Every finding on record at Shepherd of the Hills Living Center

Based on observation and interview, the facility failed to ensure all medication was secured when medication and treatment carts were left unlocked, medication keys were left in box on top of the medication cart, and keys were left in the door lock of the medication room. The facility census was 77.Review of the facility policy, titled Storage of Medication, dated July 2021, showed the following:-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier;-The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, pharmacy personnel, or staff members lawfully authorized to administered medications;-Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1. Observation of the 300/400 Hall nurses' desk on 07/29/26 at 9:28 A.M., showed the following:-No nurses/staff at the nurse's desk;-The medication room was located behind the nurse's desk;-The medication room keys were in the lock of the medication room door, visible to anyone walking by the desk;-The 300 and 400 hall treatment carts were located in the short hallway between the resident hall and the resident activity room, around the corner from the 300/400 hall nurse's desk;-Both carts were unlocked and unattended by staff;-The carts contained resident treatment supplies, including bandages and prescription ointments and creams;-An open caddy on top of the treatment cart contained toothbrush holders containing resident insulin pens. Observation of the 300/400 Hall nurses' desk on 07/29/26 at 9:30 A.M., showed the following:- Licensed Practical Nurse (LPN) H approach the nurse's desk where two medications carts were located on the outside of the desk (between the 300 and 400 resident hallways);-LPN H said he/she needed to administer pain medication to a resident;-LPN H removed a set of keys from an open pocket on the outside of a soft side cooler located on the top of the medication cart;-LPN H used the keys to unlock both the medication cart and the controlled medication locked drawer, which contained various controlled substances, including resident narcotic pain medication;-LPN H returned the keys to the open pocket on the outside of the soft side cooler;-LPN H administered the pain medication, relocked the cart and walked away from the cart leaving the keys unsecure in the cooler. Observation of the 300/400 Hall nurses' desk on 07/29/26 at 9:43 A.M., 10:00 A.M., and 10:30 A.M., showed the following:-No nurses/staff at the 300/400 hall nurse's desk;-The medication room was located behind the nurse's desk;-The medication room keys were in the lock of the medication room door visible to anyone walking by the desk.-The 300 and 400 hall treatment carts were located in the short hallway between the resident hall and the resident activity room, around the corner from the 300/400 hall nurse's desk;-Both carts were unlocked and unattended by staff;-The carts contained resident treatment supplies, including bandages and prescription ointments and creams;-An open caddy on top of the treatment cart contained toothbrush holders containing resident insulin pens. Observation of the 300/400 Hall nurses' desk on 07/29/26, at 12:10 P.M., showed the following:-Two unlocked medication carts in the common area near the dining room, the drawers could be opened without a key;-Two Certified Medication technicians (CMT) staff in the dining room with residents providing medications;-One resident in the common area near the medication carts, self-propelling in a wheelchair;-CMT G returned to the cart and prepared medications, he/she then pushed the lock halfway and returned to the dining room, the cart could be opened without a key;-CMT F returned to the cart and prepared medications, he/she returned to the dining room and did not lock the cart. During an interview on 07/29/26, at 1:05 P.M., CMT F said medication carts should be locked any time staff step away from the cart. He/She said medication carts should not be partially locked. During an interview on 07/29/26, at 2:35 P.M., LPN D said the following:-Keys were in the medication room door, however the room only contains the emergency medication kit, but the kit is locked;-The medication carts were unlocked when they were at the nurses' station;-Some CMT staff always keep the keys with them, and some staff leave the keys in a container on the top of the cart;-The carts should be locked when staff are not nearby. During an interview on 07/29/26 at 1:37 P.M., the Director of Nursing (DON) said the following:-Nurses and CMT's should keep the medication carts, controlled medications drawer, the medication room door, and the treatment carts locked when not in use;-Nurses or CMTs are responsible for medications and should keep the keys on their person;-Some of the staff leave the medication cart keys in the pocket of cooler bag on top of the cart. Staff have had issues with accessing resident medication when a staff leaves for break and forgets to leave the keys;-The medication room keys are a different set of keys and the nurse on duty should keep those on his/her person;-Medication room keys should not be left in the door, as that could potentially allow medication room access to a visitor or other employee who should not have access;-The nurses should ensure the treatment carts are locked when not in use and should not leave insulin pens on top of the treatment cart unattended. This could lead to someone potentially tampering with or stealing resident insulin pens or treatments supplies. During an interview on 07/29/26 at 2:36 P.M., LPN D said the following:-Nurses regularly leave the keys in the medication room doors;-The nurses always leave the treatment carts unlocked and leave the resident insulin pens on top of the cart;-Some of the CMTs leave the medication cart keys in the cooler bag on top of the carts;-When staff leave the carts unlocked, or keys in the medication room door, a resident, visitor, or another staff member could potentially take the resident medication;-He/She is unaware of the regulations regarding control of resident medications/controlled medications. During an interview on 07/29/26 at 3:18 P.M. CMT I said the following:-Nurses and CMTs should keep the medication and treatment carts locked at all times when not in use;-The nurses and CMTs who are responsible for the carts and medication room should keep the keys in their pockets;-If a staff member leaves the facility, they should give the keys to the nurse on duty before leaving;-Insulin should be stored in the medication room. During an interview on 07/30/26 at 1:53 P.M., the Administrator said the following:-Nurses and CMTs should ensure all medication rooms, medication carts, and treatment carts are kept locked and they should keep keys secure on their person.

