a urianry catheter;-Urinary catheter puts the resident at risk for developing multidrug-resistant organisms (MDROS) and spreading them to others;(There were no indications why or plan for the catheter to be discontinued on the resident's care plan). Review of the resident's Physician's Order Sheet, dated 9/05/25, showed a new order to bladder train the resident and discontinue the catheter. Observation on 09/07/25 at 12:30 P.M., showed the resident sitting in the dining room in his/her wheelchair. The resident's catheter bag was located under the resident's wheelchair in a privacy bag. During an interview on 09/07/25, at 2:15 P.M., the resident said he/she didn't know why he/she still had a catheter. The hospital put it in when he/she had a pelvic fracture, and no one ever removed it. During an interview on 9/08/25 at 10:35 A.M., NA Q said the resident had a catheter. He/She was not sure why the resident had a catheter. The resident had been getting up in the wheelchair for quite a while. The resident did not complaint of pain and hasn't for a while. During an interview on 09/08/25 at 5:25 P.M., RN M, said the following:-The resident came from the hospital with a urinary catheter due to trauma; he/she had a pelvic fracture; a catheter would be appropriate for severe pain with a pelvic fracture, until the resident could get out of bed and transfer to the toilet;-The resident should not have had the catheter this long. The resident has been getting out of bed, sits in his/her wheelchair and goes to the bathroom for a while now;-The indication for continued use was overlooked. 3. During an interview on 09/10/25 at 3:12 P.M. and 7:30 P.M., the Director of Nursing (DON) said the following:-Care plans are expected to be updated with new catheter use;-Staff are expected to secure the resident's catheter to his/her leg with leg straps or tape to avoid complications; -Staff are expected to ensure catheters have an appropriate indication or diagnosis for use such as neurogenic bladder, retention and prostate issues;-If there was no appropriate indication for use of a urinary catheter, staff are expected to obtain an order and discontinue the catheter. During an interview on 09/10/25 at 7:30 P.M., the Administrator (ADM) said the following:-Care plans are expected to be updated with new catheter use within a couple of days;-Staff are expected to ensure catheters have an appropriate indication or diagnosis for use such as retention, and prostate issues;-If the hospital recommends follow up appointments, the appointments should be made or a note documenting why they were not.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for colostomy (a surgical opening in the large intestine also called a stoma) care and failed to develop a plan of care to address the care and monitoring of the colostomy for one resident (Resident #40), in a review of 17 sampled residents. The facility census was 41. Review of the facility policy, Medication Orders, last revised November 2014, showed the following:-Current list of orders must be maintained in the clinical record for each resident;-Treatment orders must specify the treatment, frequency and duration of the treatment. 1. Review of Resident #40's Care Plan, dated 7/15/25, showed the following: -The resident had a colostomy; -Staff to wear gloves and gowns when assisting him/her with dressing, toileting or emptying the colostomy;(The resident's care plan did not address the care, treatment, and monitoring of the resident's colostomy.) Review of resident's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 8/08/25, showed the following:-Diagnoses of malignant neoplasm of colon and other functional intestinal disorders;-Severe cognitive impairment;-Dependent for toileting hygiene and personal hygiene;-Had an ostomy. Review of the resident's Physician's Orders, dated September 2025, showed no physician's order for colostomy care. Review of the resident's Treatment Administration Record (TAR) and Medication Administration Record (MAR), dated September 2025, showed no documentation related to the care and treatment of a colostomy. Observation on 9/09/25, at 8:56 A.M., showed the following:-The resident had a colostomy bag (a waterproof pouch that attaches to the body to collect feces) attached to his/her abdomen;-There was no date on the colostomy bag or wafer (sticky skin barrier that goes around the stoma (a surgically created opening on the abdomen, through which a section of the large intestine (colon) is brought to the surface of the skin) to attach the bag to the skin and protect the skin from waste) (to indicate when they were last changed);-Certified Nurse Assistant (CNA) G emptied the contents of the colostomy bag into a plastic bag in the trash can;-He/She cleaned the end of the bag with a wet wipe and placed a clip on the colostomy bag. During interview on 09/09/25, at 8:56 A.M., CNA G said the following:-The nurses changed the resident's colostomy bag and wafer on the night shift;-He/She did not know how often staff changed the colostomy bag and wafer;-The wafer usually had a date on it to indicate when it was changed. During interview on 9/09/25, at 11:20 A.M., Licensed Practical Nurse (LPN) D said the following:-Staff changed the resident's colostomy bag every three to four days and as needed (PRN);-He/She was not sure how often staff changed the wafer; -He/She did not think staff documented the colostomy care anywhere; -The CNAs changed the colostomy bags and wafer;-He/She was not aware of orders in the resident's medical record for colostomy care that included frequency of changing the colostomy bag and wafer. During interview on 9/09/25, at 4:16 P.M., LPN A said the following:-The night shift nurses changed the resident's colostomy bag and wafer every four days and as needed; -Staff should document colostomy care in the nurse's notes. During interviews on 9/10/25 at 10:30 A.M. and 7:30 P.M., the Director of Nursing said the following:-The wound nurse saw the resident every Friday to check the resident's stoma (surgically created opening in the abdominal wall that allows waste to leave the body instead of going through the rectum and anus) and area around the stoma;-The wound nurse should document the information in the progress notes;-She could not find any notes from the wound nurse related to the stoma in the resident's medical record;-She expected the resident to have physician's orders for colostomy care and specify how often staff was to change the colostomy and the wafer.-Documentation of colostomy bag and wafer change should be on the medication administration record (MAR) and treatment administration record (TAR).

Based on interview and record review, the facility failed to consistently monitor residents' weights as ordered, failed to identify weight loss and notify the resident's physician and the dietician of the weight loss, failed to ensure staff evaluated current interventions and/or implemented new interventions to prevent further weight loss for two residents (Residents #2 and #39), in a review of 17 sampled residents. The facility census was 41.Review of the facility policy Nutrition (Impaired)/Unplanned Weight Loss, last revised September 2017, showed the following:-The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake;-The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions;-The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis and wishes;-The staff and physician will review and consider existing dietary restrictions and modified consistency of diets;-Physician and staff will monitor nutritional status, an individual's response to interventions and possible complications of such interventions. Review of the facility's policy Weight Assessment and Intervention, revised March 2022, showed the following:-Resident weights are monitored for undesirable or unintended weight loss or gain;-Residents are weighed upon admission and at intervals established by the interdisciplinary team;-Weights are recorded in each unit's weight record chart and in the individual's medical record;-A weight change of 5 percent (%) or more since the last weight assessment is retaken the next day for confirmation;-If the weight is verified, nursing will immediately notify the dietician in writing;-Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time;-The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. One month- 5% weight loss is significant, greater than 5% is severe; b. Three months- 7.5% weight loss is significant, greater than 7.5% is severe; c. Six months- 10% weight loss is significant; greater than 10% is severe;-The physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss;-Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the dietician, the consultant pharmacist and the resident's legal surrogate;-Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment;-Interventions for undesired weight gain consider resident preferences and rights, a weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 7/10/25, showed the following:-Severe cognitive impairment;-Weight 102 pounds;-Set up or clean-up assistance with eating;-No weight loss of 5 percent (%) in one month or 10% in last six months. Review of the resident's care plan, dated 7/15/25, showed the following: -The resident was on a regular diet and could feed himself/herself after staff set up his/her tray;-Make sure the resident was getting foods/drinks he/she enjoyed;-Report his/her weight to the charge nurse so they can report any abnormal weights to the physician. Review of the Nutritional Quarterly Assessment, dated 7/17/25, showed the following:-Regular diet;-House supplement twice a day (BID);-Current weight 104.5 pounds;-Weight last quarter 111.5 pounds;-Intake 50%-75%;-The resident feeds himself/herself. Review of the resident's Physician Orders, dated August 2025, showed an order for weekly weights (original order dated 4/23/25). Review of the resident's weight record, dated August 2025, showed the following:-On 8/02/25, the resident weighed 105.5 pounds;-On 8/06/25, the resident weighed 105 pounds;-On 8/13/25, the resident weighed 103.5 pounds;-On 8/27/25, the resident weighed 106 pounds. Review of the resident's Physician Orders, dated September 2025, showed an order for weekly weights. Review of the resident's weight record, dated 9/03/25, showed the resident weighed 95.5 pounds (a weight loss of 9.48% in one month). Review of the resident's medical record showed no documentation staff re-weighed the resident on 09/03/25 to ensure the weight was accurate, no documentation staff evaluated the resident for weight loss or notified the resident's physician or the dietician when the resident had a 9.48% weight loss in one month, and no documentation staff evaluated or implemented new interventions to prevent further weight loss. During interviews on 9/10/25 at 10:30 A.M. and 7:30 P.M., the Director of Nursing (DON) said the following:-When a resident lost weight, the nurses were to check the resident's intake and assess the resident's appetite;-The nurses were to notify the physician if a resident gained or lost more than 5 pounds from the previous weight;-The nurses were to notify the dietician if a resident gained or lost weight; -The MDS Coordinator notifies the DON when a resident loses weight;-The MDS Coordinator said the resident did not have issues with weight loss. During an interview on 9/18/25, at 9:39 A.M., the Infection Preventionist said the following:-If a resident's weight showed a significant weight loss or gain, the staff were to reweigh the resident within 24 hours to ensure the weight was accurate;-If the weight was accurate and showed weight loss, staff notified the MDS Coordinator;-The MDS Coordinator put the weight loss on the care plan, notified the dietician and monitored interventions;-The aides obtained Resident #2's weight on 9/03/25 and gave it to her to enter into the electronic health record;-She missed that this weight showed a weight loss;-She should have told the MDS Coordinator on 09/03/25 of the resident's weight loss. During interview on 9/18/25, at 10:37 A.M., the MDS Coordinator said the following:-The CNAs obtained the residents' weights and gave the weights to the charge nurse to put in the computer. The computer system calculated if there was a weight loss and if the loss was significant. She reviewed the weights and gave updates to the Dietary Manager and nursing staff in the clinical meeting. She let the computer do the calculation and it would show if there was a significant weight loss;-Significant weight loss was 10 percent in the last six months and 5 percent in the last month. She looked at weight loss at three months, but she did not ever consult the dietitian. She told staff in the clinical meeting, and the dietary manager was responsible to work with the dietitian related to the weight loss;-He/She notified the physician, speech therapy, family, and the dietary manager who notifies the dietician when a resident had a significant weight loss;-Staff discussed weight loss in the morning meetings so not one person was responsible for reporting and implementing interventions.-He/She tried to catch gradual, unintentional weight loss over time, and tried to determine why the resident was losing weight and if the care plan needed reevaluated; -She was not aware the resident had lost weight. During interview on 9/18/25, at 1:18 P.M., the Registered Dietician said the following:-He/She went to the facility one to two times per month;-He/She did not look at the residents' weights in the electronic health record; staff told him/her if a resident had a weight issue;-He/She completed annual and as needed nutritional assessments and documented these in the residents' medical records; -He/She was not directly involved in care planning; however, the facility would contact him/her for advice regarding interventions related to weight loss such as adding nutritional supplements. -He/She expected staff to notify him/her if a resident had a 5% or more weight change that was related to nutrition; -Staff was to notify him/her by text or call when staff identified a weight change;-He/She communicated nutritional interventions to the Dietary Manager or the charge nurse;-He/She was not aware Resident #2 had a recent weight change;-He/She expected staff to notify him/her of Resident #2's 9.48% weight loss from 8/02/25 to 9/03/25. During interview on 9/18/25, at 2:06 P.M., Physician F, the resident's physician, said the following:-He/She expected staff to notify him/her of a weight loss or gain monthly unless he/she needed to be notified more frequently, such as a resident had a decrease in intake or had weights ordered more frequently;-He/She was not aware of Resident #2's weight loss until last week (during the recertification survey) and prescribed an appetite stimulant for the resident. 2. Review of Resident #39's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Weight 185 pounds;-Required supervision or touching assistance for eating;-No weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of the resident's weight record, dated 6/02/25, showed the resident weighed 190 pounds. Review of the resident's Physician Orders, dated July 2025, showed an order to obtain monthly weights (original order dated 05/05/25). Review of the resident's weight record showed no documentation staff obtained the resident's weight in July 2025 as ordered. Review of resident's weight record, dated 8/02/25, showed the resident weighed 173.5 pounds (a weight loss of 8.68% in two months). Review of the resident's care plan, dated 8/13/25, showed the following: -On a regular diet and can feed himself/herself;-Make sure the resident receives foods/drinks he/she enjoys;-Monitor weight monthly and report his/her weight to the charge nurse so they can report any abnormal weights to the physician. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Weight 174 pounds;-Required set up or clean-up assistance for eating;-Weight loss, but not on a physician prescribed weight-loss regimen;-Therapeutic diet. Review of the resident's weight record, dated 9/01/25, showed the resident weighed 172 pounds (a weight loss of 9.47% in three months). Review of the resident's medical record showed no documentation staff notified the resident's physician of a 9.47% weight loss in three months. Review showed no documentation the facility notified the registered dietician of the resident's weight loss, and no documentation staff re-evaluated current interventions or identified new interventions to prevent further weight loss. During an interview on 9/10/25, at 9:51 A.M., Licensed Practical Nurse (LPN) E said the following:-He/She or the CNAs weigh the residents;-He/She entered the resident's weight into the electronic health record (EHR);-If he/she saw a discrepancy in the weight, staff reweigh the resident;-If the reweigh shows a discrepancy from the previous weights, he/she would do a comparison in the EHR that included checking meal intakes and checking for edema;-If the weight was accurate, he/she notified the physician and documented in the progress notes;-He/She missed this resident's weight on 9/01/25 and should have had the resident reweighed and looked at the resident's intake. If the weight was accurate, he/she should have called the resident's physician. During interview on 9/10/25, at 7:30 P.M., the DON said the following:-She was not aware the resident had weight loss;-The MDS Coordinator notifies the DON when a resident loses weight;-The MDS Coordinator said the resident did not have issues with weight loss. During interview on 9/18/25, at 10:11 A.M., the resident's responsible party said the following: -He/She was not aware the resident had a weight loss in the last three months;-He/She expected the facility to notify him/her if the resident had a significant weight change. During interview on 9/18/25, at 10:37 A.M., the MDS Coordinator said the following: -When staff identified a resident lost weight, she was to add the weight loss and any new interventions to the care plan;-He/She was not aware of the resident's weight loss. During interview on 9/18/25, at 1:18 P.M., the Registered Dietician said the following:-He/She was not aware of a recent weight change for Resident #39;-He/She expected staff to notify him/her of Resident #39's 9.47% weight loss from 6/02/25 to 9/01/25.

Based on interview and record review, the facility failed to ensure the Dietary Director had the appropriate competencies and skills set to carry out the function of the food and nutrition services. The facility census was 41.Review of the facility's current employee list, dated 9/7/25, showed the Dietary Director began employment with the facility on 5/9/22. Review of the facility's signed, undated Dietary Supervisor Responsibilities, showed the following:-Oversee daily food service operations to ensure the preparation and delivery of nutritious, appealing meals in accordance with dietary guidelines and residents' individual needs;-Develop, review, and update menus in collaboration with dietitians and management to meet nutritional standards and resident preferences;-Create, manage, and coordinate monthly work schedules for dietary department staff to ensure adequate coverage and efficient operation;-Supervise, train, and evaluate dietary staff, including cooks and aides;-Ensure proper food handling, sanitation and safety procedures are always followed in accordance with heath regulations;-Monitor inventory levels of food, supplies, and equipment, place orders as needed, and keep within budget constraints if applicable;-Coordinate special diets and meal modifications for residents with specific health conditions or dietary restrictions;-Schedule and oversee meal service times, including tray delivery and dining assistance when necessary;-Address and resolve resident concerns related to meals or dietary services promptly and professionally;-Fill in for shifts or staffing shortages if no coverage is available, ensuring continuous operation of food services;-Handle monthly scheduling for department staff to ensure proper coverage and workload distribution;-Complete all required certifications and maintain current credentials as mandated by local, state and federal regulations;-Perform other duties or acts as directed by the administrator to support the overall functioning of the dietary department. During an interview on 9/8/25 at 9:45 A.M., the Dietary Director said the following:-He was enrolled and working through a university course, but had not completed the food safety and management training with topics such as foodborne illness, sanitation, and food purchasing/receiving;-He began the course in February 2024, then asked for and received a nine-month extension in February 2025;-The course completion had taken longer due to staff turnover and the need for him to work open positions until new staff members were hired. During an interview on 9/10/25 at 3:35 P.M., the Administrator said she was aware the Dietary Director had not completed the Food Safety and Management Training through a university program, and he was granted a nine-month extension. The Dietary Department has had open positions, and he would work those positions until new dietary staff could be hired. This placed him behind in the training program. She would expect the Dietary Director to complete the program by the end of November 2025.

Based on interview and record review, the facility failed to provide a written notice of transfer/discharge with required information to the resident and/or resident representative for three residents (Residents #5, #6, and #39), in a review of 17 sampled residents, when the facility initiated a transfer to the hospital. The facility also failed to provide a copy of the bed hold notice on transfer/discharge. The facility census was 41.Review of the facility policy, Facility-Initiated Transfer or Discharge, revised October 2022, showed the following:-Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy;-The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: -The name, address, email and telephone number of the entity which receives such appeal hearing requests; -Information about how to obtain an appeal form and; -How to get assistance in completing and submitting the appeal hearing request; e. The notice of facility bed-hold and policies; f. The name, address, and telephone number of the office of the state long-term care ombudsman; g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of resident with a mental disorder or related disabilities (as applies), and; i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices;-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;-Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs or; d. A resident has not resided in the facility for 30 days;-Notice of transfer is provided to the resident and representative as soon as practicable before the transfers and to the long-term care ombudsman when practicable;-Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer;-Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments. 1. Review of Resident #5's face sheet showed the following:-admitted on [DATE];-He/She had a durable power of attorney. Review of the resident's progress notes, dated 6/18/25, showed the resident was sent to the hospital for evaluation due to abnormal lab results. Staff notified the resident's durable power of attorney of the transfer by phone. Review of the resident's medical record showed no documentation the facility provided the resident's representative with a written notice of transfer or with a written notice of the bed hold policy at the time of transfer to the hospital on [DATE]. Review of the resident's census report showed the resident returned to the facility on 6/28/25. Review of the resident's progress notes, dated 7/7/25, showed the resident was sent to the emergency room for evaluation due to shortness of breath and chest tightness. The facility notified the resident's durable power of attorney by phone call, a message was left. Review of the resident's census report showed the resident returned to the facility on [DATE]. Review of the resident's medical record showed no documentation the facility provided the resident's representative with a written notice of transfer or with a written notice of the bed hold policy at the time of transfer to the hospital on [DATE]. 2. Review of Resident #6's face sheet showed he/she was responsible for himself/herself. He/She also had two family members who would have durable power of attorney if the resident was deemed incapacitated. Review of the resident's Nurses Notes, dated 07/18/25 at 9:52 A.M., showed the following:-The resident sat in his/her power electric recliner when his/her elbow pressed against the remote;-Due to resident's general weakness, he/she was unable to move his/her elbow in time before he/she fell out of the recliner onto the floor;-The resident immediately complained of pain in his/her right lower extremity with swelling present in his/her right knee; -Staff notified the physician and family and called emergency medical services to take the resident to the emergency room. Review of the resident's Nurses Notes, dated 07/18/25 at 2:09 P.M., showed staff called the emergency room for an update. The resident was admitted for two separate fractures in both his/her legs. The first fracture was a right distal femur (lower end of the thigh bone above the knee) fracture, and the second fracture was a left proximal tibial (upper end of shin bone close to the knee) fracture. Review of the resident's medical records showed no documentation staff completed a notice of transfer/discharge when the resident was sent to the hospital on [DATE]. Review showed no documentation staff provided the resident with a bed hold notice at the time of transfer. During an interview on 09/09/25 at 1:32 P.M., the resident and his/her family member said they did not recall every getting a discharge/transfer notice when the resident went to the hospital (on 07/18/25). The facility did not give the resident a copy of any papers. 3. Review of Resident #39's undated face sheet showed the resident's family members were listed as his/her emergency contacts. Review of the resident's Nursing Progress Notes, dated 5/08/25 at 2:17 P.M., showed the resident fell and was sent to the hospital for evaluation. The resident was admitted with a hip fracture. Review of the resident's medical records showed no documentation staff completed a notice of transfer/discharge when the resident was sent to the hospital on [DATE]. Review showed no documentation staff provided the resident with a bed hold notice at the time of transfer. 4. During interviews on 09/09/25 at 5:24 P.M and 09/10/25 at 7:00 P.M., the Director of Nursing said the following:-She expected staff to provide a copy of the discharge/transfer form to the resident or resident representative every time a resident was transferred to the hospital; -The nurses were not good about giving the forms to the resident or resident representative; -The facility did not give a copy of the bed hold notice at the time of transfer, but the residents had one in their admission packet. During an interview on 9/10/25 at 7:30 P.M., the Administrator said the following:-She expected staff to provide a written notice of transfer or discharge to the resident or their representative with every transfer to the hospital;-The bed hold policy was only provided to the resident or resident representative on admission and was not provided to the resident or resident representative with every transfer to the hospital.

Based on observation, interview, and record review, the facility failed to accurately assess the resident and correctly code the minimum data set (MDS) assessment for five residents (Residents #11, #14, #36, #6, and #7), in a review of 17 sampled residents, and one additional resident (Resident #47). The facility failed to accurately code a wound that was present on admission for Resident #7, failed to accurately code a Wanderguard alarm for Residents #11 and #14, failed to accurately code hospice for Residents #36 and #47, and failed to code active diagnoses for Resident #6. The facility census was 41.During an interview on 09/10/25 at 7:30 P.M., the Director of Nursing (DON) said the facility followed the Resident Assessment Instrument (RAI) manual for completion of the MDS. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0, showed the following:-Document active diagnoses on the MDS as follows: Diagnoses are listed by major disease category: cancer, heart/circulation, gastrointestinal, genitourinary, infections, metabolic, musculoskeletal, neurological, nutritional, psychiatric/mood disorder, pulmonary, and vision; -Examples of diseases are included for some disease categories. Diseases to be coded in these categories are not meant to be limited to only those listed in the examples; Check off each active disease. Check all that apply. I0600 (question on the MDS) heart failure (e.g., congestive heart failure [CHF], pulmonary edema); I2100 (question on the MDS) septicemia (also known as sepsis, a life-threatening complication of an infection); I2000 (question on the MDS) pneumonia;-Alarms - An alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair and floor sensor pads, cords that clip to the resident's clothing, motion sensors, door alarms, or elopement/wandering devices;-Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building;-Coding Instructions: Identify all alarms that were used at any time (day or night) during the 7-day look-back period. After determining whether an item listed in P0200 was used during the 7-day look-back period, code the frequency of use:-Hospice: O0110K1 (question on MDS) Hospice care- Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. 1. Review of Resident #11's Physician's Order Sheet, dated 04/18/25, showed an order for the resident to wear a Wanderguard (electronic monitoring device) alarm and to check for placement and functioning every night. Review of the resident's Nurses Notes, dated 04/18/25 at 12:30 A.M., showed the resident followed visitors out of the door, his/her Wanderquard sounded, and staff followed the resident out of the door and redirected him/her back inside. Review of the resident's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Diagnosis of Alzheimer's disease;-Wandering occurred one to three days (in the seven-day look back period);-No documentation the resident had wander/elopement alarm. Review of the resident's Care Plan, dated 04/23/25, showed the resident had a Wanderguard on his/her wrist which sounded an alarm if he/she got too close to the outside door since he/she forgets where he/she is at times and may try to leave the building. Review of the resident's July 2025 Physician's Order Sheets showed an order for the resident to wear a Wanderguard alarm and to check for placement and functioning every night. Review of the resident's Julys 2025 Medication Administration Record (MAR) showed staff documented staff checked the resident's Wanderguard for placement and functioning every night. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognition impairment;-No alarm devices present. Observation on 09/09/25 at 1:30 P.M., showed the resident wandered the 100 hallway. The resident had a Wanderguard device on his/her wrist. During an interview on 09/09/25 at 10:09 A.M., Licensed Practical Nurse (LPN) G said the resident had a Wanderguard on his/her left wrist. Night shift staff checked for placement and made sure it was functioning correctly. 2. Review of Resident #14's Physician's Orders, dated June 2025, showed an order for the resident to wear a Wanderguard alarm and to check for placement and functioning every night (original order dated 4/25/25). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Wandering occurred 4 to 6 days;-No documentation the resident had wander/elopement alarm. Review of the resident's Physician's Orders, dated July 2025, showed an order for the resident to wear a Wanderguard alarm and to check for placement and functioning every night (original order dated 4/25/25). Review of the resident's progress notes, dated 7/28/25 at 2:30 A.M. and 7/31/25 at 2:12 A.M., showed staff checked the resident's Wande guard bracelet and noted it was in place and functioning. Review of the resident's annual MDS, dated [DATE], showed the following:-Severe cognitive impairment;-No documentation the resident had wander/elopement alarm. Observation on 9/7/25 at 12:45 P.M. showed the resident ate lunch in the dining room with a Wanderguard in place on his/her left ankle. Review of the resident's care plan, revised 9/10/25, showed the resident had a Wanderguard in place due to frequent wandering at night. During an interview on 9/10/25 at 5:14 P.M., the Director of Nursing (DON) said the following:-The resident had a sudden increase in behaviors and wandering a few months back, resulting in the addition of a Wanderguard; -The resident still had orders for and wore a wander guard. During an interview on 9/18/25 at 10:37 A.M., the MDS Coordinator said the following:-If the resident had a Wanderguard it should be coded in section P;-She was not aware alarms needed to be coded. 3. Review of Resident #36's physician notification fax, dated 7/1/25, showed the Director of Nursing faxed a notification to the physician, stating the resident would be returning from the hospital on hospice. Review of the resident's Hospice admission Note and Hospice Certification of Terminal Illness, dated 7/1/25, showed the resident was terminally ill with a life expectancy of six months or less if the disease followed its normal course, and was admitted to hospice. Review of the resident's progress notes, dated 7/7/25 at 6:18 P.M., showed the resident continued hospice care. Review of the resident's significant change MDS, dated [DATE], showed the following:-The resident had a chronic disease that may result in a life expectancy of less than 6 months;-No special treatments, not on hospice. Review of the resident's physician progress note, dated 7/10/25, showed the resident was currently on hospice care. During an interview on 9/18/25 at 10:37 A.M. the MDS Coordinator said hospice should be marked in Section O for this resident. She was unsure as to why it wasn't marked. During an interview on 09/08/25 at 10:10 A.M., the Director of Nursing said the resident was on hospice. Hospice should be indicated on the resident's MDS. 4. Review of Resident #47's Physician's Orders Sheet, showed the resident started hospice services on 4/16/25. Review of the resident's Hospice binder showed the resident was admitted to hospice on 04/16/25. Review of the resident's significant change in status MDS, dated [DATE], showed hospice while a resident in section O0110K1 was blank. Review of the resident's quarterly MDS, dated [DATE], showed hospice while a resident in section O0110K1 was blank. Review of the resident's census showed he/she remained on hospice. During an interview on 09/08/25 at 10:10 A.M., the Director of Nursing said the resident was on hospice. Hospice should be indicated on the resident's MDS5. Review of Resident #6's face sheet showed the resident has diagnosis of chronic heart failure, sepsis and pneumonia. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 09/27/24, showed the resident's primary diagnosis was sepsis. Review of section I of the MDS showed staff did not check the box in question I2100 septicemia as the RAI manual directed. Review of the resident's quarterly MDS, dated [DATE], showed the staff coded the resident's primary diagnosis as chronic heart failure. Review of section I of the MDS showed staff did not check the box in question I0600 heart failure as the RAI manual directed. Review of the resident's quarterly MDS, dated [DATE], showed the staff coded the resident's primary diagnosis as pneumonia. Review of section I of the MDS showed staff did not check the box in question I2000 pneumonia as the RAI manual directed. 6. Review of Resident #7's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's progress notes, dated 7/14/25, showed the resident was admitted to the facility from the hospital with a superficial open area to the right buttock that was covered with a small mepilex (foam dressing). Review of the resident's admission MDS, dated [DATE], showed the resident had a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough or bruising) that was not present on admission. During an interview on 9/10/25 at 5:14 P.M. the Director of Nursing said the resident was admitted with a pressure ulcer. During an interview on 9/18/25 at 10:37 A.M., the MDS Coordinator said if a resident had a pressure ulcer present on admission it should be coded as present on admission. 7.During an interview on 09/18/25, at 10:37 A.M., the MDS Coordinator said the following:-She followed the RAI manual to accurately code the MDS and followed the instructions in the MDS manual;-If there were errors on the MDSs, it was probably just an oversight. During an interview on 9/10/25 at 7:30 P.M., the Administrator said she expected the residents' MDSs to be accurate.

Based on interview and record review, the facility failed to provide the resident or resident representative a copy of the resident's baseline care plan for three residents Resident (#5, #7, and #14). The facility census was 41. Review of the facility policy, Care Plans - Baseline, revised 2022, showed the following:-A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission;-The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: -The stated goals and objectives of the resident; -A summary of the resident's medications and dietary instructions; -Any services or treatments to be administered by the facility and personnel acting on behalf of the facility, and; -Any updated information based on the details of the comprehensive care plan, as necessary;-Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #5's face sheet showed the resident admitted on [DATE]. Review of the resident's baseline care plan, dated 5/7/25, showed no documentation the facility provided a copy or a written summary of the baseline care plan to the resident or resident representative. Review of the resident's medical record showed no documentation the facility provided a copy or a written summary of the baseline care plan to the resident or resident representative. 2. Review of Resident #7's face sheet showed the resident admitted on [DATE]. Review of the resident's baseline care plan, dated 7/14/25, showed no documentation the facility provided a copy or a written summary of the baseline care plan to the resident or resident representative. Review of the resident's medical record showed no documentation the facility provided a copy or a written summary of the baseline care plan to the resident or resident representative. 3. Review of Resident #14's face sheet showed the resident was admitted on [DATE]. Review of the resident's undated baseline care plan showed no documentation the facility provided a copy or a written summary of the baseline care plan to the resident or resident representative. Review of the resident's medical record showed no documentation the facility provided a copy or a written summary of the baseline care plan to the resident or resident representative. 4. During an interview on 9/10/25 at 6:28 P.M., Licensed Practical Nurse (LPN) A (charge nurse who admits residents) said the Director of Nursing (DON) completed the baseline care plans. He/She did not know what to do with the completed baseline care plans. During an interview on 09/18/25, at 10:37 A.M., the MDS Coordinator said the admitting nurse should complete the baseline care plan, have the resident or representative sign the care plan and to give them a copy During an interview on 9/10/25 at 7:30 P.M., the Director of Nursing (DON) said she the admitting nurse was to complete the baseline care plan on admission. The admitting nurse should have the resident or representative sign a copy of the baseline care plan, give a copy of the care plan to the resident or representative, and scan a completed and signed copy into the resident's medical record. She had not monitored if baseline care plans were completed, provided to the resident or if the baseline care plan was signed and scanned into the electronic health record.

Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. Staff did not perform proper handwashing technique during meal preparation, did not store food items and maintain and clean equipment under sanitary conditions, and did not maintain a clean and sanitary environment in the kitchen. The facility census was 37. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised [DATE], showed the following: -Employees must wash their hands: -After handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -After engaging in other activities that contaminate hands; -Gloves are considered single-use items and must be discarded after completing the task for which they are used; -The use of disposable gloves does not substitute for proper handwashing. Review of the facility policy, Food Receiving and Storage, revised [DATE], showed all food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of an undated Cleaning List, provided by the facility, showed staff were clean the can opener daily. Review of the facility policy, Sanitization, revised [DATE], showed the following: -All kitchen areas shall be kept clean; -All utensils, counters, shelves and equipment shall be kept clean; -All equipment, food contact surfaces and utensils shall be washed and sanitized using hot water and /or chemical sanitizing solutions; -Manual washing and sanitizing will employee a three-step process for washing, rinsing, and sanitizing. Sanitize with hot water or chemical sanitizing solution. -The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen. 1. Observation on [DATE] at 10:20 A.M., showed Cook Q performed the following: -He/She wore gloves and opened the door to the walk-in refrigerator by the handle; -He/She obtained two bags of raw chicken from the walk-in refrigerator, closed the door to the walk-in unit, and took the bags of chicken to the preparation counter; -He/She opened the bags of raw chicken, and then placed his/her gloved hands directly into the flour and stuffing mixture in a bowl on the preparation counter and mixed it together with his/her gloved hands; -He/She reached into the bag of chicken and removed pieces of raw chicken with his/her gloved hands, placed the chicken in the stuffing/flour mixture and then put the chicken on a pan. He/She repeated this process for 20 pieces of chicken; -He/She removed his/her gloves, and without washing his/her hands, put on oven mitts, then removed the oven mitts, picked up a container of paprika from the counter, opened it and sprinkled it onto the chicken, put on the oven mitts and placed the pans of chicken in the oven; -He/She removed the oven mitts, placed a new pan on the preparation counter and put on gloves without washing his/her hands; -He/She opened another bag of raw chicken, reached into the bag and removed pieces of raw chicken with his/her gloved hands, placed the chicken into the stuffing/flour mixture and put the chicken on a pan; -He/She removed his/her gloves, and without washing his/her hands, picked up the container of paprika from the counter, opened it and sprinkled it onto the chicken; -He/She dumped the liquid contents from the bags that held the raw chicken into the sink and put the bags into the trash can. He/She placed his/her arms, up to his/her elbows, into the trash can. The bags and his/her arms came into direct contact with the swing top lid of the trash can; -Without washing his/her hands, he/she picked up a bowl of raw chicken wings from the preparation counter, opened the door to the walk-in refrigerator by the handle, placed the bowl in the refrigerator and closed the door. Observation on [DATE] at 11:30 A.M., showed Cook Q performed the following: -He/She put on gloves, picked up raw chicken wings from a bowl with his/her gloved hands, placed the wings in a bowl containing stuffing/flour mixture, and placed the wings onto a pan; -He/She removed his/her gloves, and without washing his/her hands, opened a container of paprika, sprinkled it over the chicken, placed the pan of chicken in the oven, and closed the door to the oven. He/She covered an opened can of evaporated milk with plastic wrap, marked the date with a pen on the plastic wrap, dropped the lid to the pen on the floor, picked the lid up off the floor, opened the door to the drink refrigerator, and placed the evaporated milk inside. He/She dumped the stuffing/flour mixture from the bowl into the trash can, sorted through the meal cards, put on oven mitts, removed a pan of corn from the oven, and removed the oven mitts. -Without washing his/her hands, he/she put on gloves, opened the oven door, put the oven mitts on over his/her gloves, removed a pan of chicken from the oven, removed the oven mitts and then placed chicken from the pan into a steam table pan on the steam table with tongs. Observation on [DATE] at 12:32 P.M., showed the dietary manager wore gloves as he served the residents from the steam table. At 1:02 P.M., he opened the door to the upright refrigerator with his gloved hands, reached into the opened box of frozen hamburger patties and obtained frozen patties from the box with his/her gloved hands, placed them on a plate, opened the door to the microwave and placed the plate of frozen patties inside. 2. Observations on [DATE] between 9:05 A.M. and 12:30 P.M., and on [DATE] between 11:53 A.M. and 1:00 P.M. showed the following: -A plastic scoop was stored in the bulk sugar container. The scoop handle rested directly on the sugar; -A plastic scoop was stored in the bulk flour container. The scoop handle rested directly on the flour; -The lids on the bulk flour and sugar containers were soiled with a buildup of debris; -A buildup of dark debris was visible on the counter-mounted can opener; -An airhandler was suspended from the ceiling over the drink refrigerator and the preparation counter. There was a buildup of dusty debris on the sides of the unit, on the metal hangers and on the vents; -The stand mixer was located directly next to the trash can used for meal preparation. The bowl and beater blade, located in the bowl, were not covered; -A heavy buildup of black, dusty debris on the vent cover and the inside of the duct work located over the dishmachine; -An area of black, mold-like debris, approximately 3 feet long by 10 inches wide, was located on the wall above the metal backsplash by the dishwashing sink; -A buildup of dust and debris on the ceiling vent in the walkway between the dietary manager's office and the dishmachine area; -A buildup of dusty debris on the baffle filters and on the extinguishing system piping and nozzles within the rangehood. 3. Observations on [DATE] showed the following: -A box of frozen pork patties was stored in the upright freezer. The box and the plastic bag containing the frozen patties were open to air and were not sealed; -A box of frozen beef steak burgers was stored in the upright freezer. The box and the plastic bag containing the frozen burgers were open to air and were not sealed; -A ,d+[DATE]-gallon container of almond milk, located in the drink refrigerator, expired on [DATE]; -In the hallway near the dry food storage room, four packages of hot dog buns sat on a rack containing bread products. Two packages had a best use by date of [DATE], one package had a best use by date of [DATE], and one package had a best use by date of [DATE]. Observation on [DATE] at 12:35 P.M., showed a partial opened package of hamburger buns lay on a tray by the food preparation counter and the steam table. The best use by date on the package was [DATE]. 4. Observation on [DATE] at 10:10 A.M., showed Cook Q washed dishes in the three-compartment sink. After washing and rinsing the dishes in the first two compartments, he/she dipped and rolled a colander, a large mixing bowl, a small pan, and a stock pot in the sanitizer for approximately two to three seconds. He/She quickly dipped two spatulas, two whisks and a knife in the sanitizer. He/She washed and rinsed a second stock pot, but did not place it into the sanitizer prior to placing it on a strainer at the end of the sink. Review of the sanitizer label showed to sanitize by immersing articles in sanitizer for at least 60 seconds at a temperature of 75 degrees Fahrenheit. 5. Observation on [DATE] at 9:45 A.M., showed the drain hose for the ice machine, located in the kitchen, was placed directly into the floor drain. There was no air gap between the end of the drain hose and the floor drain. 6. During interview on [DATE] at 1:20 P.M., the Dietary Manager said the following: -The maintenance staff was responsible for cleaning the rangehood and filters. The facility had not had a maintenance staff for a couple of months and the responsibility had not been reassigned. He believed the rangehood and filters were last cleaned in [DATE]. He had not noticed the filters and rangehood needed cleaned prior to the survey; -Staff should not store scoops in the bulk containers; -He would like for bags around frozen food to be sealed and the boxes to be closed; -The facility did not have a process for checking for expired foods. He tried to check for the expired foods monthly, but didn't always have the time. -Maintenance staff had always been responsible for cleaning the air handler and ceiling vents. No one had told him anything different; -The ice machine located in the kitchen was there prior to his employment as the dietary manager. He had not checked for an air gap between the drain hose and the floor drain; -He would like for staff to run the can opener through the dishmachine daily; -He expected for the mixer bowl to be covered; -He believed staff were to immerse items in the sanitizer in the three-compartment sink for three minutes; -He expected staff to wash their hands after removing their gloves; -Staff should not touch the refrigerator doors with their gloved hands; -He was in a hurry when he touched the refrigerator door and frozen hamburger patties with his gloved hands on [DATE].

Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for two residents (Resident #9 and Resident #12), in a review of 14 sampled residents. The facility failed to ensure proper infection control was utilized for respiratory care supplies for five residents (Resident #4, #7, #18, #30 and #289). The facility failed to ensure procedures were implemented to address prevention of Tuberculosis (TB) for four newly hired employees (Activity Director, Dietary Aide I, Licensed Practical Nurse (LPN) J and Registered Nurse (RN) K) of ten new employees reviewed, when the facility failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. The facility failed to develop a policy to address Legionella Control that included specific control parameters based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards, failed to complete an assessment to identify potential sources of Legionella growth, failed to develop a water management team that conducted meetings and failed to complete a water flow map. The facility census was 37. Review of the facility's hand hygiene policy, dated 8/21/2023 showed the following: -Employees must wash their hands for at least twenty {20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: -Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); -Before and after assisting a resident with personal care (e.g., oral care, bathing, etc.); -Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); -Before and after assisting a resident with toileting (hand washing with soap and water); -After contact with a resident's mucous membranes and body fluids or excretions; -After removing gloves; -After completing duty; -When to Use Alcohol-Based Hand Rub: In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are NOT visibly soiled, use an alcohol based hand rub containing 60-95% ethanol or isopropanol for all the following situations: -Before and after direct contact with residents; -Before donning sterile gloves; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After removing gloves; -Removing PPE: Hand hygiene is always the final step after removing and disposing of personal protective equipment; -Use of Gloves: The use of gloves does not replace handwashing/hand hygiene. Review of Infection Control Guidelines for Long-Term Care Facilities, emphasis on Body Substance Precautions, dated July 1999, showed the following: -Handwashing remains the single most effective means of preventing disease transmission. Wash hands often and well; -Wash hands whenever they are soiled with body substances, before performing invasive procedures and when each resident's care is completed. Review of the facility policy, Cleaning and Disinfection of Resident Care Items and Equipment (continuous positive airway pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while one sleeps), dated 4/5/23, showed the following: -Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to manufacturer guidelines and facility policy; -Daily: Masks and cushion is to be washed with an antibacterial soap and laid to dry on a clean towel. Once dry place in zip lock bag for cleanliness. Review of the facility's infection control policy, dated 8/11/23, showed no guidance on the cleaning and storage of respiratory supplies. Review of the facility policy, Facility Infection Control Program, revised 5/2012, showed the following: -This facility's TB Infection Control Program includes the early identification, isolation, and transfer of persons with active tuberculosis. The program incorporates the following components: a. Assignment of responsibility for the oversight of TB infection control to the Infection Control Committee. The Director of Nurses (DON) is designated to oversee the TB program; d. Screening and surveillance of residents and employees for latent tuberculosis infection (LTBI) and active TB as appropriate for the current TB risk classification; e. A protocol for the prompt recognition and transfer of persons with suspected or identified active TB; -No guidance regarding when to administer and read the tuberculin skin test for new employees. Review of the Department of Health and Senior Services Tuberculosis Screening for LTCF Employees Flowchart, updated 03/11/14, showed the following: -Administer TST 1st step prior to employment. (Can coincide reading the results with the employee start date by administering TST 2-3 days prior to the employee start date); -Read results of 1st step TST within 48-72 hours of administration; -If 1st TST is negative, administer 2nd step within 1-3 weeks; -Read results within 48-72 hours of administration; -The employee cannot start work for compensation until the 1st step TST is administered and read. Review of the facility's Enteral Nutrition policy, revised December 2011, showed it did not address the storage of feeding tube syringes when not in use or how often they were to be changed. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Review of the facility's Legionella Water Management Program policy, revised July 2017, showed the following: -The facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella; -As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team; -The water management team will consist of at least the following personnel: the infection preventionist, the administrator, the medical director or designee, the director of maintenance and the director of environmental services; -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease; -The water management program includes the following elements: an interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situation that can lead to Legionella growth, specific measures used to control the introduction and/or spread of Legionella, the control limits or parameters that are acceptable and that are monitored, a diagram of where control measures are applied, a system to monitor control limits and the effectiveness of control measures, a plan for when control limits are not met and/or control measure are not effective; and documentation of the program; -The water management program will be reviewed at least once a year, or sooner if any of the following occur: the control limits are consistently not met, there is a major maintenance or water service change, there are any disease cases associated with the water system, or there are changes in laws, regulations, standards or guidelines; -The policy did not include how often or when the water management team would meet, acceptable temperature ranges for hot and cold water, how the facility was going to monitor or test resident's for Legionella if resident's developed signs and symptoms, and how results would be documented. The policy did not include reporting any cases of Legionellosis to the health department and to the state agency. During an interview on 12/28/23 at 4:16 P.M., the director of nurses (DON) said the facility did not have a policy for oxygen use/tubing change. The facility did not provide a policy regarding nebulizer tubing/equipment storage or changing. 1. Review of Resident #9's undated, continuity of care document (CCD), showed his/her diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety. Review of the resident's care plan, dated 05/30/23, showed the resident required assist of one staff for transfers, dressing, toileting and personal hygiene. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 11/24/23, showed the following: -Cognitively impaired; -Required a wheelchair; -Required substantial to maximal assistance with toileting hygiene and mobility; -Frequently incontinent of bowel, occasionally incontinent bladder. Observation on 12/11/23 at 9:00 A.M., showed the following: -Certified Nurse Assistant (CNA) M entered the resident's room and donned gloves; CNA M did not wash his/her hands and did not use a hand sanitizer; -CNA M removed the resident's pants while the resident lay on his/her bed; -CNA M opened the front of the resident's urine saturated adult brief, pulled it off and threw it away in the trash can at bedside; -With soiled gloves, CNA M picked up a package of wet wipes on the bed and wiped the resident's perineum, assisted the resident to turn over to his/her right side by touching his/her left shoulder and hip with the same soiled gloves, and used the same wet wipes on the resident's bottom, then threw the wet wipes into the trash can at bedside; -CNA M did not change gloves and obtained and placed a clean adult brief under the resident, assisted the resident to roll onto his/her back and fastened the new brief; -CNA M pulled the resident's pajama pants back on and up, still wearing the same soiled gloves; -CNA M covered the resident up with blankets, touching the blankets with the soiled gloves; -CNA M removed his/her gloves and threw them into the trash can at bedside, tied the trash up and carried it into the south hallway and placed it into a larger trash receptacle; -CNA M did not wash his/her hands or use a hand sanitizer after he/she removed the soiled gloves; -CNA M went into another resident's room, and without washing his/her hands or using a hand sanitizer, and with no gloves on, moved a walker closer to a resident and assisted the resident to a standing position; -CNA M assisted the resident into the bathroom, pulled his/her brief and pants down and assisted the resident to sit on the toilet; -CNA M straightened the resident's blankets on his/her chair, with no gloves on, and did not wash his/her hands or use a hand sanitizer; -CNA M donned gloves without washing his/her hands or using a hand sanitizer and wiped the resident's bottom with wet wipes, using his/her right hand; the resident said he/she had a small bowel movement; -With soiled gloves, and using his/her right hand, CNA M assisted the resident to a standing position, pulled the resident's brief and pants up and guided the resident back to his/her bed by touching the resident's low back; -CNA M removed his/her right hand glove during the process and threw it into the trash can at bedside, and kept his/her left hand gloved; -CNA M assisted the resident to sit in the chair, removed his/her left glove and threw it into the trash can at bedside. During an interview on 12/11/23 at 9:45 A.M., CNA M said the following: -He/She usually washed his/her hands before and after providing care to residents; -He/She did not wash his/her hands today but thought he/she had used hand sanitizer between resident cares; -He/She always put on clean gloves for resident care and changed those when they were soiled. 2. Review of Resident #12's quarterly MDS dated [DATE] showed the following: -Requires substantial/maximal assistance for toileting hygiene; -Always incontinent of bladder; -Frequently incontinent of bowel; -Diagnosis of renal failure. Review of the resident's care plan, dated 11/14/23, showed the following: -He/She has areas on his/her bottom that have poor skin integrity from sitting at dialysis and in his/her wheelchair; -He/She wished to have Calmoseptine (barrier cream) applied to areas on his/her buttocks twice daily and as needed; -He/She is occasionally incontinent of bowel and bladder; -Assist him/her with good peri-care after incontinent episodes; he/she has left hemiplegia (paralysis of one side of the body) and requires assist of one for toileting and transfers; -He/She requires assist of two for transfers and toileting due to his/her left hemiplegia. Observation in theresident'ss room, on 12/12/23 at 5:28 A.M., showed the following: -Licensed Practical Nurse (LPN) G and CNA H entered the resident's room; -LPN G and CNA H assisted the resident to a sitting position on the side of the bed; -CNA H assisted the resident to stand beside the bed; -LPN G removed the resident's incontinence brief as the resident stood at the side of the bed; -The resident was incontinent of a small amount of feces; -With gloved hands, LPN G provided pericare; -Feces was visible on the disposable wipes; -Without changing his/her gloves or washing his/her hands, LPN G opened a container of A&D ointment (skin protectant) and with the same gloved hands, dipped his/her soiled gloved hand into the A&D container and applied the A&D ointment to the resident's buttocks; -LPN G removed his/her gloves and washed his/her hands; -LPN G applied a clean incontinence brief and pulled up the resident's pajama pants; -CNA H pivoted the resident to the wheelchair. During an interview on 12/12/23 at 6:35 A.M., LPN G said the following: -He/She usually changes gloves and washes hands between dirty and clean; -He/She should have washed his/her hands after providing peri-care and before applying A&D ointment. 3. Review of Resident #289's face sheet showed the resident had diagnoses that included obstructive sleep apnea (sleep related breathing disorder). Review of the resident's December 2023 physician order sheets (POS) showed the following: -CPAP on at bedtime, off while awake; -No orders regarding the cleaning or storage of the CPAP supplies. Review of the resident's medication administration record (MAR) and treatment administration record (TAR) showed no documentation to show the resident's CPAP mask was cleaned or changed/replaced. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/08/23, showed the following: -Dependent for toileting hygiene; -Occasionally incontinent of bowel and bladder. Review of the resident's care plan, dated 12/09/23, showed the following: -Required assistance of two staff with personal hygiene, toileting hygiene, and bed mobility; -Occasional urinary incontinence; -No documentation regarding the use of a CPAP. Observation in the resident's room, on 12/10/23 at 1:35 P.M., showed the resident's CPAP mask on the resident's bed; the mask was not in a storage bag. Observation on 12/12/23 at 6:15 A.M. showed the following: -CNA A and CNA B entered the resident's room; neither staff washed his/her hands and donned gloves; -The resident lay in bed and was incontinent of bladder; -CNA A rolled the resident to his/her side; -CNA B wiped the resident's inner, upper thighs and perineum (the area between the genitals and the rectal opening) with the wet wipes; -CNA B did not change gloves and assisted CNA A to turn the resident to his/her right side, touching the resident on his/her left shoulder and left hip with soiled gloves, pulled the soiled incontinence brief out from under the resident and tucked a new incontinence brief under the resident; -CNA B then removed gloves, put on new gloves, did not wash hands with soap and water or use hand sanitizer between glove changes, put a clean chux (a disposable ultra-absorbent incontinence pad) under the resident, grabbed a tube of skin barrier cream from the resident's night stand with his/her soiled gloves, applied the skin barrier cream to the resident's buttocks and then removed one glove that was used to apply skin barrier cream; - Without washing his/her hands with soap and water or using hand sanitizer, CNA B put on one new glove, assisted CNA A to turn the resident onto his/her back by touching the resident's left shoulder and left hip and fastened the resident's new incontinence brief. Observation in the resident's room on, 12/13/23 at 8:50 A.M., showed the resident's CPAP mask on his/her table; the mask was not in a storage bag. During an interview, on 12/12/23 at 9:40 A.M., the resident said his/her CPAP mask has not been cleaned since he/she was admitted . 4. Review of Resident #18's CCD, dated December 12, 2023, showed the resident had diagnoses that included chronic obstructive pulmonary disease (COPD) (lung disorder). Review of the resident's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Feeding tube (flexible plastic tube placed into the stomach or bowel that provides nutrition) on admission; -Feeding tube while a resident. Review of the resident's care plan, updated 10/31/23, showed the resident is on gastrostomy tube (G-tube) (a tube that is inserted through the belly that brings nutrition directly into the stomach) feedings. Review of the resident's physician orders, dated December 2023, showed the following: -Ipratropium-albuterol solution (inhaled lung medication) for nebulization (by way of a machine that turns liquid medication into a mist to be inhaled); 0.5 milligrams (mg) - 3 mg (2.5 mg base)/3milliliterss mlL); amount: one vial; four times daily as needed for COPD, (start date 11/21/23); -Ipratropium-albuterol solution for nebulization; 0.5 mg - 3 mg (2.5 mg base)/3mlL; amount: one vial; inhalation, special instructions: One vial, twice daily for 7 days (Start Date 10/6/23 - End Date 10/10/23) (for Chronic obstructive pulmonarydiseasee); -Ipratropium-albuterol solution for nebulization; 0.5 mg - 3 mg (2.5 mg base)/3mlL; amount: one vial; twice daily until 10/24/23 (Start date 10/10/23) for COPD; -Monitor percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube placed directly into the stomach) patency every shift and as needed. Check residual (refers to the fluid/contents that remain in the stomach) feeding per PEG tube as needed; -Jevity 1.5 CAL (tube feeding nutrition) -50 cubic centimeters (cc)/hour (HR), continuously, with 75 cc free water flush every two hours; may disconnect feeding for showers or therapy (start date 5/10/23, end date 11/28/23); -Flush peg tube with 75 ml of water every two hours (start date 5/15/23, end date 11/28/23). Observation in the resident's room on 12/10/23 at 1:40 P.M., showed the following: -A nebulizer mask sat on a recliner beside the resident's bed; the tubing and mask were not stored in a bag when not in use; -A feeding tube syringe on the nightstand on a paper towel; the syringe was not stored in a bag/bottle when not in use. Observation in the resident's room, on 12/12/23 at 5:40 A.M., showed the resident's nebulizer mask face down on the recliner; the tubing and mask were not stored in a bag when not in use. Observation in the resident's room, on 12/13/23 at 3:35 P.M., showed the resident's feeding tube syringe on top of a paper towel on the night stand; the syringe was not stored in a bottle or bag; 5. Review of Resident #30's CCD showed the resident had diagnoses that included COPD, acute respiratory failure with hypoxia (low oxygen level), and bronchitis (respiratory infection) last diagnosed on [DATE]. Review of the resident's care plan, dated 11/27/23, showed no documentation regarding oxygen or nebulizer treatments. Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's December 2023 POS showed the following: -Pulmicort suspension (inhaled lung medication) 0.5 milligrams (mg)/2 milliliter (ml) 1 vial per nebulizer (a machine that turns liquid medication into a mist to be inhaled) twice daily (BID); -Oxygen at two liters per minute per nasal canula (LPM/NC) as needed (prn) at bedtime; -No orders addressing cleaning, changing or storage of respiratory supplies. Review of the resident's MAR and TAR showed no documentation to show the resident's oxygen tubing or nebulizer tubing/supplies were being cleaned or changed/replaced. Observation of the resident in his/her room, on 12/10/23 at 1:42 P.M., showed the resident in bed with oxygen tubing in his/her nostrils; the oxygen tubing was not labeled with a date to indicate when the tubing had last been changed. Observation in the resident's room, on 12/11/23 at 8:30 A.M., showed the following: -Oxygen tubing in a bag, taped to the oxygen concentrator, dated 11/16/23; -Nebulizer kit in a bag on the resident's nightstand; no date on the bag or supplies to show when it had last been changed. Observation of the resident in his/her room, on 12/13/23 at 8:55 A.M., showed the following: -The resident in bed, oxygen placed in his/her nares; the tubing was not labeled with a date; -Nebulizer tubing on his/her nightstand, not on apaper [NAME], not stored in a bag and undated. 6. Review of Resident #4's face sheet showed the resident had diagnoses that included COPD. Review of the resident's care plan, dated 7/17/23, showed the resident was to always use oxygen. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Received oxygen therapy; -Moderate cognitive impairment. Review of the resident's December 2023 POS showed the following: -Oxygen at two LPM per NC, titrate (adjust) to keep oxygen saturation (spo2) (measurement of how much oxygen ones blood is carrying as a percentage of the maximum it could carry) over 90 percent (%) (a normal level of oxygen is usually 95 % or higher); -No orders found for changing and storage of respiratory supplies. Review of the resident's MAR and TAR showed no documentation to show the resident's oxygen tubing had been changed/replaced. Observation of the resident in his/her room, on 12/10/23 at 1:40 P.M., showed the resident in bed with oxygen tubing in his/her nares; the oxygen tubing was not labeled with a date. Observation of the resident in his/her room, on 12/11/23 at 8:05 A.M., showed the resident in his/her wheelchair with oxygen tubing in his/her nares; the oxygen tubing was not labeled. Observation of the resident in his/her room, on 12/12/23 at 5:15 A.M., showed the resident sleeping in his/her bed with oxygen tubing in his/her nares; the oxygen tubing was not labeled. Observation of the resident in his/her room, on 12/13/23 at 8:54 A.M., showed the resident in bed with oxygen tubing in his/her nares; the oxygen tubing was not labeled. 7. Review of Resident #7's undated CCD showed diagnosis of Alzheimer's dementia (a progressive and debilitating disease that causes severe cognitive decline and affects the ability to function in daily life) and cough. Review of the resident's care plan, dated 10/04/23, showed no focus, goals or interventions for the diagnosis of cough and the as-needed use of oxygen. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively impaired; -No documentation to show oxygen use. Review of the resident's December 2023 POS, showed an order for oxygen at two to three LPM/NC to keep oxygen saturations at 91% . Observation on 12/10/23 at 1:55 P.M. showed the resident's oxygen tubing draped over the oxygen concentrator at bedside and open to air (the oxygen tubing was not stored in a bag while not in use). Observation on 12/13/23 at 9:00 A.M. showed the resident's oxygen tubing draped over the oxygen concentrator at bedside (the oxygen tubing was not stored in a bag while not in use). 8. Review of the Activity Director's employee file showed the following: -Date of hire 8/22/23; -First TST administered on 8/22/23 and read on 8/25/23 (three days after the first date of resident contact); -Second TST administered on 9/5/23 and read on 9/7/23. 9. Review of Dietary Aide I's employee file showed the following: -Date of hire 8/9/22; -First TST administered on 8/8/22 and read on 8/10/22 (one day after the first date of resident contact); -Second TST administered on 9/11/22 and read on 9/13/22. 10. Review of LPN J's employee file showed the following: -Date of hire 7/30/22; -First TST administered on 7/30/22 and read on 8/1/22 (two days after the first date of resident contact); -Second TST administered on 8/26/22 and read 8/27/22 (read in 24 hours). 11. Review of Registered Nurse (RN) K's employee file showed the following: -Date of hire 3/17/23; -First TST administered on 3/17/23 and read on 3/19/23 (two days after the first date of resident contact); -Second TST administered on 3/31/23 and read on 4/3/23. During an interview on 12/12/23 at 2:00 P.M. the Assistant Administrator said the date of hire is the first date of resident contact. 12. The facility provided no evidence or documentation that a water management team had been developed, that they had a water management program, that anyone had identified areas in the water system where Legionella bacteria could grow and spread, did not have a plan to reduce the risk of Legionnaire's disease, did not have a detailed description and diagram of the water system in the facility and had not identified areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. The facility had not tested the temperature ranges of water to ensure they were within the ASHRAE recommendations to prevent Legionella growth. No minutes from a water management team meeting were provided. During an interview on 12/12/23 at 1:20 P.M. and 12/13/23 at 11:00 A.M., the Infection Preventionist (IP)/LPN A -She became the IP a few weeks ago, starting this position on 11/27/23, and has completed the 20 hour training course; -She is in charge of TB testing; the facility does a 2 step TB test upon hire and then yearly; -The DON asks the charge nurse to administer the first TST prior to date of hire; -The TST should be read 48 hours after the test is administered; -The charge nurse tells the staff when the first TST is to be read and when the second TST is to be administered; -Staff don't always show up on the date the TST are to be read; -The first TST should be read by the first date of resident contact. During an interview on 12/13/23 at 12:30 P.M., 12/13/23 at 600 P.M.M. and 6:30 P.M. and 12/20/23 at 11:56 A.M., the DON said the following: -She became the DON one month ago; -She would expect staff to wash their hands prior to and after direct resident care; -She would expect staff to change their gloves during personal care of a resident; She would expect staff to remove soiled gloves, wash their hands or use a hand sanitizer and change gloves after providing personal care and prior to touching clean items; -Staff should wash hands with soap and water after changing gloves and after providing perineal care and before putting on new gloves; -Staff should wash hands, or at least use hand sanitizer, between changing gloves; -Oxygen, nebulizer tubing and humidification bottles should be dated/labeled when changed; -Oxygen and nebulizer tubing should be kept in a Ziploc bag when not in use; -She is not sure what the policy states, or if there is a policy regarding the changing of oxygen tubing, nebulizer tubing/masks or how often this is done; -There was not an order for cleaning of nebulizer supplies for Resident #30; -There was not an order for the changing of oxygen tubing for Resident #30 or #4; -There was not an order for cleaning/storage of the CPAP mask for Resident #289; -The four new employees (Activity Director, Dietary Aide I, LPN J and RN K) were hired under the previous DON; -The IP just assumed responsibility of employee TB testing; -She would expect feeding tube syringes to be stored in a bag if not in use; -She would expect staff to follow any facility policy. During an interview on 12/12/23 at 2:30 P.M., 12/13/23 at 6:00 P.M. and 6:30 P.M., the Administrator said the following: -The charge nurse changes respiratory supplies out, but he wasn't sure how often; -He would expect employee TB testing to be completed per the regulation. -There was currently no Legionella water management program; the only thing he could find in the binder was something that looked like the [TRUNCATED]

Based on observation and interview, the facility failed to have an adequate audible system for the residents to signal the nursing staff when they were in need of staff assistance. The facility also failed to ensure one resident (Resident #21)'s call light functioned properly when the light did not illuminate above the resident's door. The facility census was 37. The facility did not provide a policy regarding the resident call light system. Review of the DHSS exception log showed the facility did not have an approved exception for a wireless call light system. 1. Review of Resident #21's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/26/23 showed the following: -Short and long term memory problems; -Dependent on staff for toileting hygiene, personal hygiene, sitting to lying, sit to stand, and chair/bed to chair transfer; -Frequently incontinent of bladder and bowel; -Diagnoses of osteoporosis, fracture, dementia and anxiety; -Two or more no injury falls since last assessment; -One major injury fall since last assessment. Review of the resident's care plan dated 11/2/23 showed the following: -He/She is sometimes able to make his/her needs known; -He/She has had fewer episodes of confusion; -Re-direct him/her and encourage him/her to use his/her call light and ask for help if he/she does seem confused; -He/She requires assistance with transfers and most ADLs; -He/She requires assist of two for all transfers and toileting; -Make sure his/her call light is in reach; -He/She has a fall mat beside his/her bed; -He/She can place him/herself on this mat; -Sometimes it is more comfortable for him/her to lie on the mat next to his/her bed. Observation on 12/12/23 at 7:02 A.M. in the resident's room showed the following: -The resident lay on his/her back with his/her upper body on the mattress and his/her lower body on the fall mat; -The resident yelled Help, help!; -The resident scooted further off the end of the bed; -The resident had activated his/her call light; -The light on the box above his/her bed was illuminated; -The light above his/her door was not illuminated; -SA staff also activated the resident's call light by pushing the call light button. The light only illuminated in the room. The light above the door did not illuminate. No sound was emitted; -SA staff had to call for staff assistance; -Registered Nurse (RN) K entered the resident's room; -RN K confirmed the resident's call light was activated but only illuminated in the room. Observation on 12/13/23 at 8:21 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair; -The resident pushed his/her call light; -A light illuminated on the box on the wall in the resident's room; -There was no sound in or outside the resident's room when the call light was on; -The light above the resident's door did not illuminate; -The administrator changed out the light bulb above the resident's door; -The light above the resident's door still did not illuminate. During and interview on 12/13/23 at 8:30 A.M. the resident said the following: -His/Her call light had not worked for several days; -He/She has had several falls; -He/She has to yell for staff or go out in the hall and find staff if his/her call light isn't working. During an interview on 12/12/23 at 7:10 A.M. Certified Nurse Aide (CNA) B said the following: -The resident's call light has not been working on and off for the last two to three months; -The resident's call light does not light above the door; -If the call light does not light above the door and does not sound in the hallway, staff do not know the resident needs assistance. During an interview on 12/12/23 at 7:08 A.M. Registered Nurse (RN) K said the following: -The resident's call light only lights up in the resident's room; -The light above the resident's door did not work; -If the call light is activated the light should illuminate above the resident's door. 2. Observation on 12/10/23 at 1:55 P.M. showed the light above occupied resident room [ROOM NUMBER] illuminated red, indicating the bathroom call light was activated. No sound was emitted in the south hallway and no facility staff were present. During an interview on 12/11/23 at 9:00 A.M., CNA M said the following: -When a resident pushed his/her call button, a light would come on above the entry door into the resident's room; -A white light meant the resident just needed something, a red light meant the resident was in the bathroom and needed assistance; -There were no sounds emitted when the light came on; -A box at the nurses' station would display the room number as it emitted a sound; -The sound from the call light box was very soft and staff could not hear it; -Staff did not know when a call light was on unless they could see it while they were on the hallway where the light was on, or unless another staff called on the walkie-talkie for resident assistance; -The walkie-talkies used were not connected to the call light system; -Staff usually just know when the lights were on because they were always up and down the hallways and it was a small facility. During an interview on 12/12/23 at 5:50 A.M., RN K said the following: -The facility had a call light box at the nurses' station that would emit a soft sound and indicate the resident room when a call button was pushed; -The call light system was encased in a larger, clear plastic box that was locked so staff could not adjust the sound that was emitted; -Staff would not be able to hear the call light system sound if they were away from the nurses' station, but they could see the light on above the resident's room; -If staff were in a resident's room, they would not be able to hear the call light box sound and would just have to see the light on above the resident's door when they came back out into the hallway. 3. Observation on 12/12/23 at 5:52 A.M. showed the following: -Three call lights were illuminated on the east hall; -The call lights were not audible on the east hall. During anintervieww on 12/12/23 at 6:00 A.M., CMT P said the following: -He/She cannot hear the call lights; -The only way he/she knows a call light is on is by seeing the light on outside the resident's room; -If he/she is in a resident room, he/she would not know if another call light on. 4. Observation on 12/12/23 in the east hallway showed the following: -At 6:40 A.M. the light above occupied resident room [ROOM NUMBER] was illuminated. The call light did not sound in the east hallway. CNA L walked by the resident's room and into another resident's room; -At 6:46 A.M. the light above occupied resident room [ROOM NUMBER] remained illuminated. No sound was emitted on the hallway. CNA L walked by the resident's room; -At 6:52 A.M. RN K entered the resident's room and said whose got the light on? RN K assisted the resident to the bathroom and RN K exited the room; -At 6:55 A.M. the light above occupied resident room [ROOM NUMBER] illuminated red indicating the bathroom call light was activated. No sound was emitted in the hallway. 5. Observation on 12/13/23 at 8:31 A.M. showed the following: -Two call lights were illuminated on the south hall; -The call lights were audible at the nurses' station; -The call lights were not audible on the south hall. 6. Observation on 12/13/23 at 8:40 A.M. in the facility's clean and dirty utility rooms showed the following: -Both rooms had a light fixture on the walls of the room; -A call light was turned on; -The lights in the clean and dirty utility rooms did not illuminate; -There was no sound audible in the clean and dirty utility rooms; -No call light duty station was present in the clean or dirty utility rooms. During an interview on 12/13/23 at 8:40 A.M. CNA B said the following: -Staff can't hear the call lights unless you are standing at the nurses' station; -Lights do not illuminate in the clean or dirty utility rooms; -The call lights are not audible in the clean or dirty utility rooms; -The old call light system was very audible; -The new call light system can't be heard down the halls at all. During an interview on 12/13/23 at 8:21 A.M. the Administrator said the following: -The facility does not currently have a maintenance director; -In October 2023, the facility had to replace the old call light system; -Several call lights went down then the entire call light system went down; -The new call light system is only audible at the nurses' station; -The light above the resident's door should illuminate when the resident activates the call light; -He has not had any problem with the call lights not sounding at the nurses' station; -He has had to replace a few bulbs outside the resident rooms; -He has replaced a bulb outside Resident #21's room; -He was not aware Resident #21's call light was not working; -When a call light is activated, the light on the wall above the resident's bed and the light above the resident's door should illuminate; -The call lights do not sound in the residents' rooms or on the hall; -He did not realize the call lights need to be audible down the hall; -If staff were in a resident room with the door shut they would not be able to hear a call light; -The facility does not have an exception for a wireless call light system; -Facility staff do not wear pagers connected to the call light system; -Facility staff do use walkie talkies but the call light notification is not sent to the walkie talkies. MO 227930

Based on observation, interview, and record review, the facility failed to monitor the effectiveness of current fall interventions, failed to modify the interventions as necessary to prevent further falls, and failed to consistently implement fall interventions for four residents (Residents #31, #39, #40, and #41), in a review of 15 sampled residents, who had a history of [REDACTED]. The facility census was 43. 1. Review of the facility policy Falls-Clinical Protocol, dated (MONTH) (YEAR), showed the following: -Assessment and Recognition section; -The physician would help identify individuals with a history of falls and risk factors for falling. Staff would ask the resident and the caregiver or family about a history of falling. The staff and physician would document in the medical record a history of one or more recent falls. While many falls were isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause; -In addition, the nurse should assess and document/report the resident's vital signs, recent injury, especially fracture or head injury, musculoskeletal function, observing for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred, all current medications, especially those associated with dizziness or lethargy and all active diagnosis; -The staff and practitioner would review each resident's risk factors for falling and document in the medical record; -The physician would identify medical conditions affecting fall risk and the risk for significant complications of falls; -The staff would evaluate and document falls that occur while the individual was in the facility. When and where it happened, any observations of the events, etc.; -Falls should be categorized as those that occurred while trying to rise from a sitting or lying to an upright position, those that occurred while upright and attempting to ambulate and other circumstances such as sliding out of a chair or rolling from a low bed to the floor; -Falls should also be identified as witnessed or unwitnessed events; -For an individual who had fallen, the staff and practitioner would begin to try to identify possible causes within 24 hours of the fall; -If the cause of the fall was unclear, or if a fall may have a significant medial cause, or if the individual continues to fall despite attempted interventions, a physician would review the situation and help further identify causes and contributing factors; -Based on the preceding assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling; -If underlying causes could not be readily identified or corrected, staff would try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation; -The staff would follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma had been ruled out or resolved; -The staff and physician would monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals were often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences could sometimes be minimized even if falls could not be prevented; -If interventions had been successful in fall prevention, the staff would continue with current approaches and would discuss periodically with the physician whether these measure were still needed; -If the individual continued to fall, the staff and physician would re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions; -As needed, after an appropriately thorough review, the physician would document any uncorrectable risk factors and underlying causes. 2. Review of Resident's #39's care plan, dated 7/2/18, showed the following: -The resident had a personal history of falls and took medications that could increase fall risk; -He/she would not have any serious injuries due to falls; -Encourage him/her to ask for help with all transfers; -He/she took medications that could cause dizziness and drowsiness which could lead to falls. Monitor him/her after administering these medications; -Keep his/her call light within reach at all times. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 9/25/18, showed the following: -The resident's cognition was moderately impaired; -He/she required extensive assistance from one staff with bed mobility, transfers, walking in and out of his/her room, and locomotion on and off of the unit and toilet use; -He/she was frequently incontinent of bladder and always continent of bowel; -He/she used a walker and wheelchair; -He/she was not steady and was only able to stabilize with human assistance with changing from seating to standing potion, walking, turning around and facing opposite direction while walking, transferring on and off of the toilet, surface to surface transfers, and transfers between bed to chair or wheelchair; -He/she had one fall with minor injury and one fall with major injury since previous assessment (6/28/18). Review of the resident's fall risk assessment, dated 10/17/18, showed the following: -He/she had one to two falls within the past three months; -He/she was chair-bound; -He/she had problems with balance while standing and walking; -He/she had decreased muscular coordination; -He/she had a change in gait pattern when walking through a doorway; -He/she required the use of an assistive device such as a wheelchair, walker, or cane; -He/she took one or two medications that could cause lethargy (weakness) and confusion; -He/she had one or two predisposing diseases that could cause falls; -His/her total fall risk score was 12, which indicated the resident was at high risk for falls. Review of the resident's nursing notes, dated 11/18/18 at 3:57 P.M., showed the following: -The resident was observed in the hallway on his/her bottom scooting across the floor; -He/she told staff he/she was trying to transfer himself/herself to the wheelchair from the recliner without wearing shoes; -He/she was encouraged to use his/her call light for assistance and to wear shoes or grip socks during transfers. Review of the resident's care plan showed a hand written intervention, dated 11/18/18, that instructed staff to educate the resident to ask for assistance when transferring himself/herself. (This intervention was identified on the resident's care plan prior to the resident's fall on 11/18/18.) Review of the resident's nursing notes, dated 11/20/18 at 7:30 P.M., showed the following: -The resident was observed sitting on the floor beside his/her bed; -He/she told staff he/she was getting up from the bed and the bed was not locked and slid out from under him/her. Review of the resident's care plan showed an intervention was added on 11/20/18 to educate the resident to ask for assistance with transfers to bed so staff can ensure the brakes were locked. (Staff identified the intervention for the resident to ask for assistance with transfers on the resident's care plan on 7/2/18 and after the resident fell on [DATE].) Review of the resident's nursing notes, dated 12/15/18 at 1:00 A.M., showed the following: -The resident was observed on the floor in his/her room; -The resident was lying on his/her right side in front of his/her recliner with his/her wheelchair nearby; -He/she was not wearing grip socks;; -The resident told staff he/she was trying to go to the bathroom when his/her feet slid out from under him/her and he/she landed on his/her bottom. Review of the resident's Post Fall Huddle Guide Form, dated 12/15/18, showed the following: -The resident was at risk for falls; -The resident had not fallen in the past four weeks (documentation showed the resident fell on [DATE]); -The resident had brittle bones; -The resident was going to the bathroom at the time of the fall; -Staff was caring for other residents at the time of the fall; -The resident had not fallen recently, but every fall was basically because the resident was hurting and was weak; -Changes made to the resident's care plan to decrease the risk of future falls included the resident needed to wear grip socks when self-transferring or have the resident use his/her call light and ask for assistance with transfers. (Staff documented in the nurses notes on 11/18/18, they encouraged the resident to wear grip socks after he/she fell while not wearing the socks on 11/18/18.) Review of the resident's care plan showed an intervention was added on 12/17/18 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident's care plan on 7/2/18 and after the resident fell on [DATE] and 11/20/18.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/her cognition was intact; -He/she required limited assistance from one staff with transfers and locomotion on and off of the unit; -He/she required extensive assistance of one staff with toileting; -He/she walked in his/her room once or twice with assist from one staff; -He/she did not ambulate out of his/her room; -He/she was frequently incontinent of bladder and always continent of bowel; -He/she used a walker and wheelchair; -He/she was not steady and was only able to stabilize with human assistance with changing from seating to standing potion, walking, turning around and facing opposite direction while walking, transferring on and off of the toilet, surface to surface transfers, and transfers between bed to chair or wheelchair; -He/she had one fall with minor injury and one fall with major injury since previous assessment (6/28/18); -He/she had impairment with one side of his/her lower extremities during range of motion (ROM); -He/she had two non-injury falls and one minor injury fall since previous assessment. Review of the resident's Care Plan Conference Summary, dated 12/26/18, showed he/she was at high risk for falls due to trying to do things for himself/herself. (There was no evidence staff evaluated or modified current interventions to prevent the resident from falling.) Review of the facility's fall investigation, dated 1/25/19, showed the resident was found on the floor in front of his/her wheelchair in his/her room on 1/25/19 at 4:50 P.M. The resident stated he/she was transferring himself/herself from the recliner to the wheelchair when he/she slipped and fell on to the floor. Review of the resident's Post Fall Huddle Guide Form, dated 1/25/19, showed the following: -The resident was transferring himself/herself from the recliner to wheelchair; -Root cause of the fall: the resident did not use his/her call light to ask for assistance; -Changes to the resident's care plan to decrease the risk of further falls included to remind the resident the importance of using call light to get help while transferring. Review of the resident's care plan showed an intervention was added on 1/25/19 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident's care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, and 12/17/18.) Review of the facility's fall investigation, dated 1/30/19, showed the following: -On 1/30/19 at 11:55 P.M., the resident was getting himself/herself out of bed without wearing socks, slid down the side of the bed, and landed on the floor; -Intervention put into place to prevent further incidents included educating the resident of the need for grip socks at all times that shoes were not on. Review of the resident's Post Fall Huddle Guide Form, dated 1/30/19, showed the following: -The resident was trying to get out of bed without his/her shoes on; -Root cause of the fall: the resident did not use his/her call light to ask for assistance and he/she was not wearing shoes or gripper socks at the time of the incident; -Changes made to the resident's care plan to decrease the risk of future falls included the resident needed to wear grip socks when self-transferring or have the resident use his/her call light and ask for assistance with transfers; -System problem that needed to be communicated to other departments included to be sure to place non-grip socks on the resident at bedtime. Review of the resident's care plan showed an intervention was added on 1/30/19 to educate the resident of the need for grip socks at all times that shoes were not on. (Staff documented they provided education to the resident after he/she fell when not wearing grip socks on 11/18/18 and 12/15/18.) Review of the facility's fall investigation, dated 2/1/19, showed the following: -On 2/1/19 at 3:00 P.M., the resident slipped and fell on to the floor in his/her room while trying to transfer himself/herself from the recliner to the wheelchair; -Intervention put into place to prevent further incidents included to re-educate the resident to use the call light for assistance with transfers. Review of the resident's Post Fall Huddle Guide Form, dated 2/1/19, showed the following: -He/she was taking himself/herself to the bathroom from the recliner; -Root cause of the fall: the resident slipped when he/she tried to get up; -There were no changes to the resident's care plan that would decrease the risk for future falls; -The facility was unable to develop interventions to prevent further falls. Review of the resident's care plan showed an intervention was added on 2/1/19 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident's care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, and 1/25/19.) Review of the facility's fall investigation, dated 2/14/19, showed the following: -On 2/14/19 at 1:15 P.M., the resident was found lying on the floor in his/her room. The resident could not remember what had happened; -Intervention to prevent further incident included to educate the resident to use call light when needing to transfer. Review of the resident's Post Fall Huddle Guide Form, dated 2/14/19, showed the following: -The resident was found lying on the floor on his/her right side and he/she could not tell staff what he/she was doing; -Root cause of the fall: the resident complained of having a headache and nausea with vomiting before lunch. He/she was being treated for [REDACTED]. -The resident had a room at the end of the hall and could not always be heard when he/he asked for help; -Intervention that could be made to decrease risk for future falls included moving the resident closer to the nurse's station and to check on him/her more frequently; -Remind the resident to use the call light when he/she wanted to get up. Review of the resident's care plan showed an intervention was added on 2/14/19 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident's care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, and 2/1/19.) Review of the resident's nursing notes, dated 2/24/19 at 6:36 P.M., showed the following: -The resident was observed on the floor lying on his/her back between the bed and recliner; -The resident told staff he/she was trying to get up to change into his/her night clothes; -He/she pushed away from his/her sink with brakes not in the locked position; -Re-educated resident on the importance of using call light for assistance and to make sure the brakes were in the locked position if he/she was going to self-transfer. Review of the resident's Post Fall Huddle Guide Form, dated 2/24/19, showed the following: -There were no changes made to the care plan that could decrease the resident's risk for future falls; -Interventions that could be made to decrease the risk for future falls or injuries was to move resident to a room that was closer to the nurse's station; -Due to resident's frequent fall history, he/she needed to be closer to the nurse's station; -Fall could have possibly been prevented. Review of the resident's care plan showed an intervention was added on 2/24/19 to educate the resident to use his/her call light for assistance with transfers and ensuring grip socks were on, and wheelchair brakes were locked. (Staff identified the interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers on the resident's care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19, and 2/14/19. Staff also provided education to the resident after he/she fell when not wearing grip socks on 11/18/18, 12/15/18, and 1/30/19.) Review of the facility's fall investigation, dated 2/25/19, showed the following: -On 2/25/19 at 10:20 A.M , the resident was found sitting on the floor in front of his/her recliner; -Intervention to prevent further falls included educating the resident to use call light for assistance when he/she needed to get up. Review of the resident's Post Fall Huddle Guide Form, dated 2/25/19, showed the following: -The resident was transferring himself/herself; -Root cause of the fall: the resident did not ask for help -Need to consult PT/OT about mobility/positioning/seating (no documentation was found the resident received PT/OT consult); -Changes made to the resident's care plan to decrease the risk of future falls included reminding the resident to use his/her call light when he/she wanted help. Review of the resident's care plan showed an intervention was added on 2/25/19 to educate the resident to use his/her call light for assistance with transfers. (Staff identified the interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers on the resident's care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19, 2/14/19 and 2/24/19.