Based on record review and interview the facility failed to document notification of the responsible party or emergency contact of the resident's change in health condition, transfer to and return from the hospital for one Resident (Resident #1). The facility census was 77.Review of the undated facility policy, titled Condition Change, Resident, showed the following:-After all resident falls, injuries of changes in physical or mental function, monitor the resident;-Notify the resident's responsible party;-Monitor resident's condition frequently;-Notify physician of condition change, need for treatment orders and/or medication order changes. Review of the undated facility policy, titled Charting and Documentation, showed the following:-Chart all pertinent changes in the resident's condition, as well as routine observations;-Any transfers, including to the hospital, should include date and time transfer was made, reason for the transfer, dated and time the family was notified and by whom, location and mode of transfer, resident's response to the transfer, all pertinent observation;-Other documentation should include any time the physician or family is called about the resident as well as their response. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following:-admission date of 01/14/25;-Diagnoses included: Dementia (decline in mental ability severe enough to interfere with daily life) with anxiety, repeated falls, acute cerebrovascular insufficiency (sudden drop in blood flow to the brain caused by blocked arteries or low blood pressure), paroxysmal atrial fibrillation (an irregular and often very rapid heart rate that can lead to blood clots in the heart);-Two emergency contacts listed with name and phone number. Review of the resident's care plan, last updated 04/16/26, showed no information regarding family or emergency contact. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 05/22/26, showed the resident has a moderate cognitive impairment. Review of the resident's nursing notes for June 2026, showed the following:-On 06/18/26 at 2:42 P.M., the certified nurse assistant (CNA) informed the registered nurse (RN) that the resident was talking with slight slurring. The nurse assessed the resident, and vitals were obtained: Blood pressure (BP) was 68/42 (normal 120/80), Heart rate (HR) was 94 (normal 60-100), recheck BP was 78/44, HR was 142, Oxygen saturation was 90% (normal 95 to 100%). The resident was placed on oxygen at 3 liters, increased up to 97%. Decreased oxygen to 2 liters and called 911. The Director of Nursing (DON) sat with the resident while waiting for the ambulance. Emergency Medical Services (EMS) arrived and transported the resident to the hospital;-On 06/18/26, at 11:00 P.M., staff contacted the emergency room (ER) for report. The ER nurse explained via phone that the patient was given intravenous (IV) fluids for dehydration. The ER doctor also suggested swapping the tizanidine (short-acting muscle relaxer) order and instead using Robaxin (muscle relaxant for short-term relief) for less sedating effects on the patient;-No documentation of family or responsible party notification. Review of the emergency department note, dated 06/18/26, showed the resident arrived at the ER at 2:50 P.M. and was discharged from ER at 6:27 P.M. During an interview on 07/29/26, at 10:45 A.M., Resident #1 said that he/she went to the hospital for treatment of low blood pressure and not feeling well. The hospital brought him/her back to the facility later that day. He/She does not know if the staff contacted his/her family. During an interview on 07/29/26, at 10:30 A.M., RN A said when a resident has a change in condition or is sent to the hospital, the nurse should contact the family. This information should be documented in the resident's chart. During an interview on 07/29/26, at 10:40 A.M., RN B said the following:-If a resident is sent out to the hospital, he/she would chart the resident's condition;-He/she would notify the physician, the family, the DON, and hospice, if applicable and document the notification;-If the resident re-admits, he/she would chart that the resident returned, including contact made with the family, DON, and physician. During an interview on 07/29/26, at 11:05 A.M., Social Services said the following:-Nursing staff should document the reason the resident was transferred to the hospital and notifications (physician, family, and management);-When a resident returns from the hospital, staff should chart how they arrived, such as via ambulance or private vehicle, the time they returned, and the resident's overall appearance;-Staff should notify the family and physician when the resident returns, and document the information in the resident's chart;-He/She is unaware if Resident #1's