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/her cognition was mildly impaired; -He/she required extensive assistance of two staff with bed mobility, transfers, ambulation, and locomotion off of the unit, and toilet use; -His/her ROM was limited on one side of both upper and lower extremities; -He/she used a walker and wheelchair; -He/she was occasionally incontinent of bladder and always continent of bowel; -He/she was not steady and was only able to stabilize with human assistance with changing from seating to standing potion, walking, turning around and facing opposite direction while walking, transferring on and off of the toilet, surface to surface transfers, and transfers between bed to chair or wheelchair; -He/she was at risk for falls; -He/she had two non-injury falls and minor injury fall since previous assessment (12/16/18). Review of the facility's fall investigation report, dated 3/14/19, showed the following: -The resident fell on to the floor on 3/14/19 at 8:25 A.M. when he/she attempted to transfer himself/herself from the wheelchair to the recliner; -The resident complained of left arm pain. Review of the resident's Post Fall Huddle Guide Form, dated 3/14/19, showed the following: -The resident was transferring himself/herself from his/her wheelchair to the recliner when he/she slipped and fell against the wheelchair; -Staff was feeding residents in the dining room and assisting other residents from the dining room to their rooms at the time the incident occurred; -Root cause of the fall: the resident did not like to ask for assistance and he/she stated he/she was reaching for the call light when he/she fell ; -Changes made to the resident's care plan to decrease the risk of future falls included moving the resident closer to the nurse's station; -Interventions that could decrease the risk for future falls or injuries included to encourage the resident to use call light and wait for assistance, and to check on the resident frequently. (Staff identified the interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers on the resident's care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19, 2/14/19, 2/24/19, and 2/25/19.) Review of the resident's care plan showed it was updated on 3/14/19 to show the resident fell and broke his/her humerus (long bone in the upper arm between the elbow and shoulder). Review of the resident's physician's progress note, dated 3/15/19 (physician assessed the resident on 3/14/19), showed the following: -The resident complained of left shoulder/upper arm pain; -The resident fell while he/she was trying to transfer himself/herself from the wheelchair to bed; -Examination revealed the resident was holding onto his/her left upper arm; -There was tenderness noted to the proximal humerus; -X-ray of the left shoulder was ordered which was positive for [MEDICAL CONDITION] (situated to the center of the body or the point of attachment) left humerus; -Recommended an appointment with orthopedic physician (physician that specialized in bones); -Limit physical activity and movement of the arm; -Pain management regimen was put into place. Review of the resident's hospital records, dated 3/15/19, showed the following: -Diagnosis: [REDACTED]. -A shoulder immobilizer was placed on the left shoulder. Review of the resident's care plan conference summary, dated 3/20/19, showed the following: -The resident was at high risk for falls due to the need for assistance with transfers; -The resident fell very frequently because he/she tried to do things on his/her own without asking for help; -He/she fell and broke his/her humerus, but still continued to fall; -He/she was unable to have surgery as he/she was not a candidate for surgery at this time. Review of the resident's nursing notes, dated 3/28/19 at 5:33 P.M., showed the resident's physician assessed resident and a new order was received to move the resident closer to the nurse's station. (Staff noted an intervention to prevent falls for the resident was to move him/her closer to the nurses station after the resident fell on [DATE], 2/24/19, and 3/14/19.) Review of the resident's nursing note, dated 3/29/19 at 3:44 P.M., showed the resident's physician was updated of the resident not wanting to move from his/her current room to another room. Review of the resident's social service progress note, dated 3/29/19, showed the following: -The resident said he/she did not want to move from his/her current room because he/she just got it all set up the way he/she liked it; -The resident said he/she did not like all the noise there was closer to the nurses station and it was much quieter where he/she currently was; -The resident was reassured he/she would receive the same care if he/she moved closer to the nurse's station. Review of the physician's response to the social service progress note, dated 4/2/19, showed the following: -When he/she was at the facility on 3/28/19. The resident was crying out in pain from his/her shoulder fracture; -He/she heard the resident calling out in pain because he/she was on the resident's hallway; -Nursing staff was at the nurse's station and was unable to hear the resident's cries; -The resident told him/her at that time and at the previous visits he/she did not use the call light. During an interview on 4/11/19 9:00 AM., the resident said the following: -He/she did not remember anyone asking him/her to move rooms; -It was his/her fault he/she fell because he/she would not call for assistance. Observation on 4/11/19 at 9:00 A.M. showed the resident's private room was the last room furthest from the nurses station on the south hall. During an interview on 4/11/19 at 10:05 A.M., the resident's physician said the following: -The resident had fallen multiple times; -The resident's fall on 3/14/19 resulted in a fractured humerus; -Nursing staff told him/her recommendations were made to move the resident closer to the nurses station but the resident did not want to move; -He/she wrote an order to move the resident closer to the nurse's station on 3/28/19; -He/she received a faxed response from the facility that stated the resident did not want to move rooms; -He/she responded back to the facility and said he/she was concerned nursing staff could not hear the resident when he/she yelled or cried out. He/she heard the resident calling out in pain because he/she was on that hall close by, but the staff was unable to hear the resident's cries at the nurse's station; -The resident told him/her he/she quit using the call light because it did him/her no good. Staff took too long to help him/her and he/she just quit using it; -He/she expected staff to at least encourage the resident to move closer to the nurses station, even if it was only temporarily; -There was a room available (first room on the right from the nurse's station on the east hall). During an interview on 4/12/19 at 5:00 P.M., the Director of Nursing (DON) said the following: -The resident used to be in a room closer to the nurse's station, but wanted to move to a private room. He/she moved when a private room became available; -She and other staff talked to the resident several times about using his/her call light, but the resident was independent; -The resident started to experience falls when he/she would forget to put on grip socks; -Staff has been educated to frequently monitor the resident, which included walking down the hall to check on him/her frequently throughout the day (at least hourly); -The resident fractured his/her left humerus and was sent to the hospital; -The resident fell after he/she was moved away from the nurses station; -The resident refused to move to another room that was closer to the nurse's station; -Staff, including the DON, the restorative aide and the MDS Coordinator, discussed falls in the IDT meetings; -Care plans were updated during the meetings; -He/she did not know how to prevent the resident from falling. 3. Review of Resident #31's Fall Risk Assessment, dated 10/28/18, showed the following: -Alert; -History of one to two falls in the past three months; -Chair bound; -Adequate vision; -Unable to perform gait/balance evaluation; -Blood pressure drop less than 20 millimeters of mercury between lying and standing; -Took three to four medications that caused lethargy or confusion; -Had one to two predisposing diseases; -Total fall risk score of 14, indicating the resident was at high risk for falling. Review of the resident's Care Plan, updated 11/25/18, showed the following: -[DIAGNOSES REDACTED]. -He/she had frequent falls and took medication that could increase his/her fall risk due to side effects. The resident fell while arranging things on his/her bed. Staff should arrange things for the resident to prevent falls. Staff should assist the resident with transfers and dressing. Keep personal items in easy reach, and provide clear pathways. Staff should offer to pull the bed linens down. Remind him/her not to transfer without assistance and keep call light within easy reach. Staff should educate the resident to use the call light. Make sure the wheelchair wheels were locked and grip socks were worn before transferring. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required limited assistance of one staff member with bed mobility and personal hygiene; -Required extensive assistance of one staff member with transfers, dressing and toileting; -Walking in room and in corridor did not occur; -Not steady, but able to stabilize without staff assistance with moving from seated to standing position and while moving on and off the toilet; -Not steady, only able to stabilize with staff assistance during surface-to-surface transfers (transfer between bed and chair or wheelchair); -Impaired functional limitation in range of motion of one upper extremity and both lower extremities; -Wheelchair mobility device; -Sustained two or more falls with no injury in the previous three months; -Sustained one fall with injury in the previous three months. Review of the resident's care plan conference summary, dated 12/12/18, showed the resident was at high risk for falls because he/she tried to do thing himself/herself and was too unsteady. Review of the resident's nurses notes, dated 1/26/19, showed at 1:50 A.M., the resident was found sitting on the bathroom floor in his/her room. The resident stated he/she was transferring himself/herself from the toilet to the wheelchair. While pulling up his/her pants, he/she lost balance and sat down on the floor. Review of the fall investigation, dated 1/26/19, showed the following: -The resident fell in the bathroom to the floor while transferring himself/herself from the toilet to the wheelchair and lost balance while pulling up his/her pant; -Intervention was to educate the resident to use the bathroom call light when needing to transfer. Review of the POS [REDACTED] -Staff knew the resident was at risk for falls and was at high risk for injury from falls related to age and brittle bones; -The resident was transferring himself/herself from the toilet to the wheelchair and trying to pull up his/her pants; -The underlying root cause of the fall was the resident lost his/her balance. Staff was unsure if the resident's wheelchair was locked; -Staff documented need to consult with physical therapy about mobility, positioning and seating to decrease the risk of additional falls; -Staff documented encourage the resident to use the call light for help with transfers to and from the bathroom as changes to the resident's care plan to decrease the risk of future falls; -Staff documented to remind the resident frequently to use the call light as interventions to decrease the risk of future falls; -Staff documented the resident was not very steady and was getting more forgetful as system problems to communicate to other departments or disciplines. Review of the resident's care plan, updated 1/26/19, showed the resident had frequent falls. Staff should educate the resident to use the bathroom call light when needing to transfer. (The intervention for staff to educate the resident on the use of the call light was identified on the resident's care plan prior to the resident's fall on 1/26/19.) Review of the resident's telephone orders, dated 1/30/19, showed an order fo (TR

Based on observation, interview and record review, the facility failed to maintain a system to monitor residents who used psychopharmacological medications to ensure attempts were made for gradual dose reductions (GDR) in an effort to reduce or discontinue these medications for seven residents (Resident #6, #9, #15, #19, #31, #37, and #40) in a review of 15 sampled residents. The facility failed to identify and treat two residents (Resident #15 and #19) who exhibited symptoms of potential side effects associated with the use of antipsychotic medications including tongue thrusts, rocking back and forth, tremors and chanting. The facility also failed to ensure three residents (Resident #15, #19, and #40) orders for as needed (PRN) [MEDICAL CONDITION] medications were limited to 14 days as required except if an attending physician believed that it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the as needed order. The facility census was 43. 1. Review of the facility policy Tapering Medications and Gradual Drug Dose Reduction dated (MONTH) 2007 showed the following: -After medications were ordered for a resident, the staff and practitioner should seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; -All medications should be considered for possible tapering. Tapering that was applicable to antipsychotic medications should be referred to as gradual dose reduction; -Resident who use antipsychotic drugs should receive gradual dose reductions and behavioral interventions, unless clinically contraindicated in an effort to discontinue these drugs; -Periodically, the staff and practitioner would review the continued relevance of each resident's medications; -The attending physician and staff would identify target symptoms for which a resident was receiving various medications. The staff would monitor for improvement in those target symptoms and provide the physician with that information; -The staff and practitioner would consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication was benefiting the resident; -The staff and practitioner would consider tapering under certain circumstances including when the resident's clinical condition had improved or stabilized, the underlying causes of the original target symptoms had resolved, non-pharmacological interventions including behavioral interventions had been effective in reducing symptoms or a resident's condition had not responded to treatment or had declined despite treatment; -The physician would review periodically whether current medications were still necessary in their current doses; -The physician would order appropriate tapering of medications as indicated; -When a medication was tapered or stopped the staff would closely monitor the resident and would inform the physician if there was a return or worsening of symptoms; -When a medication was tapered or stopped the staff and practitioner would document the rationale for any decisions to restart a medication or reverse a dose reduction; -Resident who use antipsychotic drugs should receive gradual dose reductions unless clinically contraindicated in an effort to discontinue the use of such drugs. Pertinent behavioral interventions would also be attempted; -Within the first year after a resident was admitted on an antipsychotic medication or after the resident was started on an antipsychotic medication the staff and practitioner should attempt a GDR in two separate quarters (with at least one month between the attempts) unless clinically contraindicated. After the first year, the facility should attempt a GDR at least annually, unless clinically contraindicated; -For any individual who was receiving an antipsychotic medication to treat behavioral symptoms related to dementia, the GDR may be considered clinically contraindicated if the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician had documented the clinical rationale for why any additional attempted dose reduction at the time would be likely to impair the resident's function or increase distressed behavior; -For any individual who was receiving an antipsychotic medication to treat a psychiatric disorder other than behavioral symptoms related dementia (for example, [MEDICAL CONDITION] bi-polar mania, or depression with psychotic features), the GDR may be considered contraindicated if the continued use was in accordance with relevant current standards of practice and the physician had documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder or the resident's target symptoms returned or worsened after either most recent attempt at a GDR within the facility and the physician had documented the clinical rational for why any additional attempted dose reduction at the time would be likely to impair the residents function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; -Attempted tapering of sedatives and hypnotics should be considered as a way to demonstrate whether the resident was benefiting from the medication or might benefit from a lower or less frequent dose. Tapering should be done consistent with the following: For as long as a resident remained on a sedative/hypnotic that was used routinely and beyond the manufacturer's recommendations for duration of use, the physician should attempt to taper the medication at least quarterly unless clinically contraindicated. Clinically contraindicated means the continued use was in accordance with relevant current standards of practice and the physician had documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder or the resident's target symptoms returned or worsened after either most recent attempt at a GDR within the facility and the physician had documented the clinical rationale for why any additional attempted dose reduction at the time would be likely to impair the residents function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. 2. Review of www.drugs.com showed the following: -[MEDICATION NAME][MEDICATION NAME]([MEDICATION NAME]) is an antipsychotic medication. It works by changing the effects of chemicals in the brain. It is a long-acting injection used to treat [MEDICAL CONDITION] and symptoms of [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]). Check with your physician immediately if any of the following side effects occur while taking [MEDICATION NAME]: trembling and shaking of the fingers and hands, lip smacking or puckering, restlessness or need to keep moving (severe). Oral [MEDICATION NAME]: The most commonly reported side effects included sedation, increased appetite, extrapyramidal symptoms, and parkinsonism (a neurological disorder resembling [MEDICAL CONDITION](a disorder of the central nervous system that affects movement, often including tremors)); -[MEDICATION NAME] ([MEDICATION NAME]) belongs to a group of drugs called benzodiazepines. [MEDICATION NAME] affects chemicals in the brain that may be unbalanced in people with anxiety. The sedative effects of [MEDICATION NAME] may last longer in older adults. Accidental falls are common in elderly patients who take benzodiazepines. [MEDICATION NAME] should be used for only a short time; -[MEDICATION NAME] (aripiprazole) is an antipsychotic medication. It works by changing the actions of chemicals in the brain. [MEDICATION NAME] is not approved for use in psychotic conditions related to dementia. [MEDICATION NAME] may increase the risk of death in older adults with dementia-related conditions. 3. Review of Resident #19's physician's orders sheet (POS), dated 6/1/18 to 6/30/18, showed the following: -The resident's [DIAGNOSES REDACTED]. -On 6/1/18, [MEDICATION NAME] (antipsychotic medication) 25 milligrams (mg) three times a day (TID); -On 6/18/18, [MEDICATION NAME] was discontinued and [MEDICATION NAME][MEDICATION NAME] mg was ordered to be administered every two weeks. Review of the resident's psychiatric evaluation, dated 7/6/18, showed the following: -The resident received [MEDICATION NAME] 25 mg intramuscularly (IM) every two weeks; -The resident was oriented to person; -The resident denied any suicidal or homicidal ideation; -The resident's mood was okay and his/her insight and judgement were limited; -Assessment revealed impulse control disorder (psychiatric disorder characterized by impulsivity/failure to resist temptation, an urge, or the inability to not speak on a thought); -The resident had a history of [REDACTED].>-Plan was to admit him/her to the senior behavioral health department and provide good care environment and medication management. Review of the resident's psychiatric evaluation, dated 7/7/18, showed the following: -The resident was referred to behavioral health for being agitated and trying to hit people; -He/she had worsening of his/her cognitive impairment and memory; -He/she was very irritable, had increased confusion and was unable to be redirected; -The resident's psychiatric history included a history of dementia. Review of the resident's Level One Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] of Related Condition (PASRR), dated 7/13/18, showed the following: -The resident was argumentative and he/she hit staff, yelled, and had hallucinations and delusions; -The resident was not diagnosed with [REDACTED]. -Primary reason for nursing home placement was [MEDICAL CONDITION] and dementia with behavioral disturbances. Review of the resident's undated [MEDICAL CONDITION] Disorder Diagnostic Tool, undated, provided by the facility, showed the following: -The resident was delusional; -The resident had hallucinations; -The resident had grossly disorganized behaviors; -The resident had negative symptoms such as affective flattening (a person's face appeared immobile and unresponsive, there was poor eye contact and reduced body language), alogia (characterized by brief, laconic, empty replies. Decreased fluency and productivity of speech which may arise from diminution of thoughts), and avolition (characterized by an inability to initiate and persist in goal directed activities). Review of the resident's Medication Administration Record [REDACTED] -[MEDICATION NAME][MEDICATION NAME] mg/2 ml administer 2 ml IM every two weeks. Staff documented medication administered on 7/3/18; -Resident had an order for [REDACTED].M.; -Resident had an order for [REDACTED]., 7:00 A.M., 11:00 A.M., 3:00 P.M., 7:00 P.M., and 11:00 P.M. Staff documented the resident received [MEDICATION NAME] 1 mg tablet as ordered on [DATE] to 7/4/19; -He/she did not receive [MEDICATION NAME] 1 mg tablet on 7/5/18 at 3:00 P.M., 7:00 P.M., or 11:00 P.M. (Staff did not document why the resident did not received the medication.) Record review showed the resident was transferred to an outside behavioral health facility on 7/6/18 and readmitted to the facility on [DATE]. Review of the resident's POS, dated (MONTH) (YEAR), showed the following: -On 8/1/18, the resident was readmitted with orders for [MEDICATION NAME] (antidepressant) 50 mg at bedtime (HS), and [MEDICATION NAME] 0.25 mg twice daily (BID), [MEDICATION NAME] 2 mg/ml; administer 1 ml injection IM every four hours PRN (as previously ordered on [DATE]), and [MEDICATION NAME][MEDICATION NAME] mg/2 ml administer 2 ml IM every 2 weeks (as previously ordered on [DATE]); -On 8/3/18, orders were obtained to administer [MEDICATION NAME] 0.25 mg BID for four days then discontinue and if needed, increase [MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be complete by facility staff, dated 8/8/18, showed the following: -His/her cognition was moderately impaired for making daily decisions; -He/she had behaviors such as physical aggression and verbal aggression toward others for one to three days during the look back period; -Behaviors interfered with the resident's care and social interaction; -The resident required extensive assistance from two staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -He/she did not walk; -He/she had limited range of motion (ROM) with one side of both upper and lower extremities; -He/she was frequently incontinent of bowel and bladder; -He/she weighed 193 pounds; -He/she received antipsychotic medications for the previous seven days; -He/she received antipsychotic medications on a routine basis; -A gradual dose reduction (GDR) was not attempted and/or documented as contraindicated by the physician. Review of the resident's care plan, dated 8/10/18, showed the following: -He/she had been having inappropriate behaviors; -He/she had a new order for [MEDICATION NAME] to be administered IM every two weeks and the dose could be increased if his/her behaviors continued; -He/she had struck another resident and would take his/her fist and swing into the air; -Staff was to tell him/her this was not appropriate and could not be tolerated; -He/she yelled at other residents and staff; -Staff was to provide a calm quiet environment when he/she became agitated; -He/she was paralyzed on his/her left side; -He/she had a stroke and his/her speech was slurred and he/she was hard of hearing; -He/she also had times of [MEDICAL CONDITION]; -Staff was to try to redirect him/her when he/she was in a [MEDICAL CONDITION] state and assist him/her from becoming upset. Review of the resident' POS, dated 8/1/18 to 8/30/18, showed on 8/24/18 [MEDICATION NAME][MEDICATION NAME] increased to 50 mg IM every two weeks. Review of the resident's medical record showed no documentation to support the reason for increasing the [MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks. Review of the resident's POS, dated 9/1/18 to 9/30/18, showed the following: -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (original order dated 8/1/18 and was open ended). Review of the resident's MAR, dated 9/1/18 to 9/30/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME] 1 ml PRN on 9/9/18 and 9/13/18; -Staff administered [MEDICATION NAME][MEDICATION NAME] mg IM on 9/12/18. No documentation the medication was administered on 9/26/18. Review of the resident's POS, dated 10/1/18 to 10/31/18, showed the following: -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (order was started on 8/1/18 and was open ended). Review of the resident's MAR, dated 10/1/18 to 10/31/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME] 1 ml PRN on 10/12/18; -The resident received [MEDICATION NAME][MEDICATION NAME] mg IM on 10/10/18 and 10/23/18. Review of the resident's medical record showed no evidence a gradual dose reduction of the resident's antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) (YEAR) or documentation to show a GDR would have been contraindicated. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/her cognition was moderately impaired for daily decision making; -He/she had no behaviors; -He/she required extensive assistance from one staff with bed mobility and personal hygiene; -He/she required extensive assistance from two staff with transfers and toileting; -His/her ROM was limited on one side of both upper and lower extremities; -He/she was frequently incontinent of bowel and bladder; -He/she weighed 188 pounds (five pounds loss since previous assessment on 8/8/18); -He/she received antipsychotic medications one day during the seven day look back period; -The resident received antidepressants and antianxiety medications seven times during the previous seven day look back period; -There was no GDR attempted and/or documented as contraindicated by the resident's physician. Review of the resident's POS, dated 11/1/18 to 11/30/18, showed the following orders: -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (order was started on 8/1/18 and was open ended). Review of the resident's MAR, dated 11/1/18 to 11/30/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME][MEDICATION NAME] mg IM on 11/6/18, 11/14/18, and 11/20/18; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 11/13/18, showed the pharmacist reviewed the resident's medications and did not address the resident's antipsychotic and [MEDICAL CONDITION] medications. Review of the resident's medical record showed no evidence a gradual dose reduction of the resident's antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) (YEAR), and no documentation to show a GDR would have been contraindicated. Review of the resident's POS, dated 12/1/18 to 12/31/18, showed the following: -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (order was started on 8/1/18 and was open ended). Review of the resident's MAR, dated 12/1/18 to 12/31/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME][MEDICATION NAME] mg IM on 12/4/18 and 12/18/18; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 12/11/18, showed the pharmacist reviewed the resident's medications and did not address the resident's antipsychotic and [MEDICAL CONDITION] medications. Review of the resident's medical record showed no evidence a gradual dose reduction of the resident's antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) (YEAR), and no documentation to show a GDR would have been contraindicated. Review of the resident's POS, dated 1/1/19 to 1/31/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 ml every four hour IM PRN (original order dated 8/1/18 and was open ended). Review of the resident's MAR, dated 1/1/19 to 1/31/19, showed the resident received [MEDICATION NAME] 50 mg at HS daily. Review of the resident's treatment administration record (TAR), dated 1/1/19 to 1/31/19, showed the following: -Staff administered [MEDICATION NAME][MEDICATION NAME] mg/2 ml to the resident on 1/1/19, 1/15/19, and 1/29/19; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 1/8/19, showed the pharmacist reviewed the resident's medications and did not address the resident's antipsychotic and [MEDICAL CONDITION] medications. Review of the resident's medical record showed no evidence a gradual dose reduction of the resident's antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) 2019, and no documentation to show a GDR would have been contraindicated. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/her cognition was moderately impaired for daily decision making; -He/she had no behaviors; -He/she required assistance of one staff with bed mobility, locomotion off of the unit, and personal hygiene; -He/she was dependent on staff for toilet use; -His/her ROM was limited on one side of both upper and lower extremities; -He/she was incontinent of bowel and bladder; -He/she weighed 170 pounds (18 pound weight loss since previous assessment on 11/8/18); -He/she did not receive antipsychotic medications one day during the seven day look back period; -He/she received antidepressant medications six times during the previous seven day look back period; -He/she did not receive antianxiety medications; -There was no GDR attempted and/or documented as contraindicated by the resident's physician. Review of the resident's POS, dated 2/1/19 to 2/28/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 ml every four hour (IM) PRN (original order dated 8/1/18 and was open ended). Review of the resident's MAR, dated 2/1/19 to 2/28/19, showed the resident received [MEDICATION NAME] 50 mg at HS daily. Review of the resident's TAR, dated 2/1/19 to 2/28/19, showed the following: -The resident received [MEDICATION NAME][MEDICATION NAME] mg/ml on 2/12/19 and 2/26/19. -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 2/12/19, showed the pharmacist reviewed the resident's medications and did not address the resident's antipsychotic and [MEDICAL CONDITION] medications. Review of the resident's medical record showed no evidence a gradual dose reduction of the resident's antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) 2019, and no documentation to show a GDR would have been contraindicated. Review of the resident's POS, dated 3/1/19 to 3//31/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 mg/ml every four hour (IM) PRN (original order dated 8/1/18 and was open ended). Review of the resident's MAR, dated 3/1/19 to 3/31/19, showed the resident received [MEDICATION NAME] 50 at HS daily. Review of the resident's TAR, dated 3/1/19 to 3/31/19, showed the following: -Staff documented the resident received [MEDICATION NAME][MEDICATION NAME] mg/2 ml on 3/12/19 and 3/25/19; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 3/18/19, showed the pharmacist reviewed the resident's medications and did not address the resident's antipsychotic and [MEDICAL CONDITION] medications. Review of the resident's medical record showed no evidence a gradual dose reduction of the resident's antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) 2019, and no documentation to show a GDR would have been contraindicated. Review of the resident's POS, dated 4/1/19 to 4/30/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 mg/ml every four hour (IM) PRN (original order dated 8/1/18 and was open ended). Review of the resident's MAR, dated 4/1/19 to 4/30/19, showed the resident received [MEDICATION NAME] 50 mg at HSdaily. Review of the resident's TAR, dated 4/1/19 to 4/30/19, showed the following: -The resident received [MEDICATION NAME][MEDICATION NAME] mg/2 ml IM on 4/9/19; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Observation on 4/09/19 at 11:16 A.M. showed the resident sat in his/her wheelchair. The resident was thrusting his/her tongue and had a tremor in his/her right arm and hand. Observation on 4/10/19 at 6:11 A.M. showed the resident lay in bed. The resident had a tremor in his/her right arm and the resident was repeatedly chanting. The resident's speech was unclear. Observation on 4/12/19 at 8:30 A.M. showed the resident had a tremor in his/her right hand. Review of the resident's medical record showed there was no documentation of the resident's face/mouth movements or tremors. During an interview on 4/12/19 at 10:20 A.M., Certified Nursing Assistant (CNA) B said he/she noticed the resident's tremor and mouth and tongue movement since he/she started at the facility in (MONTH) (YEAR). During an interview on 4/12/19 at 9:15 A.M., Certified Medication Technician (CMT) D said the following: -He/she was familiar with the resident; -Potential side effects of antipsychotic medications included behaviors the opposite of what was being treated, increased anxiety, decreased appetite, and decreased alertness; -The resident had not always had thrusting of his/her tongue and tremors, and had just developed those symptoms within the last six months. During an interview on 4/19/19 at 1:16 P.M., Licensed Practical Nurse (LPN) C said the following: -He/she was not aware of any assessment that assessed residents for involuntary movements at the facility; -He/she was familiar with these assessments, but they were not conducted at the facility. During an interview on 4/12/19 at 10:45 A.M., Registered Nurse (RN) C said the following: -Tardive dyskinesia (neurological disorder characterized by involuntary movements of the face and jaw) was a side effect of antipsychotic medications; -He/she thought the resident showed signs of tardive dyskinesia which started within the past two or three months; -The resident received injections (antipsychotic medication) every two weeks; -He/she thought the resident's tremor started approximately six or seven months ago ([MEDICATION NAME][MEDICATION NAME] increased on 8/24/18 and no GDR had been attempted); -Non-pharmacological approaches to try with the resident would include talking with him/her and reorienting him/her, but he/she did not think the resident had the mental capacity to understand. During an interview on 4/19/19 at 1:12 P.M., the MDS Coordinator said the following: -He/she was not aware of any kind of assessment that assessed involuntary movements; -He/she went by the nurse's assessment when completing MDSs, but would conduct his/her own assessment if he/she did not agree with other nurse's assessment; -He/she said the resident came to the facility after he/she had a stroke, but was unsure of the resident's symptoms of tardive dyskinesia and tremor. During an interview on 4/12/19 at 5:00 P.M., the Director of Nursing (DON) said the following: -Side effects of antipsychotic medications included tardive dyskinesia and shaking of the hands (tremors); -The resident had been on antipsychotic medications for over a year; -He/she thought the resident had shaking of his/her hand and symptoms of tardive dyskinesia prior to his/her admission to the facility; -He/she didn't believe a GDR had been attempted for the resident's [MEDICATION NAME]; -He/she expected staff to monitor for side effects that could be potentially caused by medication, and notify the physician when they were noticed; -There was no system for monitoring antipsychotic medication use; -Pharmacy recommendations were left on an envelope at the desk with the physician's name on it so he/she could review them and either accept or decline the pharmacist's recommendations; -He/she was not aware of the regulation regarding [MEDICATION NAME] PRN orders only being good for 14 days then the resident must be physically re-assessed for continued use; -He/she would expect nursing staff to remind the physician for the PRN [MEDICATION NAME] renewal when it was time (14 days after ordered); -He/she was not aware the pharmacist was not conducting the GDR recommendations like he/she was supposed to; -The current pharmacist had been there for the past year. During an interview on 4/18/19 at 3:10 P.M, the Administrator said the following: -He/she was unaware of any GDR attempts for the resident; -The resident's [MEDICATION NAME] dose had been increased not decreased at any time. During an interview on 4/12/19 at 2:15 P.M., the resident's physician said the following: -A side effect of antipsychotic medication use would include tardive dyskinesia and tremors; -He/she did not notice the resident's symptoms of tardive dyskinesia and tremors all of the time, but did once in a while; -He/she expected staff to assess and report any signs and symptoms of any potentially medication related side effects, such as tardive dyskinesia and tremors; -He/she was unable to recall if the resident's GDR had been individually assessed. 4. Review of Resident #15's psychiatric in-patient progress note, dated 10/24/18, showed the following: -He/she was admitted to the psychiatric unit because of increased confusion, aggression, and sexually inappropriate behaviors; -His/her medications included [MEDICATION NAME] ([MEDICATION NAME]) 0.125 mg BID; -Impression: Alzheimer's dementia late onset and impulse control disorder; -Plan: encouraged the use of environmental modifications and non-pharmacological approaches of management of behavioral and psychological symptoms and to monitor for medications side effects. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was admitted to the facility on [DATE]; -The resident's cognition was intact; -The resident had no behaviors or [MEDICAL CONDITION]; -The resident was independent with activities of daily living (ADLs); -The resident was continent of bowel and bladder; -The resident received antipsychotic medications seven days out of the previous seven-day look back period. Review of the resident's POS, dated 10/26/18 to 10/31/18, showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (antipsychotic medication) 2 mg at bedtime (HS); -[MEDICATION NAME] (sedative; antianxiety medication) 1 mg BID PRN for increased anxiety (order was open ended with no stop date); -[MEDICATION NAME] 0.125 mg BID for delusions and behavioral disturbances. Review of the resident's MAR, dated 10/26/18 to 10/31/18, showed the following: -The resident received [MEDICATION NAME] 1 mg PRN for increased anxiety on 10/26/18 and 10/27/18; -The resident received [MEDICATION NAME] 2 mg at HS daily; -The resident received [MEDICATION NAME] 0.125 mg BID for delusions and behavioral disturbances daily. Review of the resident's care plan, dated 11/7/18, showed the following: -The resident took medications that could cause side effects that could increase fall risk; -Monitor him/her after administering antidepressants and antianxiety medications for signs of drowsiness or dizziness; -The resident had [DIAGNOSES REDACTED]. -The resident loved to talk about keeping bee hives and the things bees did; -There was no evidence to show why the resident

Based on observation, interview, and record review, the facility failed to comprehensively assess pain, provide pain medication, intervene when the resident cried out and exhibited facial grimacing indicating pain, and failed to notify the physician when the resident refused wound treatments due to pain for one resident (Resident #9), in a review of 11 sampled residents. The facility census was 44. 1. Review of the facility's Pain Assessment and Management policy from Nursing Services Policy and Procedure Manuel dated October 2010, showed the following: -The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -The pain management program is based on a facility-wide commitment to resident comfort; -Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -It is important to recognize cognitive, cultural, familial or gender-specific influences on the resident's ability or willingness to verbalize pain; -Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. 2. Review of Resident #9's care plan last updated 4/13/17 showed the following: -[DIAGNOSES REDACTED]. -PAIN: Problem: I have pain that I rate as a five on a scale of one to ten; -Goal: I wish to have my pain controlled; -Approach: Talk to me about the importance of keeping off of my coccyx (tail bone) to help pain control. Talk with me about the importance of getting pain control even with the use of medications. Talk to the physician about the implementation of a pain medication. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/5/17, showed the following: -Cognitively intact; -Required extensive assist of one staff for bathing; -Required limited assist of one staff for toilet use and dressing; -Always continent of bowel and bladder; -Received scheduled pain medication; -Did not receive PRN (as needed), pain medication or non-medication intervention for pain; -No pain. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Start date 11/29/16, [MEDICATION NAME] (a non-steroidal anti-[MEDICAL CONDITION] used to treat pain and inflammation associated with arthritis) 75 milligrams (mg) twice a day; -Start date 11/7/16, [MEDICATION NAME] extra strength 500 mg one to two tabs every eight hours for pain and/or elevated temperature; -Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also preset as an intact or open/ruptured blister) bilateral buttocks. Orders per wound consulting company (a consulting company utilized by the facility that provides assessments and treatment orders for wounds and pressure ulcer on a weekly basis). Cleanse areas with normal saline, apply collagen powder (stimulates tissue growth in wounds) powder and then cover with moisture barrier twice a day and as needed with soiling. Review of the resident's May 2017 Treatment Administration Record (TAR) showed staff documented the resident refused his/her treatment to his/her buttocks twice a day on the following dates: -5/14/17 evening shift; -5/15/17 day and evening shift; -5/16/17 day and evening shift. There was no documentation to show the reason the resident refused his/her treatment for [REDACTED]. Review of the resident's May 2017 Medication Administration Record [REDACTED] -Staff administered [MEDICATION NAME] 75 mg one tablet at 7:00 A.M. and 8:00 P.M. for pain on 5/1/17 to 5/17/17; -Staff did not administer the resident's PRN [MEDICATION NAME] 5/1/17 to 5/17/17. Observation on 5/16/17 at 1:47 P.M. showed the following: -The resident sat in his/her recliner at a 90 degree angle with his/her feet on the floor; -Licensed Practical Nurse (LPN) L and LPN R entered the resident's room and asked the resident if they could observe his/her open wound on his/her buttocks; -LPN L and LPN R assisted the resident to a standing position; -The resident's right buttock had five moist open areas with red centers and white edges; -The resident's left buttock had six moist open areas with purple edges and red centers; -The wounds were draining a small amount of red tinged fluid onto the pad that was under the resident; -The resident made facial grimacing and said, It's raw and hurts when you touch it. The resident said if staff did not touch the wound it did not hurt. when staff did the treatment but did not hurt as long as staff was not touching the areas. Review of the resident's medical record showed no evidence staff assessed the resident's pain, administered PRN pain medication, or informed the physician and/or the nurse practitioner from Mobile Wound Solutions of the resident's refusal of treatment. During interview on 5/16/17 at 2:04 P.M., LPN L said the following: -The resident had complained of pain with the treatment in the past; -He/she did not offer the resident any PRN pain medication and wasn't sure if the resident had PRN pain medication; -He/she only did pain assessments on residents prior to giving PRN pain medication after the certified nursing assistant (CNA ) or certified medical technician (CMT) notified him/her a resident was in pain; -He/she had not called the resident's physician to notify him/her of the resident's refusal of treatment and or pain during treatment. During interview on 5/16/17 at 2:06 P.M., LPN R said the following: -The resident vocalized pain when staff touched the resident's buttocks for treatment; -The resident didn't have pain on his/her buttock if staff didn't touch it; -The resident had refused his/her treatments to the buttocks, but he/she wasn't sure why; -He/she had not given the resident any PRN pain medication prior to treatment or at any time; -He/she had not contacted the physician or the nurse practitioner regarding the resident's pain with the treatment and/or the resident's refusal for treatment. Observation on 5/17/17 at 11:15 A.M. showed the following: -LPN S/wound nurse, Nurse Practitioner (NP), and clinical nurse from the wound consulting company entered the resident's room; -LPN S/wound nurse assisted the resident to a standing position; -The wound consulting company's clinical nurse measured the resident's open areas on his/her buttocks; -The resident told the NP the treatment hurt him/her and he/she did not want the staff to do it anymore; -The NP educated the resident on the need for treatment and medications available to help with the pain; -Staff failed to offer the resident pain medication for his/her pain, after the resident vocalized pain. During interview on 5/17/17 at 11:25 A.M., the wound consulting company's NP said the following: -The facility had not contacted him/her regarding the resident's refusal of treatments; -Staff not providing the resident with his/her treatments could cause the resident's wounds to worsen and take longer to heal; -He/she would expect the facility to contact him/her if the resident was having pain and/or refusing treatments due to pain; -He/she was going to order the resident medication that the nurses would put on the open areas prior to treatment to help with the pain and numb the area. Review of the resident's physician order, dated 5/17/17, showed the following: -Tylenol 325 mg, two tablets every eight hours for pain. Do not exceed 3 grams in a 24-hour period; -[MEDICATION NAME] 5% gel (a numbing gel), staff to apply to the resident's buttocks 30 minutes prior to treatment twice a day. Review of the resident's May 2017 TAR showed the following: -[MEDICATION NAME] Gel 5% to be applied to the resident's bilateral buttocks 30 minutes prior to treatment in the A.M. and P.M.; -The staff did not apply the [MEDICATION NAME] gel to the resident's buttocks prior to treatment as ordered on [DATE] or 5/18/17; -Staff documented [MEDICATION NAME] 5% gel was not available from pharmacy; -The resident refused his/her treatment in the AM and PM on 5/17/17 and 5/18/17. Review of the resident's May 2017 MAR indicated [REDACTED] -Tylenol 325 mg, two tabs three times a day (every eight hours) for pain, do not exceed 3 grams in a 24-hour period; -No documentation staff administered Tylenol at 3:00 P.M. on 5/17/17 as ordered; -No documentation as to why the medication was not given. During interview 5/18/17 at 11:20 P.M., LPN S/wound nurse said the following: -The resident said his/her buttocks hurt with the treatment and he/she didn't want the treatment; -The resident was at risk for having pain; -He/she did not do a pain assessment on the resident prior to treatment; -He/she did not treat the resident for pain prior to treatment; -The [MEDICATION NAME] gel that was ordered on [DATE] by wound consulting company was not available because he/she had just ordered it from the pharmacy on 5/18/17. During interview on 5/18/17 at 5:12 P.M., the Director of Nursing (DON) said the following: -She expected staff to complete pain assessments on all residents shiftly; -The resident was at risk for pain; -She thought the resident was in extreme pain with the open wounds on his/her buttocks; -She had seen the resident's buttocks; -She was not aware staff was not providing PRN pain medication to the resident; -She expected staff to offer and administer PRN pain medication to residents in pain; -She expected staff to contact the resident's physician if the resident refused treatments.

Based on observation, interview and record review, the facility staff failed to identify risk factors indicating the resident was at a high risk for developing pressure ulcers, failed to complete a full body assessment on the resident when he/she acquired a pressure ulcer in the facility, failed to notify the resident's physician of his/her complaints of pain, failed to plan care to identify goals and interventions associated with skin breakdown and/or pressure ulcers, and failed to monitor the resident's skin on an ongoing basis in an attempt to prevent skin breakdown and other associated illnesses for one of three sampled residents (Resident #1) with skin issues. On [DATE], staff identified a pressure ulcer on the resident's coccyx. Facility staff failed to complete a full body assessment and follow-up with the physician following discovery of the resident's pressure ulcer. On [DATE], the resident presented to an area emergency room with complaints of shortness of breath and gluteal (buttock) pain. Upon physical examination at the hospital, the physician observed the resident had a large [MEDICAL CONDITION] (bacterial infection below the skin surface) over his/her sacrum (pelvic vertebrae area) and gluteal cleft (groove between the buttocks) extending into his/her perineal fold, an open area on the coccyx (tail bone) that had tunneled and an open area on the perineal fold. The open areas were draining purulent material. The resident also had significant [DIAGNOSES REDACTED]tous (redness of the skin) excoriated rashes under both breasts, which had an odor. The resident was admitted to the Intensive Care Unit of the hospital with [DIAGNOSES REDACTED]. Facility staff were not aware of the resident's skin condition at the time of the resident's transfer to the hospital. The facility census was 50. 1. Review of Resident #1's physician orders, dated [DATE], showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review showed the following order: -Cleanse open areas, Stage II pressure ulcers (full thickness tissue loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as a intact or open/ruptured blister), and skin tears with normal saline, apply [MEDICATION NAME] ointment (antibiotic ointment), and dress with OpSite (a clear dressing) as needed (PRN) daily for 14 days, then reevaluate. Review of the resident's admission nursing assessment, dated [DATE], showed staff assessed the resident as follows: -Had pain daily; -Rash on buttock and up the back; -General skin condition pale and dry; -Required assistance with showers, dressing and grooming; -Incontinent of bowel and bladder, "dribbles." Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed: -Moderately impaired cognitive skills for daily decision making; -Assist of one staff with bed mobility, transfers, ambulation, dressing, personal hygiene, bathing, and toileting; -Used a walker/wheelchair; -Continent of bowel and bladder; -Not at risk for pressure ulcers; -No untreated pressure ulcers; -No skin conditions. -Section M-Skin Conditions showed staff documented a formal assessment instrument such as the Braden or Norton scale assessment document was used to determine pressure ulcer risk for the resident. Review of the resident's medical record showed the record did not contain any information to show staff completed a pressure ulcer risk assessment on the resident as indicated in the MDS assessment. Review of the resident's admission MDS Care Area Assessments (CAAs) (identified by responses coded on the MDS that reflect conditions, symptoms, and other areas of concern and then provide a framework for developing the care plan specific to each resident), dated [DATE], showed pressure ulcers as a triggered care area due to assistance needed for toileting. Review showed staff documented on the CAA that the resident did not have any skin issues at that time. Review of the resident's care plan, dated [DATE], showed staff did not plan care with goals and interventions to address the resident's potential for impaired skin integrity or pressure ulcers as triggered by the CAAs, nor goals and interventions to prevent the development of skin breakdown and/or pressure ulcers. Review of the resident's daily nursing assessment, dated [DATE] through [DATE], showed staff documented: -On [DATE], the resident was incontinent of bowel, the resident complained of diarrhea, and unable to get to the bathroom in time; -On [DATE], the resident was incontinent of bowel once and had diarrhea once. The resident complained of diarrhea at times, being worse in the morning, and said he/she was incontinent this morning, but is better now; -On [DATE], the resident was incontinent of bowel once and had diarrhea twice; -On [DATE], the resident had complaints of loose stools and stomach cramps, wanted to go to bed; -On [DATE], the resident complained of stomach cramps and and was incontinent that morning. Review showed the resident's most recent plan of care, dated [DATE], did not contain any information regarding the resident's increased episodes of incontinence and diarrhea. Review of the resident's skin/wound log, dated [DATE], showed the wound nurse documented a newly identified facility acquired Stage II pressure ulcer on the resident's coccyx, which measured 0.6 centimeters (cm) x 0.5 cm and 0.1 cm depth. The wound nurse documented interventions to address the area included the application of ointments and dressings. The wound nurse documented he/she notified the resident's physician by fax on [DATE] of the resident's open area. Review showed the wound nurse did not document any information to show he/she conducted a full body assessment to assess for other skin conditions/open areas. Review of information faxed to the resident's physician regarding a change in condition, dated [DATE], showed the wound nurse documented the resident had an open area that measured approximately 0.5 cm x 0.5 cm on the coccyx. The wound nurse documented he/she applied normal saline, [MEDICATION NAME], and OpSite dressing to the area as needed, per the standing order dated [DATE]. Additionally, the wound nurse documented "please advise." Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of information faxed to the resident's physician regarding a change in condition, dated [DATE], showed staff documented the resident complained of hemorrhoid pain and swelling and requested medication for this. Review showed staff did not include any information about the resident's open area in the faxed notice. Review of the resident's daily nursing assessment dated [DATE] at 9:35 A.M., showed the resident complained of hemorrhoid pain and the resident's rectum appeared swollen. Review of the resident's physician orders, dated [DATE], showed the following orders: -Tucks medicated hemorrhoid wipes (for immediate relief from burning, itching and irritation associated with hemorrhoids)- apply 1 wipe three times daily to affected area, may keep at bedside; -Hemorrhoid cream to rectal area twice daily, as directed on package. Review of the resident's Certified Nurse Aide (CNA) care sheet (a document used by the CNAs to record identified care issues for the residents for their shift), dated [DATE], showed staff documented the resident had "a spot on his/her butt." Review of the resident's wound care measurement and assessment document, dated [DATE], showed staff documented the resident had a Stage II pressure ulcer on his/her coccyx with small amount of bloody drainage and no odor. Staff documented the resident complained of pain at the wound site and tenderness "to the touch." Review showed staff did not document any information to show they notified the resident's physician of the resident's complaints of pain and tenderness to the coccyx area, nor the bloody drainage from the open area. Review of the resident's plan of care, dated [DATE], showed staff did not update the plan of care regarding the resident's pressure ulcer identified on [DATE], nor the resident's complaints of pain and tenderness to the wound, and the bloody drainage from the coccyx area. Review of the resident's CNA care sheet, dated [DATE], showed staff did not document any information regarding skin issues. Review of the resident's Treatment Administration Record (TAR), dated [DATE], showed facility staff documented they administered the PRN treatment of [REDACTED]. Review of the resident's CNA care sheet, dated [DATE], showed staff did not document any information regarding skin issues. Review of the resident's CNA care sheet, dated [DATE], showed staff did not document any information regarding skin issues. Review of the resident's daily nursing assessment, dated [DATE], showed the resident complained of loose stools. Staff documented they administered Tylenol ES (extra strength) and would continue to monitor for a fever. Review of the resident's nurse's notes, dated [DATE] at 12:00 P.M., showed staff documented the resident remained in bed all morning with complaints of hemorrhoid pain. Staff documented they administered pain medication for the resident's hemorrhoids and Tylenol ([MEDICATION NAME]) given. The resident said he/she did not want to eat lunch and did not want to go to his/her family member's graduation. Staff documented they planned to monitor the resident. Review showed staff did not document any information to show they notified the resident's physician of the resident's continued complaints of pain and refusal to eat. Review of the resident's MAR, dated [DATE], showed staff documented they administered the PRN order for normal saline, [MEDICATION NAME], and OpSite to the open area to the coccyx . Review of the resident's nurse' notes, dated [DATE] at 9:15 A.M., showed staff documented the resident had diminished lung sounds, "his/her face was puffy", the resident's legs were [MEDICAL CONDITION], and he/she complained of hurting all over. Staff documented they applied oxygen at two liters per nasal cannula and administered Tylenol to the resident. Staff documented the resident "rested quietly." Staff documented they faxed the physician. Staff then documented the resident complained of arm pain and "not feeling well" at 11:35 A.M. Staff notified the nurse practitioner at 11:40 A.M. and received new orders to send the resident to the emergency room . The resident left the facility by ambulance at 11:45 A.M. Review of the resident's change in condition report faxed to the resident's physician, dated [DATE] at 6:30 A.M., showed staff documented the resident complained of dyspnea (shortness of breath) with transfers, the resident's lung sounds were diminished with rhonchi (coarse rattling sounds), and face is puffy but both lower extremities show no sign of [MEDICAL CONDITION]. Staff documented they will continue to monitor, and "please advise." Review of the resident's condition change report faxed to the resident's physician, dated [DATE] at 7:00 A.M., showed staff documented that when staff were applying hemorrhoid cream this morning, RN B noted the resident's right perineal fold was swollen, red, extremely tender, and hard upon palpation. The resident complained of pain upon light touch. Staff documented they did not note any drainage or open area. Review of the resident's daily nursing assessment, dated [DATE], showed staff documented: -At 9:15 A.M., the resident's lungs were diminished, face puffy and was complaining of hurting all over. Legs with dependent [MEDICAL CONDITION]. Oxygen on at two liters per nasal cannula. Tylenol giver per medication technician. Now resting quietly. Faxed the physician; -At 11:35 A.M., resident still complaining of right arm pain and not feeling well; -At 11:40 A.M., called nurse practitioner, new orders received and noted; -At 11:45 A.M., ambulance arrived for transport. Review of the resident's history and physical from an area hospital, dated [DATE], showed on [DATE] emergency room (ER) staff identified a large area of [MEDICAL CONDITION] that was fluctuant (moveable) in nature over the resident's sacrum, gluteal cleft, and extending into his/her perineal fold. Additionally, ER staff identified an open area over the resident's coccyx that appeared to be approximately 1 cm x 1 cm with tunneling of an undetermined depth. ER staff documented the sacral wound ([MEDICAL CONDITION]) measured greater than 15 cm in length and appeared to be approximately 5 to 10 cm wide and expanded over the gluteal fold. Additionally, ER staff identified open areas on the resident's perineal folds that drained purulent material (any product of inflammation that contains pus). The resident had [DIAGNOSES REDACTED]tous (redness of the skin) rashes underneath both of his/her breasts, over his/her left eye, and in his/her groin. The hospital physician contacted the facility and spoke to a "ward clerk and a nurse", who said there was not any documentation in the resident's record regarding a sacral wound. Review showed facility staff told the hospital physician that they assessed an area on the resident's perineal fold to be tender, hard, swollen and red that morning. Facility staff said they treated the resident for hemorrhoids for the past three days with Tucks cream. The ward clerk and nurse at the facility said the resident reported several times that this was very painful. The hospital physician contacted the resident's primary care physician who said he/she last saw the resident about a month ago at the facility and the resident did not have any signs of [DIAGNOSES REDACTED] over the sacrum or any breakdown at that time. The primary care physician said he/she had not been contacted since that time. Review showed the resident was admitted to the Intensive Care Unit (ICU) of the hospital with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 3:30 P.M., CNA A said: -He/she gave the resident a shower on [DATE] and did not recall any redness under the resident's breasts, but did make sure to put powder under them because the resident would get redness in the breast creases; -He/she thought the resident's bottom looked okay on this date; -About a week before the resident went to the hospital, CNA A noted an area on the resident's bottom, but was not sure if the area was open or not; -CNA A reported the redness under the resident's breasts in the past; -The resident had a personal alarm that constantly alarmed because the resident tried to go to the bathroom by him/herself; -The resident had been having a lot of diarrhea in the two weeks prior to going to the hospital. During an interview on [DATE] at 2:00 P.M., CNA D said he/she noticed the resident's bottom to be red prior to being sent to the hospital. He/she put paste on it and reported this to the charge nurse. The charge nurse looked at the resident's hemorrhoids and bottom. During an interview on [DATE] at 2:15 P.M., CNA F said he/she assisted the resident to the bathroom, and the resident usually just urinated. CNA F did not look at the resident's bottom when the resident only urinated. During an interview on [DATE] at 3:09 P.M., CNA E said about three days before the resident went to the hospital, CNA E and another CNA noted the resident's bottom was red. CNA E reported this to the charge nurse and the charge nurse said he/she would look it. During an interview on [DATE] at 11:23 A.M., Registered Nurse (RN) B (the facility treatment nurse) said he/she thought someone on the night shift reported to him/her on [DATE] that the resident had an open area. RN B assessed the resident's open area on the coccyx, but did not assess any other areas of the resident's skin. RN B said when CNAs report open areas on a resident, he/she does not do a full body skin assessment, and only assesses the area of concern as reported by the CNA. During an interview on [DATE] at 1:00 P.M. RN B said he/she faxed a change in condition report to the resident's physician on [DATE], but RN B didn't think he/she ever received a response from the physician. RN B said [DATE] was the only time he/she notified the physician about the resident's pressure ulcer. He/she said once a fax was sent, it is placed in a folder and "once in a while" staff go through them (the folders). During an interview on [DATE] at 11:44 A.M., the DON said she expected staff to follow up with faxes to physicians "within a day or so" to ensure they received it and/or find out why the facility had not received a response. During an interview on [DATE] at 11:49 A.M., RN C said he/she observed the resident's bottom on [DATE] and noted an opsite dressing covering an area. RN C said he/she did not remove the dressing and only observed the rectal area. RN C said he/she could not recall how the resident's skin looked. RN C said he/she did not look at the perineal area because he/she assumed the wound nurse had assessed that area. During an interview on [DATE] at 12:55 P.M., RN C said he/she completed daily assessments of the resident, but did not go in-depth with skin assessments because that is what the treatment nurse did. RN C did not "strip the residents down" and look at their skin but did a "visual of them." RN C said he/she relied on the CNAs to report skin issues. RN C thought the CNAs were putting [MEDICATION NAME] (antibiotic) powder on the resident. During an interview on [DATE] at 1:45 P.M., RN C said the resident had been having loose stools for several days prior to sending a fax to the physician on [DATE]. During an interview on [DATE] at 11:30 A.M., the Director of Nursing (DON) said the facility used the Braden scale assessment form to determine residents' risk for the development of pressure ulcers, but it had not been used consistently. The DON said the facility utilized the MDS to determine if residents were at risk for pressure ulcers. During an interview on [DATE] at 11:30 A.M., the DON said the resident was not assessed as high risk for the development of pressure ulcers because the resident did not have any pressure ulcers when he/she came to the facility and the resident only needed limited assistance with positioning. The DON said when staff assessed a resident as high risk for the development of pressure ulcers, it was addressed in the resident's care plan. The DON said she expected CNAs to report any observations of skin issues to the charge nurse. During an interview on [DATE] at 3:00 P.M., the DON said the resident had a history of [REDACTED]. The DON was not aware of this until after the resident went to the hospital, when the resident's family informed the DON of this. During an interview on [DATE] at 3:00 P.M., the DON said the facility did not have an actual outline for a pressure ulcer prevention program, but they used the admission assessment, the MDS assessment, as well as individual needs of the residents. The DON said staff are directed to assess each resident's skin during showers and when providing care to residents. During an interview on [DATE] at 3:40 P.M., the Administrator said the facility did not have a policy to address pressure ulcer prevention. During an interview on [DATE] at 11:22 A.M., the Administrator said she expected staff to monitor each resident's skin during care, activities, etc, and report skin issues to the appropriate staff. During a telephone interview on [DATE] at 8:45 A.M., Physician A (the resident's primary care physician) said he/she was not notified of the resident's pressure ulcer. Physician A said he/she expected facility staff to contact him/her regarding the pressure ulcer. Physician A last saw the resident on [DATE] and examined the resident, but he/she only had slight redness (buttocks/perineal area). Physician A said the resident had abscesses in the past. Physician A said the resident should be considered high risk for the development of pressure ulcers due to a history of abscesses, his/her nutritional status, and chronic [MEDICAL CONDITION]. Physician A said the facility should have put interventions in place to address the resident's risk of pressure ulcers/other skin conditions beyond the facility protocol of cleansing with normal saline, applying [MEDICATION NAME] and a dressing. During a telephone interview on [DATE] at 3:35 P.M., Physician A said he/she would have given different treatment orders for this resident had he/she been notified of the resident's pressure ulcer identified on [DATE]. During an interview on [DATE] at 1:48 P.M., Physician B (the hospital physician who evaluated the resident when the resident was admitted to the hospital) said the abscess on the resident's perineal fold and the rashes under his/her breasts would not have developed overnight, but "would have taken about a week to develop." Physician B said the area on the resident's sacrum was a result of pressure and infected fecal material. Review of the resident's record of death, filed [DATE], showed the resident died at a local hospital on [DATE] with the underlying cause of death to be: -Hypoxemic [MEDICAL CONDITION]; -Pneumonia; -Sepsis. MO 616 Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began head to toe assessments of each resident using a Braden scale (assessment form for pressure ulcers that determines risk factors for pressure ulcers) and body inspection forms completed by licensed staff. The facility began implementation of contacting physicians with any changes in residents' skin condition and with orders followed upon receipt. The facility also began implementation of updating resident care plans accordingly to identify skin issues. The facility began inservicing staff on identification of factors relating to skin breakdown as well as what to look for and how to complete skin assessments appropriately. The facility began inservicing CNAs on who and when to notify of changes in skin condition. The facility devised a CNA skin assessment report that CNAs complete during each shower and/or bathing. The facility also began implementation of obtaining accurate MDS information. The facility had not completed the corrective actions including inservicing education, skin assessments, physician notification, care planning and MDS information. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to ensure residents with pressure sores received the necessary care and services to promote healing, to prevent the development of newly acquired pressure ulcers, and to prevent infection for two residents (Residents #1 and #4) out of 13 sampled residents. The facility identified four residents with pressure ulcers. The facility census was 49. 1. Review of Resident #1's physician progress notes [REDACTED]. -On 11/01/11, nursing requested see resident today due to worsening of lesion to right lower back and right posterior thigh; -At site of former ecchymotic (dark purplish/red in color) area, there was a reddish area with open ulcer in center, yellow base; -Open area to posterior right thigh deeper, larger than previously, will get C&S (culture and sensitivity) of both wounds; -Needs to stay out of wheelchair for long periods. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 01/19/12, showed the following: -Was cognitively intact; -Required extensive assistance with two persons plus assist with bed mobility, transfers, dressing, and toileting; -Impairment on both sides upper extremities; -Had an indwelling catheter; -Was at risk for pressure sores; -Had one unhealed pressure ulcer at a Stage I (an observable, pressure related altercation of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues) or higher; -Had one Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer with oldest date of 10/24/11 with granulation tissue; -Was present on prior assessment. Review of the resident's Care Area Assessment (CAA) dated 01/19/12, showed the following: Category: Urinary incontinence/Pressure areas; -Resident is incontinent frequently staff reports; -Has an area to the right posterior thigh that is due to friction of getting in and out of bed, it gets sore; -Daily treatment is done to this and monitored during routine care, showers and treatments; -No other skin issues at present. Review of the resident's condition report, (a report staff faxed to the resident's physician), showed the following: -On 01/31/12, may we dc (discontinue) order to cleanse the lower back right side apply [MEDICATION NAME], it is healed, and also order to cleanse right post thigh, with [MEDICATION NAME], also healed. The physician replied, yes and signed the order on 02/01/12; -On 02/14/12, the resident has open areas on back of thigh that are bleeding. Do you want a treatment started to this area?; -The physician replied and ordered to cleanse with sterile NS (normal saline) or water every day, then apply [MEDICATION NAME] (an antibiotic) to open areas, cover with opsite (a clear covering), change dressing daily and PRN (as needed) and signed the order on 02/14/12. Review of the resident's physician's orders [REDACTED]. -Cleanse right posterior thigh with NS or H2O (water), apply [MEDICATION NAME] to open areas, cover with opsite for 14 days and reevaluate. Review of the resident's MDS, dated [DATE], showed the following: -Was cognitively intact; -Required extensive assistance with two persons plus assist with bed mobility, transfers, dressing, and toileting; -Impairment on both sides upper extremities; -Had an indwelling catheter; -Was at risk for pressure sores; -Had no unhealed pressure ulcers; -No pressure ulcers were present on prior assessment (MDS dated [DATE], stated resident had pressure ulcers). Review of the resident's physician order [REDACTED]. Diagnoses: [REDACTED]. -To be out of w/c (wheelchair) for two hours or more before and after lunch to keep pressure off posterior thigh wound; -At least twice a day, through the day, was to lay down in bed to get pressure off ulcers right thigh; -Cleanse right posterior thigh with NS (normal saline) or water, apply [MEDICATION NAME] (an antibiotic ointment) to OA (open area), and cover with opsite for 14 days then reevaluate (ordered 02/14/12). Review of the resident's care plan reviewed 04/16/12, showed the following: -Category: ADL's (activities of daily living); -I need assistance to sit up and get out of bed with bed mobility; -I need extensive assistance with mobility, transfers, ambulation in room, dressing, toilet, hygiene and total assist with bathing; -I have incontinent spells but can alert staff to when needs to use toilet. -Category: Pressure ulcers; -Problem: At risk for skin breakdown due to [MEDICAL CONDITION], limited ability to reposition self, and incontinent episodes. -Approaches: Monitor skin for changes in skin integrity; -Provide treatments as ordered per physician; -Keep linens clean, dry, and wrinkle free; -Assist with position changes while in bed; -Good peri care with each incontinent episode and PRN (as needed); -Encourage rest periods during the day to prevent areas of pressure after being up in wheelchair for extended periods. Review of the resident's treatment administration record (TAR) dated 04/01 thru 04/30/12, showed the following: -Staff failed to record the treatment had been completed to the resident's right posterior thigh on 04/01, 04/15, 04/18, 04/19, 04/21, 04/23, 04/24, 04/27, 04/28, 04/29, and 04/30/12; -The only documentation staff had recorded on the back of the TAR was the following: -On 04/09/12 (untimed) the resident said he/she was not turning over; -On 04/10/12 (untimed) changed resident's catheter d/t (due to) was leaking and there were only two days till change date; -Right post thigh bloody, dressing applied (there was no assessment or documentation of the wound measurements, wound bed, whether there were any signs of infection); -On 04/13/12 (untimed) #1 area (on the human diagram) showed the #1 area was on the resident's right lower front calf area) noted today from catheter tubing in bed rubbed against right leg and caused tear. (Staff did not note the size of the skin tear, nor describe the appearance of the skin tear); -On 04/26/12 (untimed) #2 area (on the human diagram) showed the #2 area was located on the resident's right inner posterior thigh) abraised (a scraping away of a portion of skin) approximately 6 cm (centimeters) by 7 cm, red skin peeling, skin around area with foul odor noted. Applied barrier cream to coccyx and placed an opsite over half of #3 area (on the human diagram), staff failed to list a #3 area); -There was no further documentation on the back of the TAR. Review of the resident's nurses notes for April, 2012, showed no documentation about the resident's skin condition. Review of the resident's treatment administration record (TAR) dated 05/01 thru 05/31/12, showed the following: Cleanse the right posterior thigh with normal saline or water, apply [MEDICATION NAME] to open areas and cover with opsite for 14 days then reevaluate and PRN; -Staff failed to record the treatment had been completed to the resident's right posterior thigh on 05/01 through 05/04, 05/07, 05/09, 05/10, 05/11, 05/13, 05/14, 05/16, 05/17, 05/18, 05/20 through 05/23, 05/24 through 05/27, and 05/30/12; -The only documentation staff had recorded on the back of the TAR regarding the resident's skin issues were the following: -Under describe type of problem: Staff recorded an open area right posterior thigh; -On 05/12/12, (untimed) wound to posterior thigh left open to air; -On 05/17/12, (untimed) [MEDICATION NAME] applied to right posterior thigh d/t tender, pink, slightly open, and doctor updated. (There were no measurements, no staging of the area). Review of the resident's condition report showed the following: -On 05/17/12, the resident had a light pink tender area posterior left thigh where thigh touches chair. [MEDICATION NAME] applied, may we continue this treatment and change every three days; -The physician replied okay. Review of the resident's TAR continued in May, 2012, showed the following: -Treatment on TAR showed cleanse right posterior thigh with NS and water, apply [MEDICATION NAME] to open areas, cover with opsite for 14 days and reevaluate and PRN. -On 05/28/12, (untimed) post thigh 2 (two) open areas/bloody, [MEDICATION NAME] (a non stick dressing) and [MEDICATION NAME] applied; [MEDICATION NAME] applied. (Staff did not measure the open areas, describe the wound bed, whether there were any exudates, odor, nor Stage); -On 05/29/12, (untimed) Right posterior thigh 2 open areas with red drainage, [MEDICATION NAME] and [MEDICATION NAME] applied; -On 05/31/12 (untimed) Right posterior thigh looking better, pink areas, but red open areas smaller now and less drainage. (Staff failed to stage, measure and record the open areas, describe the wound bed, if there were any signs and symptoms of infection, and if there were any odors and failed to record the size of the red area that was covered with the [MEDICATION NAME]). (Staff did not change the TAR to reflect the new order of [MEDICATION NAME] to be applied to the left thigh that was received on 05/17/12 as ordered by the physician, nor did the TAR show the [MEDICATION NAME] was changed every three days as ordered). Review of the resident's nurses notes for May, 2012, showed no documentation regarding the resident's skin condition, or that staff had discussed with the resident the possible outcome(s) from prolonged periods of sitting in a chair. Review of the resident's physician orders [REDACTED]. -To be out of w/c (wheelchair) for two hours or more before and after lunch to keep pressure off posterior thigh wound; -At least twice a day, thru the day, was to lay down in bed to get pressure off ulcers right thigh; -Cleanse right posterior thigh with NS (normal saline) or water, apply [MEDICATION NAME] (an antibiotic ointment) to OA (open area), and cover with opsite for 14 days then reevaluate (ordered 02/14/12. The physician's orders [REDACTED]. Review of the resident's TAR for June, 2012, showed the following: -Treatment on TAR showed cleanse right posterior thigh with NS and water, apply [MEDICATION NAME] to open areas, cover with opsite for 14 days and reevaluate and PRN; -There was no treatment listed with the [MEDICATION NAME] to the resident's left thigh as ordered; -Staff recorded the resident's dressing change was completed on 06/04 and 06/07/12; -The other days in the month were left blank; -The back of the TAR was completely blank. Review of the resident's nurses notes for June, 2012, showed no documentation regarding the resident's skin condition, or that staff had discussed with the resident the possible outcome(s) from sitting for long periods in a chair. Observation showed the following: -On 06/11/12 at 11:15 A.M., the resident was sitting up in his/her wheelchair; -At 12:50 P.M., the resident was sitting up in his/her wheelchair; -At 1:30 P.M., the resident remained sitting up in his/her wheelchair; -At 2:00 P.M., the resident remained sitting up in his/her wheelchair; -At 3:00 P.M., the resident remained sitting up in his/her wheelchair; -At 4:00 P.M., the resident remained sitting up in his/her wheelchair; -At 5:07 P.M., the resident was sitting up in his/her wheelchair eating his/her supper meal; -On 06/12/12, the resident was in his/her room, sitting up in his/her wheelchair eating breakfast; -At 9:00 A.M., the resident was sitting up in his/her wheelchair; -At 10:00 A.M., the resident went to the group interview in his/her wheelchair; -At 1:30 P.M., the resident turned on his/her call light, resident remained sitting up in his/her wheelchair and told staff he/she needed to go to the bathroom. During interview on 06/11/12 at 5:05 P.M. CNA P said the resident knows when he/she has to have a bowel movement; -Has had a catheter for several months; -Has open area on his/her right buttock; -Refuses to lie down, likes to sit up. During interview on 06/14/12 at 9:00 A.M., Licensed Practical Nurse (LPN) G said the following: -Had done treatments on the resident; -Resident had an open area on the inner right under the buttock cheek; -Looked at the TAR and go do the treatment; -Has never done a skin assessment on the resident; -Said staff should measure the size length, width and depth, stage them; -Would stage the resident's open area as a Stage II, due to the top layer of skin is off, not real deep, it does bleed and painful; -Record any drainage, the wound bed, color, surrounding skin color; -The open area was approximately a good 3 to 4 cm in length with odd shape; -Saw the open area last night; -He/she had never written anything down about the pressure sore; -The surrounding skin was mottled and dark with patches of white, that was as big as the palm of a hand; -Resident has [MEDICAL CONDITION] and legs are black, skin has dark patches, did not look infected; -He/she had not educated the resident on the importance of turning and repositioning and getting off his/her bottom; -The resident used a wheelchair and the only time he/she was in bed was when he/she was put to bed at night. During interview on 06/13/12 at 6:45 A.M., LPN I said the following: -When he/she assessed the resident's skin on 06/13/12, there was no dressing on the resident's open area; -Placed [MEDICATION NAME] and opsite on it; -Treatment was daily and as needed; -Does dressing and treatments on nights if needed; -Day or evening shifts usually measures the wounds; -The open area was pressure and feels it is more a Stage III; -He/she didn't know how to Stage a pressure sore, that it was more than the first layer of skin missing, and pink tissue; -Outside skin had white scar tissue around it; -The open area was on the resident's right posterior upper leg, below the buttock that measured 1 cm x 0.5 cm x 0.2 cm with deep pink tissue. 2. Review of Resident #4's Braden Scale (a standardized assessment too used for predicting pressure sore risk) dated 01/10/12, showed the following: Sensory Perception -Slightly limited - score of three; Moisture -Constantly moist skin- score of one; Activity -Bedfast (confined to bed)-score of one; Mobility -Very limited-Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently; -Score of two; Nutrition -Very poor-Never eats a complete meal. Rarely eats more than a third of any food offered. Takes fluid poorly; -Score of one; Friction and Shear -Problem-Requires moderate to maximum assistance in moving; -Complete lifting without sliding against sheets is impossible; -Required frequent repositioning; -Score of one; Total score was nine. Nine or below is considered Severe Risk. Review of the resident's care plan dated 01/26/12, showed the following: -I am at risk for skin breakdown and pressure ulcers due to my diabetes and immobility; -I have a surgical wound to my right heel and came to the facility with a pressure ulcer to my left heel; -Please report any new skin conditions to my charge nurse; -Make sure treatments are being done and the condition of my heels is documented on the back of the Treatment Administration Record (TAR) with each change; -Keep heel protectors on bilateral so they do not touch the bed; -Keep my feet elevated due to the [MEDICAL CONDITION] in my legs; -Support and elevate my arms/hands on pillows due to [MEDICAL CONDITION]; -I have generalized [MEDICAL CONDITION]; -Turn me often and keep me clean and dry; -I am not a candidate for a shower chair or bed. Review of the physician's progress note dated 04/05/12, showed the following: -Bilateral heel suspension boots; -[MEDICATION NAME] Santyl/[MEDICATION NAME] powder to bilateral heels. Cover with gauze secure with Kerlix. Change daily; -[MEDICATION NAME] Santyl/[MEDICATION NAME] powder to left hip; -Continue to float heels. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 04/12/12, showed the following: -Brief Mental Status (BIMS) was a 15 (13-15 was cognitively intact); -The resident required extensive assist of two staff with bed mobility, transfers, dressing, and bathing; -The resident had a urinary catheter; -He/she was frequently incontinent of bowel movements; Skin and ulcer treatment -Pressure reducing device for bed; -Applications of dressings to feet; (Turning and repositioning was not marked on the MDS). Review of the Physician order [REDACTED]. Diagnoses -[MEDICAL CONDITION] and abcess leg except foot; -[MEDICAL CONDITION]; -Diabetes; Orders -Sit in chair three times daily with meals; Treatments -Collagenenase Santyl/[MEDICATION NAME] powder left hip wound. Change every day. Cover with gauze and adhesive dressing; -Bilateral heel dressings change daily. Cleanse with skin cleanser. Apply Collagense to 4 x 4, then [MEDICATION NAME] powder, then place on wound. Kling to hold in place. Review of the physician's progress note dated 05/10/12, showed the following: -Multiple pressure wounds; -Left heel Stage III; ( Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III varies by anatomical location. Bone/tendon is not visible or directly palpable); -Right heel Stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Stage IV can extend into muscle and/or supporting structures making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable). -Left trochanter Stage III (not noted as present on the prior MDS dated [DATE] or included on the most recent care plan; -Sacrum wound; -Four pressure ulcers; -Severe debility with contracture; -Obesity; Plan -May sit in the chair three times daily with meals; -Keep good posture- No slouching; -Continue current wound care and dressings; -Dietary consult and nutrition assessment. Review of the Treatment Administration record (TAR) dated May, 2012, showed the following: -On 05/02/12, the buttock area was bright red. Skin was shedding. Stage II open area below the coccyx. The resident complained of burning pain to the area; -On 05/04/12, the buttocks area was red/macerated; -On 05/08/12, heels opened bilaterally with small amount of green drainage on each. The hip wound was open and had green drainage; -On 05/11/12, had bilateral heel dressings changed to wounds. Moderate amount of green drainage noted to old dressings. Resident reports pain to left heel when touched; -On 05/13/12, the dressing to bilateral heels was changed. Both had small amount green drainage. Left hip dressing changed. Open with green drainage; -On 05/15/12, the right heel wound bed appeared to have white slough with slight pink around wounds. This appeared to be a Stage III. Left heel dressing changed. Left hip dressing changed appeared to be a Stage III; -On 05/16/12, the dressing to left hip was changed. Tan color drainage noted. Right heel dressing changed. Left heel dressing changed moderate amount light green/tan drainage, edge of open area posterior inner aspect white slough noted also black tissue present. Warm, red, open area on top side of left foot noted. Cleansed with Normal Saline and [MEDICATION NAME] applied; -On 05/21/12, had an open area on left hip approximate size of a quarter. Has red outer edges with yellow center; -On 05/24/12, the dressing was changed to the right heel . Small amount of green drainage on the old dressing. Left heel had a green drainage and green center; On 05/31/12, the left heel had yellow center. The right heel had black edges with red/yellow drainage. Review of the TAR dated June, 2012, showed the following: -On 06/04/12, treatment was completed. All granulation tissue was present. Small amount of drainage; -On 06/06/12, dressing to right heel red with drainage. Yellow drainage in the center; -On 06/07/12, the left hip wound dressing was changed. Slough present; -On 06/07/12, the right heel dressing was changed. Yellowish green drainage and slough noted. Right edge of wound bed and part of the left edges was black hardened tissue. Left heel dressing changed. Yellow slough present; On 06/09/12, the right heel ulcer measured 6 cm x 6 cm the center was pink with small amount of yellow drainage. On the top right area 4.5 cm x 2 cm black, scabbed area. The left heel was 2 cm x 2 cm with 1 cm x 1 cm yellow center. Left trochanter wound measured 2 cm x 1.5 cm red on outer edge with yellow center; On 06/11 12, dressings changed to the bilateral heels. Right heel had stringy red/yellow drainage and a foul odor. Left heel had a yellow crusty center; Review of the report sheet dated 06/07/12 showed the following: -Areas on the buttocks worse; -Open and bleeding. Observation on 06/11/12 at 3:30 P.M. showed the resident did not have a pressure relief mattress on the bed. During interview on 06/11/12 at 3:35 P.M., CNA W said the following: -The resident did not like the air mattress that had been on the bed; -Currently had a standard mattress on his/her bed; -The resident was in the bed most of the time; -The resident gets up once in awhile. Observation on 06/11/12 at 3:37 P.M., showed the following: -CNA AA and CNA W turned the resident to his/her right side; -The resident had a Stage II (Partial thickness loss of dermis presenting as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising). pressure ulcer approximately 1 cm x 0.5 cm; -CNA AA lifted the resident's left buttock: -The resident had a Stage II pressure ulcer approximately 2.5 cm x 1 cm. During interview on 06/11/12 at 3:40 P.M., the resident said the pressure ulcers on the buttocks were painful and when he/she asked staff to get him/her up the staff did not do so. During interview on 06/11/12 at 4:25 P.M., the DON said the following: -The Registered Nurse (RN) does the assessments of pressure ulcers; -The Licensed Practical Nurse (LPN) was responsible for the dressing changes; -Pressure ulcers should be measured at least weekly; -The licensed nurses have access to information on measuring wounds and staging wounds in the treatment book. During interview on 06/11/12 at 4:30 P.M., LPN G said the following: -The pressure ulcers to the buttocks were present when he/she worked on 06/08/12; -The pressure ulcers were not documented at that time; -The physician was not notified; -He/she was unsure how to Stage the pressure ulcers. During interview on 06/11/12 at 5:15 P.M., CNA F said the resident was repositioned every two hours. During interview on 06/12/12 at 8:18 A.M., the MDS coordinator said the licensed staff that do the treatments was responsible for staging pressure ulcers. He/she said was unaware of any open areas on the residents skin except for the heels. During interview on 06/12/12 at 9:00 A.M., CNA O said the resident had pressure ulcers on his/her heels. He/she said no new areas had been reported. During interview on 06/12/12 at 9:20 A.M., CNA L said the following: -A change in skin condition or wound should be reported to the charge nurse; -He/she was unaware of any new areas on the resident. Observation on 06/12/12, showed the following: -At 11:20 A.M. the resident was lying in the bed on his/her back with the Head of bed (HOB) elevated 30 degrees; -At 11:30 A.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 11:45 A.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 12:15 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 12:30 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 12:45 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 1:00 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 1:20 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 1:45 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; -At 2:05 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees. -At 2:20 P.M. the resident was lying in the bed on his/her back with the HOB elveated 30 degrees; -At 2:45 P.M. the resident was lying in the bed on his/her back with the HOB elevated 30 degrees; (Staff did not reposition the resident for at least 3 hours and 25 minutes). During interview on 06/13/12 at 1:30 P.M., RN V said the following: -There was no set time or set date that pressure ulcers were measured. Observation on 06/13/12 at 1:45 P.M., showed the following: -RN V assessed residents skin while in his/her room; -RN V removed the dressing from the right heel; -Large amount of purulent drainage was noted; -On the right heel was a Stage IV pressure ulcer (measured 6 ? cm x 6 cm with depth of 0.2 cm); -On the left heel was a Stage III pressure ulcer (measured 1 cm x 1 cm with depth of 0.2 cm); -On the top of the right foot was a Stage II pressure ulcer (measured 1 cm x 1cm); -On the left hip was a Stage III pressure ulcer (measured 2 cm x 2 cm with depth of 0.3 cm); -On the right buttock was a Stage II pressure ulcer (measured 3 cm x 1 cm); -On the left buttock was a Stage II pressure ulcer (measured 1 cm x 0.8 cm). During interview on 06/18/12 at 12:00 noon, the resident's physician said the following: -The licensed nurses at the facility had not been trained to stage pressure ulcers; -Expected licensed nursing staff to measure the depth, length, and width of pressure ulcers once weekly; -Expect the resident to be repositioned at a minimum of every two hours. During interview on 07/02/12 at 4:10 P.M., the Administrator said the following: -The resident was hospitalized on [DATE]; -Resident had been hospitalized for [REDACTED]. -The resident is expected to return on Thursday, July 5, 2012; -The resident will have a wound vac placed; -The staff will be trained on the use of the wound vac. During interview on 06/13/12 at 12:13 P.M., the Director of Nursing (DON) said the following: -If a resident has a pressure sore, staff should assess every two to three days; -Assessment included staging, description of the wound, measure the width, the length and the depth, look at surrounding tissue, and describe the wound bed. She said the only assessment sheets they have was on the back of the TAR's and this was where staff should be documenting assessments; -She said the staging of pressure sores and the assessment information is kept on the TAR for staff to have available; -She said residents are assessed in the showers and if there is an open area, the staff are to report it to the charge nurse and the charge nurse was to go immediately and assess it; -She said Certified Nurse Aides (CNA's) are to report any open areas, red areas, and any changes in conditions. Review of policy and procedure (provided by the facility during the survey) titled Pressure Ulcer Advisory Panel, dated February, 2007, showed the following: Pressure ulcer stages -Suspected deep tissue injury; -Stage I, Stage II, Stage III, Stage IV, Stage IV, and unstageable; Assessment and treatment of [REDACTED]. -It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of addidtional ulcers of the deterioration of the pressure ulcer(s) be recongnized, assessed and addressed. Any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers. -When assessing the ulcer itself, it is important to: -Differentiate the type of ulcer (pressure-related versus non-pressure related) because interventions may vary depending on the specific type of ulcer; -Determine the ulcer's stage; -Describe and monitor the ulcer's characteristics; -Monitor the progress toward healing and for potential complications; -Determine if infection is present; -Assess, treat and monitor pain, if present; and -Monitor dressings and treatments. Ulcer Characteristics -It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility; -When a pressure ulcer is present, daily monitoring, (with accompanying documentation, when a complication or change is identified), should include: -An evaluation of the ulcer, if no dressing is present; -An evaluation of status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); -The status of the area surrounding the ulcer (that can be observed without removing thedressing); -The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example; increased redness or swelling around the wound or increased drainage from the wound); -Whether pain, if present being adequately controlled; -At a minimum, documentation should include the date observed and: -Location and staging; -Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth, and the presence, location and extent of any undermining or tunneling/sinus tract; -Exudate, if present: type (such as purulent/serous), color, odor, and approximate amount; -Pain, if present: -Wound bed; -Description of wound edges and surrounding tissue.

Based on observation, interview and record review the facility failed to provide adequate supervision to ensure one resident, (Resident #1), a resident with a history of elopement who presented with psychiatric [DIAGNOSES REDACTED]. After exiting through the window the resident accessed a staff member's vehicle in the facility parking lot and drove away from the facility pulling into the path of a vehicle on State Highway 63 causing the vehicle to leave the roadway to avoid hitting the resident, before the resident drove to a family member's home. The resident's family member contacted the facility to advise the facility of the resident's whereabouts. In addition, facility staff failed to provide adequate supervision to ensure licensed facility staff directed assessment and appropriate emergency response for one resident (Resident #2), who sustained a fall in his/her bathroom, striking his/her head on the wall and who presented with a head injury and change in neurological status. Instead, unlicensed contract staff picked the resident up off the floor by holding the resident under his/her arms and around his/her abdomen while the administrator held the resident's legs. Staff did not provide appropriate cervical or spinal alignment when moving the resident. Licensed staff reported the resident's room was too crowded (with staff), and would not disperse as directed. The resident sustained [REDACTED]. The census was 44. 1. Review of Resident #1's geriatric psychiatric evaluation dated [DATE], from an area hospital showed the following: -The resident was brought to the hospital on [DATE] under a civil commitment because of his/her profoundly disabling delusions, hallucinations and anxiety; -His/her chief complaint was that he/she did not know what happened, he/she got lost, and he/she was trying to find his/her doctor; -The history of his/her present illness includes walking out in front of cars, he/she states that he/she is trying to find his/her sister or his/her car, wanted to see his/her dentist because he/she had teeth problems; -His/her family stated that he/she was increasingly anxious, paranoid, fearful and having difficulties taking care of him/her; -His/her family stated that he/she was not taking his/her medication as advised; -His/her family stated that he/she had a significant decline in his/her ability to care for himself/herself at home; -His/her family stated that he/she was having increasing paranoia, confusion and disorientation; -The resident was diagnosed with [REDACTED]. Review of the resident's care plan conference summary notes dated [DATE] showed team discussion of the following: -Discussion of the resident's schizophrenia; -Noted no mood or behaviors. Review of the resident's undated care plan conference summary notes showed team discussion of the following; -April weight; -Discussion of the resident's Alzheimer's, schizophrenia, flat effect, delusions; -Elopement risk; -Concerns about finding placement for the resident, and speaking to the administrator regarding placement: Review of care plan notes dated [DATE] through [DATE] showed the following: -On [DATE] the resident eloped from the facility, and staff brought back the resident to the facility without incident; -On [DATE] the resident eloped from the facility, and staff brought back to the facility without incident; -On [DATE] the resident eloped from the facility, and staff brought back to the facility without incident; -On [DATE] a meeting was held discussing the resident's elopement problem from the facility, and the resident should be on hourly rounds; -On [DATE] a meeting was held with the resident's family who were "bitter" about the facility considering discharge of the resident, and a discussion to the administrator regarding family concerns. Review of the resident's physician history and physical dated [DATE] showed the following Diagnoses: [REDACTED]. -Depression; -Anxiety; -Glaucoma. Review of the resident's nurses notes dated [DATE] through [DATE] showed the following: -On [DATE] at 7:00 P.M. resident made several attempts to go out the front door setting off the alarm and punching numbers on the key pad; -On [DATE] resident signed self out in the sign out book, resident redirected to his/her room; -On [DATE] at 9:30 A.M. showed east hall door alarm sounding, resident said he/she attempted to open the door to see what it was like outside. Review of the physician progress notes [REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated [DATE] showed the facility assessed the resident as follows: -Resident independent to transfer, ambulate and dress; -No mood or behavior indicators; -No wandering behaviors noted; -Resident takes antipsychotic medications. Review of the care plan conference summary notes dated [DATE] showed discussion of the resident's Alzheimer's, schizophrenia, flat effect, delusions, and past attempts at elopement with last known attempt on [DATE]. Review of the resident's care plan last updated [DATE] directed staff as follows: -The resident ambulated independently, required a Wanderguard (an alarm system that senses a bracelet or anklet worn by a resident that locks a door and makes an audible alarm when the resident is in proximity of the door sensor); -Ensure Wanderguard is working appropriately; -Resident to wear glasses at all times; -Resident to eat meals in room; -Noted the resident with a history of elopement and directed staff to monitor the resident for safety. During interview on [DATE] at 10:04 A.M. Registered Nurse (RN) A said the following: -The resident was not able to make his/her own decisions, but was still his/her own responsible party; -The resident wore two Wanderguard bracelets, around his/her wrist and ankle ; -The resident constantly tests the facility's security, will lean on 15 second doors; -The resident has been out at least twice, but he/she could not recall the dates; -Staff checked the resident every two hours like all other residents; -Five additional residents in the facility wore Wanderguard devices, unknown if other residents had elopement attempts. Review of the resident's nurse's notes dated [DATE] showed the following: -On [DATE] at 5:30 A.M. certified nurse aide (CNA) reported resident leaving from apparently a dining room door, aide states earlier resident stated he/she was leaving. Nurse informed resident could not leave and could not lean against the door; -On [DATE] at 6:20 A.M. Nurse asked where resident was and CNA said in his/her room; -On [DATE] at 7:35 A.M. resident's family member called and states resident in his/her apartment. CNA informed nurse last time he/she visualized the resident was at 7:00 A.M. when the resident was standing by his/her bed by the window. Went to the room and found the window wide open and the screen pushed out. Review of the Missouri State Highway Patrol accident report with investigation and accident date of [DATE] showed the following: -On [DATE] at 7:20 A.M. a car driven by the resident east on Missouri Route W pulled into the path of a southbound driver on US Highway 63; -The southbound driver reports " He/she swerved to miss it, and ran off the road " . -The resident's actions caused the southbound driver to swerve to avoid a collision, causing the driver's vehicle to leave the wet asphalt roadway, leaving tire marks for 134 feet, and strike the ground leaving damage to the undercarriage; -The resident was driving a car owned and insured by certified medical technician (CMT) B. Review of the physician orders [REDACTED]. During interview on [DATE] at 8:09 A.M. CNA E said the following: -The resident was usually asleep when he/she was on duty; -He/She was on duty as a night shift CNA the morning of [DATE]; -On [DATE] at approximately 5:00 A.M. he/she was in another resident's room, left in response to an audible dining room door alarm; -Upon entering the dining room the exit door alarm continued to sound, and he/she met the resident who said that he/she was "trying to get out of here"; -He/She then met another staff in the hall, informed that staff to inform the nurse (Director of Nurses - DON) that the resident said he/she was trying to get out and caused the dining room exit door to alarm; -He/She left the resident in the dining room, and went back down the hall to continue job duties; -He/She did not provide any supervision or monitoring of this resident after this elopement attempt. During interview on [DATE] at 4:30 P.M. CNA D said the following: -The resident was very quiet and sneaky characteristically; -The resident was usually asleep when he/she was on duty; -He/She was on duty on [DATE] at 5:15 A.M.; -CNA E informed him/her on [DATE] at approximately 5:15 A.M. the resident was pushing on the dining room door, causing the alarm to go off, and the resident said he/she was going to leave the facility; -CNA E told him/her to inform the DON who was working that shift about the resident's behavior; -He/she told the DON the resident attempted to leave through the dining room door and the resident said that he/she was going to leave. During interview on [DATE] at 11:25 A.M. CNA C said the following: -He/She worked with the resident since the resident's admission; -The resident wore two Wanderguard bracelets, around his/her wrist and ankle; -The resident frequent displayed " weird " behaviors such as staring at the convenience store across the high way for hours out the window; -The resident eloped from the facility previously, and crossed the highway to a snack business because of a malfunction in the Wanderguard system, which had been fixed since that prior incident; -He/She received no instruction to provide additional monitoring for the resident in report on [DATE] when he/she came on duty at 6:00 A.M. -He/She worked the day of [DATE] starting at 6:00 A.M., and was assigned to the resident; -On [DATE] he/she first observed the resident in bed around 6:45 A.M., when he/she gave the resident a verbal reminder to get ready for breakfast; - On [DATE] around 7:00 A.M. he/she walked by the residents room and saw the resident opening the curtains to his/her window, which was the last time the resident was visualized; -He/She was not aware the resident attempted to elope on the early morning of [DATE]. During interview on [DATE] at 10:23 A.M. the Director of Nurses (DON) said the following: -At 5:30 A.M. on [DATE] it was reported by CNA D to her the resident attempted to leave the facility through the dining room door, and the resident voiced he/she was leaving; -There was no additional monitoring of the resident put into place on [DATE] after she was informed the resident attempted to leave and verbalized intention to leave; -When she asked about the resident's whereabouts around 5:45 A.M., a CNA (unknown) reported the resident was in his/her room; -She asked the CNA at 6:00 A.M. on [DATE] where the resident was and the CNA stated the resident was in his/her room; -She was present when the resident eloped on [DATE]; -CNA C was the last person to see the resident in the facility at approximately 7:00 A.M. when the aide saw the resident in his/her room standing by the window opening the curtains; -She knows of multiple elopement attempts by the resident, the last one being on [DATE] when the resident opened the door in the therapy hallway; She has been the director of nursing since the resident was admitted ; -She was aware of the resident's elopement risk; -The resident wears a Wanderguard at all times; -The facility completes no formal elopement risk assessment of residents, only use nursing judgment; -Staff routinely visualize all residents every two hours; -The resident had shown signs of increasing paranoia at the end of June and early [DATE] staring at the Casey's store across the highway for hours on end worried the store would be robbed; -She has observed the resident frequently watching visitors leaving the front door and key pad entries (that would temporarily disable front door lock); -The resident frequently asked staff for scissors to remove his/her Wanderguard bracelet; -The resident wanders into other resident's rooms; -She feels the resident is not capable of making decisions due to her mental state; -The facility will have to readmit the resident if no one else will take the resident. During interview on [DATE] at 10:30 A.M. CMT B said the following: -The resident walks well, uses glasses for poor vision; -The resident frequently sets off door alarms with elopement attempts. - On [DATE] at approximately 6:00 A.M. he/she provided the resident with medication, and the resident would not answer questions or converse, just stared. -On [DATE] the Missouri State Highway Patrol called him/her at 8:00 A.M. and relayed his/her car had been stolen, (by Resident #1) and was sitting along the road; -He/She left the keys in his/her car console, and parked his/her car in the rear parking lot of the facility approximately 75 feet from the resident's room window; -The Highway Patrol said the resident pulled out in front of an individual on the Highway 63 causing the individual to run into the ditch with damage to the individual's car; -The resident was brought back to the facility by the county Sheriff; -When the resident returned to the facility he/she said he/she went to see his/her family member; -The resident's family member lives about a mile away with the only access via Highway 63. During interview on [DATE] at 3:44 P.M. the facility administrator said the following: -After the resident's previous elopement from the facility in [DATE] they realized they could not meet the resident's needs and attempted placement by sending resident information to three nearby facilities, did not know if the facilities ad locked units, (the administrator had no record of attempts); -In hindsight he should have pursued other places; -Other residents wear Wanderguard devices, but are not high risk for elopement; -The resident threatens to leave so often staff cannot provide one on one supervision; -The facility felt they could meet the resident's needs because they resident had a Wander guard and the alarms were fixed, (following the elopement in [DATE]); -The facility completes no formal elopement risk assessments. -Before the elopement on [DATE], they asked the resident's sister to consider transfer to another facility, because the resident needed a more secure locked unit; -The resident's family was reluctant to agree to transfer the resident due to convenience of visitation, and ability to make local phone calls to the resident; -Did not want to accept the resident back because one on one supervision would be continuously needed; -The resident and all residents were on every two hour checks, no additional supervision was provided to the resident on [DATE] after the resident attempted to leave from the dining room door; -He was aware the resident had a history of [REDACTED]. -He did not secure windows with concerns about state regulations; -He had not contacted the state agency to discuss if windows could be partially or fully secured; -The resident drove away from the facility at 7:18 A.M. (documented by facility surveillance cameras in a back parking lot/employee vehicle); -All staff had knowledge the resident was an elopement risk; -No additional monitoring of the resident was completed by staff on [DATE] before elopement; -The resident was the only resident at high risk for elopement. Observation on [DATE] showed the resident's room window approximately four feet above ground level. The sash window opened without difficulty allowing exit. Observation showed the facility located within close proximity to State Highway 63, a major north south traffic route. The facility produced no policy or procedures after repeated requests in regards to elopement, resident monitoring and supervision or use of Wanderguards. 2. Review of the Resident #2's quarterly minimum data set (MDS), a federally required assessment tool required to be completed by facility staff, dated [DATE] showed: -His/her cognitive status was moderately impaired; -He/she was independent with transfers and walking in his/her room; -He/she was independent with toilet use and personal hygiene; -He/she had impairment on both sides for functional range of motion in the upper extremities (shoulders, elbows, wrists and hands); -He/she used a cane/crutch; -He/she had [DIAGNOSES REDACTED]. -He/she experienced falls since the last assessment with zero no injury falls, zero injury falls and zero major injury falls. Review of the resident's care plan updated [DATE], showed he/she was not steady with transitions, but he/she was able to stabilize without human assistance. The care plan showed the following interventions: -"I am independent for mobility;" -"I am independent for transfers;" -"I am independent for walking in my room;" -"I need extensive assistance to ambulate in the corridor and off the unit;" -"I use a cane when I am ambulating. May gait is steady and slow;" -"I am legally blind due to glaucoma;" -"I bathe myself and need assistance washing my back." Review of the resident's nurses note, dated [DATE] showed: -At 2:15 P.M., resident in bathroom and fell forward on wall. Hematoma and open wound on forehead, nose and upper lip. Resident complained of neck pain, will not squeeze hand. He/she remains alert. Transferred to bed, wounds cleaned; -At 3:00 P.M., resident to emergency room via ambulance, report called to emergency room ; -At 2:30 P.M. (actual order of charting in the nurses notes), resident's physician notified, order received, contract physical therapy assistant (contract PTA) G will go to emergency room with resident. During an interview on [DATE] at 1:00 P.M. and 2:20 P.M., contract PTA (Physical Therapy Assistant) G said he/she was on his/her way to get a resident to work with when he/she knocked on Resident #1's door. The resident said, "Help me, help me" faintly. When contract PTA G opened the door, he/she found the resident on the floor in the bathroom with his/her head tilted slightly to the left with his/her legs and arms under him/her. The top of the resident's head was against the wall and a pool of blood was under him/her. Contract PTA picked the resident up from the floor while another staff supported the resident's legs. When he/she picked up the resident, an aide held the resident's head with his/her palms over the resident's ears. He/she said the aide held on like this until they got the resident to the bed. The resident's pillow was on the bed and it was not moved, (resident's head placed on a pillow). He/she carried the resident under the arms with his/her arms around the resident's stomach. He/she said the main concern at the time was the resident's color as he/she was turning blue/purple. During an interview on [DATE] at 8:00 P.M., Registered Nurse (RN) F said the resident was found on the floor in his/her bathroom with his/her arms under him/her, knees bent and head bent all the way back. RN F said the resident was bleeding and he/she, the Administrator and contract PTA G moved the resident to the bed and RN F did an assessment on the resident. The resident did not want to go to the hospital, but RN F said he/she told the resident he/she had to go. The resident did not squeeze RN F's hands. RN F said staff probably should have maintained cervical spine immobilization on the resident's neck, but did not. He/she said the ambulance staff was upset that the resident was moved. During an interview on [DATE] at 4:10 P.M., RN F said the contract PTA was already in the resident's room when the ward clerk at the desk told him/her to go to the resident's room STAT (immediately, without delay). When RN F arrived, the contract PTA and a couple staff were already in the room. The resident was in such a position, he/she had to be moved. The staff rolled the resident to his/her side as somebody (RN F could not recall) held the resident's shoulders and head and neck. Contract PTA held the resident under his/her arms and around his/her belly and got the resident up from the floor while the administrator held the resident's legs but could not see how he held the resident's legs due to overcrowding in the room. RN F said the resident's room was so crowded and he/she asked those who did not need to be in the room to leave, but they did not. RN F said he/she made the request for the crowd to disperse a few times. RN F did not direct the staff moving the resident on how to properly move the resident. During an interview on [DATE] at 10:55 A.M., the facility administrator said contract PTA G found the resident on the floor after the fall. The ward clerk paged for staff to go to the resident's room. He did not initially go. He saw a certified nurse aide come to the nurses desk to retrieve a backboard. He said that is when he went to the resident's room. He said there was no way to get the backboard into the bathroom. Staff carried the resident to his/her bed, but the administrator was not close enough to do anything. The resident was bleeding from his/her head and there was blood on the floor. The resident was very limp. The administrator said one aide supported the resident's head as contract PTA G carried the resident and he helped with the resident's legs. He said there were a lot of people in the room. Review of the resident's ambulance trip ticket, dated [DATE] showed: -At 2:48 P.M., facility called to request ambulance; -At 2:50 P.M., ambulance en route; -At 2:50 P.M., ambulance arrived at the facility; -At 2:51 P.M., ambulance crew arrived at resident's side; -At 3:08 P.M., ambulance departed with resident; -Assessment notes showed staff got the resident up after the resident sustained [REDACTED]. -Resident told facility staff he/she had pain in the head and neck; -Resident had no sensation in his/her upper extremities; -Neuro checks were completed before and after spinal immobilization by the ambulance crew; -Ambulance crew found resident on bed; -Facility staff moved the resident from the bathroom to the bed prior to ambulance crew arrival; -Resident began having neck pain; -Resident had a one inch laceration on his/her forehead and an abrasion on his/her nose; -When ambulance crew arrived, facility staff were not providing in-line spinal immobilization; -At 2:53 P.M., resident had no movement or sensation; -Ambulance crew immobilized the resident in a cervical collar and a long spine board and secured him/her with straps for transport to the emergency room . During an interview on [DATE] at 3:38 P.M., Emergency Medical Technician (EMT) H said facility staff moved the resident prior to emergency medical service (EMS) ' s arrival and had propped the resident's head up on a pillow. The resident did not have feeling from his/her neck down. EMT H said EMS trained facility staff to never move any resident with any fall. He/she said it was obvious the resident had a head injury due to the laceration on his/her head. EMT H said if the facility staff would have left the resident where he/she was, EMS personnel would have stabilized the resident's head properly. He/she said it generally only takes EMS five minutes to arrive at the facility and said he/she had concern with how long the facility waited before calling for EMS. Review of the resident's physical exam from the emergency room , dated [DATE] at 5:18 P.M. showed the resident was completely flaccid in the upper and lower extremities and had a 0.5 centimeter (cm) laceration on his/her forehead. The clinical impression was listed as paralysis and head injury. The resident was taken via air ambulance service for specialized treatment in head and neck injuries. Review of an admission note, dated [DATE] showed the resident was brought in from a skilled nursing facility to an outside hospital, after he/she fell after standing up from the toilet. The resident felt like he/she was unconscious for approximately two to three minutes. At the outside hospital, the resident was found to have quadriplegia. Imaging studies showed the resident had a central cord syndrome lesion with quadriplegia at the level of C2-C6. Resident refused intubation for the injury. The resident denied any recent changes in his/her health. His/her only complaint prior to the fall was bilateral knee pain, which was a chronic issue. Upon examination, the resident had motor deficit below the level of T1 (first thoracic vertebra) and sensory deficit between L1 and L2 (first and second lumbar vertebra). Magnetic resonance imaging (MRI) showed C2-C6 spinal cord injury. The resident was admitted to medical-neuro intensive care unit. Review of the resident's neurosurgery consult, dated [DATE] showed the resident lived in a nursing facility and fell off the toilet and struck his/her head. He/she had a history of [REDACTED]. The neurologic exam showed flaccid (limp) musculature with no movement on command. The resident reported he/she did not have sensation below the level of T8 (the eighth thoracic vertebrae) and that was verified through both painful stimuli and soft touch. Radiography showed via magnetic resonance imaging (MRI) that the cervical (neck) spine had multiple areas of stenosis (narrowing) from the level of C4-C7 (the fourth through seventh cervical vertebrae) with T2 (second thoracic vertebrae) signal change and multiple areas of both associated disk and facet degenerative disease with what appeared to be a relatively narrow canal that was likely a hyperextension injury. The neurosurgeon's plan was no acute surgical intervention with central cord style symptomatology. The patient would tend to do better if he/she was given four to six weeks convalescence so he/she may undergo the maximum improvement prior to decompression. Given the resident's adamant desire that he/she have no significant intervention to include intubation, (mechanical ventilation) under any circumstances, there does not appear to be adequate neurosurgical intervention that can cause the resident to have a significant improvement. The neurosurgeon recommended palliative care consultation. During an interview on [DATE] at 3:45 P.M., the DON said the facility did not have cervical collars in the building so it would not have been her expectation that one was used to move the resident. The DON said he/she did not find out about the incident until the next day. She said she did not think that staff should have done anything differently because the room was so crowded. The facility has to call the sheriff ' s department to request an ambulance. She later said the county did have 911 services, but the staff did not use it. During an interview on [DATE] at 9:00 A.M., the Director of Nursing (DON) said the resident would return to the nursing home. The resident was paralyzed since the accident and took in a pureed diet as deemed appropriate by a swallow study. The resident was independent prior the fall. During an interview on [DATE] at 3:11 P.M., internal medicine physician H said the resident did not have any fractures, but his/her neck was in "bad shape." Internal medicine physician H was not aware facility staff moved the resident after the fall. He/she said it should have been protocol to leave the resident and let emergency medical service staff immobilize the resident so the spine was immobilized appropriately. He/she said the resident would return to the facility on [DATE] on hospice due to not eating or drinking. Review of the Mayo Clinic's website, showed most head trauma involved injuries that are minor and don't require hospitalization . However, call 911 or the local emergency number if any of the following signs or symptoms are apparent: -Severe head or facial bleeding; -Bleeding from the nose or ears; -Severe headache; -Change in level of consciousness for more than a few seconds; -Confusion; -Loss of balance; -Weakness or an inability to use an arm or leg. If severe head trauma occurs: -Keep the person still. Until medical help arrives, keep the injured person lying down and quiet, with the head and shoulders slightly elevated. Don't move the person unless necessary, and avoid moving the person's neck; -Stop any bleeding. Apply firm pressure to the wound with sterile gauze or a clean cloth. But don't apply direct pressure to the wound if you suspect a skull fracture; -Watch for changes in breathing and alertness. If the person shows no signs of circulation (breathing, coughing or movement), begin CPR. Review of the National Institute of Neurological Disorders and Stroke's website, available at: <http://www.ninds.nih.gov/disorders/central_cord/central_cord.htm> showed, central cord syndrome is the most common form of incomplete spinal cord injury characterized by impairment in the arms and hands and to a lesser extent in the legs. The brain's ability to send and receive signals to and from parts of the body below the site of injury is reduced but not entirely blocked. This syndrome is associated with damage to the large nerve fibers that carry information directly from the cerebral cortex to the spinal cord. These nerves are particularly important for hand and arm function. Symptoms may include paralysis or loss of fine control of movements in the arms and hands, with relatively less impairment of leg movements. Sensory loss below the site of the injury and loss of bladder control may also occur, as well as painful sensations such as tingling, burning, or dull ache. The overall amount and type of functional loss is dependent upon the severity of nerve damage. Central cord syndrome is usually the result of trauma that causes damage to the vertebrae in the neck or herniation of the vertebral discs. It also may develop in persons over the age of 50 due to gradual weakening of the vertebrae and discs, which narrows the spinal column and may contribute to compression of the spinal cord when the neck is hyper-extended. The state agency requested a facility policy related to emergency response to resident injuries and was provided with a policy on emergency protocol related to fire, evacuation and tornado/windstorm. The facility had no policy to address emergency response to resident Complaint #MO and # MO NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility initiated inservice education regarding elopement risk, resident behavior and supervising residents at risk for elopement. Resident #1 was monitored with line of sight supervision until discharge. The facility identified no other residents at risk at that time. The facility still needed to develop an elopement risk assessment tool and assess all residents for risk with the tool. The facility had not updated all resident care plans reflecting the elopement risk assessment . The facility also had not completed development or implementation of policy and procedure in regards to elopement risk or response or staff inservice thereof. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1RSMo) requiring that prompt remedial action be taken to address Class I v

Based on interview and record reviewed the facility failed to identity and transfer two of three sampled residents, ( Resident #1 and #2) to the hospital in a timely manner when Resident #1, a resident with a history of respiratory problems, presented with a change in condition including low oxygen saturations and elevated temperature, and Resident #2, a resident with a cardiac history, presented with decreased oxygen saturation and chest pain. The facility's census was 45. 1. Review of Resident #1's hospital history and physical dated 1/2/11 showed the resident admitted to the emergency room (ER) with complaints of fever, shortness of breath, and decreased oxygen saturation. The resident was admitted to the hospital for right lower lobe pneumonia, [MEDICAL CONDITIONS] exacerbated and dehydration. The resident was admitted to the intensive care unit (ICU). Review of the resident's hospital x-ray report dated 1/3/11 showed the resident had right basilar pneumonia and [MEDICAL CONDITION]. Review of the resident's physician's orders [REDACTED]. Review of the resident's physician's orders [REDACTED]. Strength 500 milligrams one or two tablets every four to six hours as needed for elevated temperature. Review of the resident's medical record showed no nurse's notes documented on 1/28/11. Review of the resident's dietary intake sheet for January 2011 showed the resident ate 95-100% of breakfast except on 1/29/10, when staff noted the resident ate only 20% of breakfast and the resident refused lunch and fluids. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - On 1/29/11 at 2:00 A.M. resident received two tablets of extra strength Tylenol for a temperature of 100.3 (normal 98.6 degrees Fahrenheit taken orally), no route documented. The resident's temperature at 2:40 A.M. was 99 degrees, and no documentation the resident received any other doses of Tylenol on 1/29/11; - No documentation of the resident receiving any [MEDICATION NAME] breathing treatments on 1/28/11 or 1/29/11. Review of the resident's facility nursing report sheet, undated showed: - On 1/28/11 at 10:00 P.M. to 6:00 A.M. shift documented resident received one Tylenol and one [MEDICATION NAME] ([MEDICATION NAME] with 660 milligrams of Tylenol), at 2:00 A.M., resident's temperature at 11:45 P.M. was 100.7, temperature at 1:50 A.M. was 100.3, temperature at 2:00 A.M. was 99 degrees and temperature at 4:00 A.M. was 98.7 degrees; - On 1/29/11 resident refused lunch, at 3:00 P.M. resident's temperature was 102.1, pulse 125 (normal 60-80 beats per minute), oxygen saturation 83% , resident to the hospital at 5:00 P.M. Review of the Mosby's diagnostic and laboratory test reference sixth edition, copyrighted 2001, showed a normal oxygen saturation was considered greater than 95% and oxygen saturations less than or equal to 75% were possible critical levels. Review of the resident's antibiotic flow sheet dated 1/29/11 at 3:00 P.M. showed the resident had a temperature of 100.1, pulse 110 and oxygen saturation of 76 % on four liters of oxygen. Flow sheet showed routine [MEDICATION NAME] and [MEDICATION NAME] given. During interview on 2/9/11 at 1:25 P.M. Certified Nurse Aide (CNA) C said he/she worked on 1/29/11 2:00 P.M. to 10:00 P.M. CNA C said he/she checked on the resident about 3:30 P.M. and noticed the resident was shivering, had a red face and he/she took the resident's temperature and it was 101 degrees. CNA C said he/she reported the resident's temperature to Registered Nurse (RN) B and RN B said the resident had received Tylenol at 3:30 P.M., (the MAR indicated [REDACTED].M.). CNA C said RN B told her the resident's oxygen saturation was 74% when he/she checked it earlier. CNA C said he/she was concerned about the resident's low oxygen saturation so at 4 :00 P.M. he/she rechecked the resident's oxygen saturation and it was 84 % on oxygen. CNA C said RN B was working on getting the family to transfer the resident to the hospital. CNA C said the family came to the facility and wanted the resident transferred to the hospital by ambulance so he/she went and got RN B to talk to the family. Review of a written statement dated 1/30/11 showed CNA D said he/she noticed on 1/29/11 the resident was not feeling very well. CNA D said the resident ate poorly at breakfast and only drank water at lunch. CNA D said he/she asked the nurses about the resident and they said the resident did not have a temperature. CNA D said at shift change he/she changed the resident's clothes due to him/her being incontinent of urine. CNA D said before the ambulance arrived he/she went to the resident's room to check to see if the resident was ready to go and the resident was soaked with urine. CNA D said he/she was told by RN B they did not have time to clean the resident up so the resident was sent by ambulance soaked in urine. Review of the resident's nurse's notes dated 1/29/11 showed no documentation until 3:00 P.M. At that time RN B noted the resident's temperature was 100.1 degrees, pulse 116, and oxygen saturation 73% on four liters of oxygen, face flushed, shivering, right upper and lower lobes with inspiratory and expiratory wheezes, last night temperature 100.7, nurse practitioner notified and orders received, (no documentation that resident refused to go to the hospital). At 4:52 P.M. (family member) notified and in facility requesting resident to be transferred to the hospital by ambulance. Resident transferred to the hospital by ambulance. During interview on 2/8/11 at 9:50 A.M. RN B said when he/she got to work on 1/29/11 at 2:00 P.M. he/she was informed the resident had a temperature through out the night of 1/28 and all day that day (1/29), the resident had received Tylenol for the temperature. RN B said he/she checked on the resident about 2:30 P.M., noticed the resident's face was red and flushed, resident breathing hard, oxygen saturation was 73%, had oxygen on, was in a fetal position, shivering, wheezing inspiratory and expiratory, and had a temperature of 100.7. RN B said he/she left the resident's room and checked on a couple of other residents and then went back and checked on Resident #1. RN B said when he/she checked back on the resident he/she saw the resident was miserable and confused. RN B said the resident refused to go to the hospital. RN B said around 4:00 P.M. he/she received an order from the nurse practitioner to transfer the resident to the hospital. RN B said about 4:00 P.M. he/she called the resident's family members to take the resident to the hospital. RN B said the resident's family member informed her they were not comfortable transferring the resident to the hospital in a car. RN B said he/she probably would not feel comfortable sending the resident to the hospital by personal car with an oxygen saturation of 73%. RN B said he/she took the resident's vital signs when he/she arrived at work and when transferred to the hospital. Review of the resident's physician's orders [REDACTED]. to transfer the resident to the ER for evaluation, if resident refused to go start a Z-pack (antiinfective). Review showed no documentation in the resident's record he/she refused to go to the ER or a Z-pack was ordered. During interview on 2/7/11 at 10:55 A.M. the resident said he/she had been sick about two days and kept getting worse so was sent by ambulance to the hospital, about one week ago. The resident said he/she had a lot of breathing problems. The resident said he/she was really sick and did not refuse to go to the hospital. During interview on 2/15/11 at 9:00 A.M. the resident's family member said he/she had been informed by the DON that his/her family member had been ill since noon on 1/29/11. The family member said RN B called him/her on 1/29/11 at 4:00 P.M. and informed him/her that he/she needed to come to the facility and take his/her family member to the hospital. The family member said RN B said as long as the resident could sit up the resident did not meet criteria for ambulance transport. The family member said RN B informed him/her that the resident had been sick, running a temperature all day, had low oxygen saturations and needed to go to the hospital. The family member said RN B told him/her the resident had not been very responsive, was confused and needed to go to the hospital. The family member said he/she told RN B if the resident's oxygen saturations were that low he/she did not feel comfortable transferring the resident to the hospital in his/her car. The family member said he/she was worried what he/she would do if the resident stopped breathing or had a [MEDICAL CONDITION] on the way to the hospital. The family member said he/she went to the facility and found the resident in bed curled up in a fetal position, drenched with sweat, had urinated on him/herself, shaking uncontrollable and mumbling about planting tomato plants that morning. The family member said the aides informed him/her they had been trying to get RN B to call an ambulance for the resident. The family member said the aides took the resident's temperature when he/she arrived at the facility and it was 102.9 degrees. The family member told the aides to go get RN B. The family member said when RN B entered the resident's room he/she told him/her to call an ambulance because he/she was not transferring the resident in that condition to the hospital. The family member said when the ambulance arrived it took three staff to sit the resident up on the side of the bed, the resident was usually ambulatory. The family member said when ambulance staff A arrived at the facility he/she was upset that he/she had been informed it was a routine transfer not an emergency transfer. The family member said ambulance staff A said there should have been a medic on the transport and the ambulance was going to be running lights and sirens to the hospital. The family member said at the hospital ambulance staff A apologized to them and said they had been informed the resident only had a low grade temperature when being paged out, they were not informed of the resident's respiratory status until they arrived at the facility. Review of a written statement dated 1/30/11 showed the Director of Nurses (DON) said she had spoken with RN B who admitted he/she had called the resident's family to transfer the resident to the hospital. The DON said RN B did not think the resident met criteria for transport by ambulance. RN B said when family came to the facility they insisted the resident be transferred to the hospital by ambulance. RN B said he/she did not page out the ambulance as an emergency only as a transport so they did not bring any oxygen with them. During interview on 2/17/11 at 9:15 A.M. ambulance staff A said the nursing home paged out the ambulance on 1/29/11 at 4:34 P.M. as a routine transfer to the hospital. The ambulance staff said since the call was for a routine transfer he/she did not call in a medic. Ambulance staff A said when he/she arrived at the facility, facility nurse RN B informed him/her the resident's oxygen saturation was 70% with oxygen on and the resident had a temperature of 102.1 degrees. Ambulance staff A said they informed RN B he/she should have called out the ambulance as an emergency transfer. Ambulance staff A said he/she asked RN B if he/she had given the resident a breathing treatment and RN B said not since the morning routine ordered dose. Ambulance staff A said he/she was not licensed to administer a breathing treatment to the resident. Ambulance staff A said he/she was informed by RN B the resident had just gotten sick the last few minutes. Ambulance staff A said the resident informed him/her that he/she had been ill all day. Ambulance staff A said they ran lights and sirens the 16 miles to the hospital. Review of the resident's ambulance report dated 1/29/10 showed: - Ambulance paged out at 4:34 P.M. as a routine transfer; - Resident's temperature 102.9 degrees, oxygen saturation 79%, disoriented, labored respirations, wheezing and skin red and hot; - Ambulance paged out for routine transfer, on arrival found resident having trouble breathing, nursing home staff said resident had been sick for three days, resident had no breathing treatments in the afternoon, resident with wheezes throughout, resident too weak to sit on side of bed (usually ambulatory), resident had been incontinent of urine and skin very hot and clammy to the touch. Review of the resident's facility transfer and referral record dated 1/29/11 showed: - Resident's appetite poor; - Resident continent of bowel and bladder; - Reason for transfer was an elevated temperature for 24 hours and oxygen saturation below 73%; - Vital signs at time of transfer temperature 102.1, pulse 125, respirations 22, oxygen saturation 83%; - On 1/28/11 started increased temperature, chills, Tylenol given; - On 1/29/11 at 3:00 P.M. resident had an elevated temperature, expiratory wheezes, chills, flushed. Review of the resident's emergency room report dated 1/29/11 at 5:28 P.M. showed: - Resident presented to the ER with cough, congestion, low oxygen saturation, shortness of breath, fever, chills and weakness over last 24-48 hours; - Recent treatment for [REDACTED]. - Assessment on admission noted skin hot and dry, temperature 102.9, chest x-ray showed bilateral basilar pneumonia; - Admit to intensive care unit of hospital with [DIAGNOSES REDACTED]. Review of the resident's hospital history and physical from the resident's admission on 1/29/11 showed the resident had presented to the ER with dyspnea (shortness of breath). The resident said he/she had started getting sick on the 28 th, didn't feel well, tired, dyspneic, cough with sputum production. The resident said he/she had a fever the night of the 28th. The resident had a recent hospitalization due to right lower lobe pneumonia. The resident's temperature was 102.9 with 98% oxygen saturation on 10 liters nonbreathing mask, he/she does appear to be ill. The resident presents with bilateral pneumonia, fever,[MEDICAL CONDITION] secondary to the pneumonia and [MEDICAL CONDITION] exacerbated. During interview on 2/7/11 at 11:50 A.M..the DON said she would have expected staff to send for the ambulance immediately and to notify her. The DON said they had concerns about the resident not being sent out in a timely manner and the ambulance not being called sooner. During interview on 2/9/11 at 1:45 P.M. the resident's physician's nurse practitioner (NP) said RN B called him/her and reported the resident refused to go to the emergency room , NP does not recall the time of this call. The NP said he/she told RN B the resident needed to go to the ER and to notify the resident's family. The NP said he/she instructed RN B to send the resident to the ER by ambulance and the ambulance would be covered . The NP said this resident gets sick fast and his/her oxygen saturations go down fast too. 2. Review of Resident #2's physician's progress note dated 11/19/10 showed: The resident had chronic [MEDICAL CONDITION] resistant staph aureus infection with osteo[DIAGNOSES REDACTED] in his/her shoulder following surgery, the resident also had chronic [MEDICAL CONDITION] and severe [DIAGNOSES REDACTED], [MEDICAL CONDITION], systolic heart failure, hypertension and history [MEDICAL CONDITION]. The resident was alert and cooperative. Review of the resident's echocardiogram (cardiac diagnostic test), dated 1/12/11 showed the resident had severe left [MEDICAL CONDITION] enlargement, sclerotic mitral valve with mild regurgitation, heavily calcified aortic valve with severe [DIAGNOSES REDACTED]; compared to prior study dated 12/20/09 the systolic function is now severely reduced, (all indicating significant cardiac findings). Review of the resident's February 2011 physician's orders [REDACTED]. Review of the facility's shift report sheet showed on 1/20/11 the resident was given two [MEDICATION NAME] for all over pain, with no assessment including vital signs documented. The report sheet showed an order at 11:00 A.M. to send the resident to the emergency room . Review of the resident's MAR indicated [REDACTED].M. for all over pain and showed at 11:00 A.M., resident no better. Review of the resident's nurse's notes showed on 1/20/11: - At 8:20 A.M. resident lying in bed, diaphoretic (sweating), respirations labored and shallow, lungs clear with diminished lower lobes, responds inappropriately to questions, disoriented and states there are cats in his/her room, when resident asked about pain resident points to chest and said it hurts when taking a breath. Urine tea colored, ate no breakfast, (no vital signs documented or any documentation the resident received oxygen); - Untimed nursing entry showed physician's clinic nurse updated on resident condition and will talk with physician, continue to monitor resident (no vital signs or documentation of assessment of the resident); - At 10:30 A.M. urine specimen obtained; - Untimed nursing entry (written after 10:30 entry), resident's spouse notified of resident's condition, spouse asked for resident to be sent to the emergency room if ok with the physician; - At 11:00 A.M. order received to send the resident to the emergency room . Review of the resident's medical record dated 1/20/11 showed no documentation of any vital signs or oxygen saturations. The resident's medical record showed no assessment of the resident after 8:20 A.M. on 1/20/11. During interview on 2/7/11 at 10:45 A.M. RN E said the resident was usually alert and oriented. RN E said on 1/20/11 at 8:20 A.M. a staff member had informed him/her the resident wasn't him/herself, RN E said this was the first time he/she saw the resident that day. RN E said around 9:10 A.M. he/she called the physician's clinic in Memphis. RN E said the physician was not in so he/she left a message for the physician to call the facility. RN E said the physician did not call back and when he/she was on the phone with the clinic about another resident he/she asked again about speaking with the physician concerning Resident #1, RN E was unsure of the time of this phone call. RN E said around 11:00 A.M. he/she received an order to transfer the resident to the emergency room . Review of the resident's ambulance record dated 1/20/11 showed: - The ambulance was called out at 11:02 A.M. as an emergency response; - Resident's chief complaint respiratory distress, respirations shallow, labored and diminished lower lobe with respirations at 24 per minute, resident pale, cool and diaphoretic; - The ambulance dispatched to the facility for a resident with respiratory distress and a cardiac history. On arrival at the facility found resident in bed with oxygen on, resident pale and diaphoretic. When transferring the resident to the ER cot the resident said he/she hurt all over. The nursing home staff reported the resident's oxygen saturation was low and the resident was confused. The resident's vital signs on arrival at the facility was oxygen saturation 74%-90% on 4 liters of oxygen the resident was placed on a nonrebreathing mask and oxygen saturation improved. The resident's vital signs at 11:34 were blood pressure 102/62, pulse 101, respirations 24 and oxygen saturation with four liters of oxygen was 99%. Review of the resident's transfer and referral record dated 1/20/11 and untimed showed the resident transferred to the hospital due to respiratory distress. The resident was diaphoretic, respirations labored and shallow, lungs with diminished lower lobes, confused not making any sense, chest pain hurt to breathe, urine dark with foul odor, ate no breakfast. Vital signs 96.9 temperature, 100 pulse, 24 respirations, oxygen at 2 liters per nasal cannula with saturation of 96%. Review of the facility's schedule/policy for contacting Resident #2's physician showed the physician's home phone number, cell number and clinic numbers. The policy stated if it is urgent to contact the provider at their home, cell or pager number. The policy showed the resident's physician was scheduled in the Memphis clinic on Thursday 1/20/11 at 7:00 A.M.. During an interview on 2/25/11 at 10:00 A.M. the receptionist at the Memphis clinic said the physician's hours and clinic locations had changed about one year ago and the facility's policy was no longer accurate. The receptionist said the resident's physician working hours at the Memphis clinic were 9:00 A.M. to 5:00 P.M. Review of a written statement dated 2/8/11 showed RN E said he/she remembered on 1/20/11 at 6:00 A.M. report the night shift nurse said the resident had been slightly confused during the night but it had resolved. RN E said he/she did not check on the resident until 8:15 A.M. when staff reported the resident was confused, ate 0% of breakfast, and was sweaty. RN E said the resident was often sweaty in the morning. RN E said he/she went to check on the resident and took vital signs which he/she did not record. RN E said he/she called the Memphis clinic and spoke with the physician's nurse due to the physician not being in yet. RN E said the physician's nurse told him/her that he/she would tell the physician when he arrived at the clinic. RN E said he/she called the clinic about another resident and was told the physician was not in yet. RN E said the physician was in at 11:20 A.M. and that is when the order was received to transfer the resident to the emergency room . During interview on 2/8/11 at 10:30 A.M. the resident's physician said he/she was not in the clinic when facility staff called to report the change in the resident's condition. The resident's physician said he/she would have expected facility staff to call him/her directly. The resident's physician said the facility had his/her cell number, home number and pager number and would have expected them to call him/her directly when a resident with cardiac history complained of chest pain. The resident's physician said any resident complaining of chest pain was a potentially serious problem. During interview on 2/7/11 at 11:50 A.M. the DON said she would have expected the nurse to have taken the resident's vital signs and documented them in the resident's chart. The DON said she had some concerns about how the resident's change in condition was handled and was investigating. During interview on 2/15/11 at 9:00 A.M. the DON said facility staff can contact the resident's physician directly as they have access to the physician's home, cell and pager numbers. The DON said the facility is not to call the physician's clinic and leave messages or wait until the physician's office opens. The staff can call the physician directly. The DON said she was not notified of either Resident #1's or Resident #2's change in condition. The DON said she would have expected the staff to notify her immediately. During interview on 2/7/11 at 8:40 A.M. the DON said it was her expectation staff follow the nursing responsibility policy. Review of the facility's undated policy for nursing responsibility showed: - Obtain vital signs on resident's that are not doing well; - Document pertinent information such as change in condition, pain, and change in behaviors; - It is the nurse's responsibility with a change in condition or concerns to report to the physician by filling out "Resident Change of Condition " form" (this form not filled out for Resident #2). Complaint # MO 256