family was notified of his/her discharge to the hospital or return. During an interview on 07/29/26, at 2:35 P.M., Licensed Practical Nurse (LPN) D said the following:-When a resident is sent to the hospital, nursing staff should make a progress note that includes the resident's condition, notification of DON, physician, family, and hospice, if applicable;-When a resident returns from the hospital, staff should complete an assessment of the resident and notification should be made;-This information should be documented in the resident's chart. During an interview on 07/29/26, at 3:05 P.M., LPN E said the following:- Resident #1 was transported to the emergency room;-He/She does not know if the family was contacted when the resident was transferred to the hospital, or when he/she returned;-All notifications made should be documented in the resident's chart. During an interview on 07/30/26, at 1:50 P.M., LPN C said the following:-He/She re-admitted Resident #1 when he/she returned from the hospital;-He/She does not recall if he/she contacted the family upon the resident's return;-Nursing staff should document notifications (physician, DON, and emergency contact) when a resident returns from the hospital;-An assessment and vital signs should also be documented upon return. During an interview on 07/30/26, at 10:40 A.M., the DON said the following:-Resident #1 was sent by ambulance to the hospital due to elevated heart rate and low blood pressure;-The physician was contacted and a message was left for the family;-The hospital did not call the facility when the resident was discharged from the hospital;-The family should have been notified when the resident returned from the hospital;-All notifications should be documented in the resident's chart. During an interview on 07/30/26, at 1:55 P.M., Administrator said the following:-Nursing staff should document the resident's condition prior to being sent to the hospital;-Notifications, including the physician and responsible party, should be made and documented;-Staff should document when the resident returns from the hospital, along with responsible party notifications. #3050052

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week when the facility did not have consistent RN coverage on the weekends. The facility census was 75.Review showed the facility did not have a specific policy pertaining to the scheduling of an RN. 1. Review of the facility's nurse schedule, timecard reports for all RNs, and facility form entitled Salaried Personnel - Direct Resident Care Logs (Salaried Time Log - logged working hours by salaried employee), dated December 2025, January 2026, and February 2026, showed the following:-On Saturday, 12/06/25, no RN was scheduled. The Minimum Data Set Coordinator/RN (MDS - a federally mandated comprehensive assessment tool completed by facility staff)) worked for 6.9 hours; -On Saturday, 12/20/25, no RN was scheduled and no RN logged time; -On Saturday, 12/27/25, no RN was scheduled. The MDS RN worked for 4.4 hours; -On Sunday, 12/28/25, no RN was scheduled. The MDS RN worked for 3.8 hours; -On Saturday, 01/03/26, no RN was scheduled. The MDS RN worked for 4.4 hours; -On Sunday, 01/04/26, no RN was scheduled and no RN logged time; -On Saturday, 01/17/26, no RN was scheduled and no RN logged time; -On Sunday, 01/18/26, no RN was scheduled and no RN logged time; -On Saturday, 01/31/26, no RN was scheduled. The MDS RN worked for 4.7 hours; -On Sunday, 02/01/26, no RN was scheduled. The MDS RN worked for 4.1 hours; -On Saturday, 02/07/26, no RN was scheduled and no RN logged time;-On Sunday, 02/08/26, no RN was scheduled and no RN logged time. During an interview on 02/12/26, at 1:15 P.M., RN K said he/she worked every other weekend. The RN was not sure how they scheduled RN coverage on the alternate weekends or when he/she had requested off. During an interview on 02/12/26, at 1:20 P.M., the Director of Nursing (DON) said the facility currently had only one floor RN, who works every other weekend. They try to fill in hours on the alternate weekends with the DON, one as-needed (prn) RN, and the MDS Coordinator, who is an RN. When the DON works on the floor, he/she records the time on the Salaried Personnel - Direct Resident Care Logs (Salaried Time Log). The prn RN and MDS RN record their weekend time by using the time clock. During an interview on 02/13/26, at 8:10 A.M., the DON said the facility did not have a policy specific to RN coverage. They should just follow the regulations. During an interview on 02/12/26, at 1:25 P.M., the facility Administrator said they had a shortage of RNs on staff. There were gaps on some weekends, and they were not always in compliance with the required RN coverage of eight consecutive hours daily.

Based on record review and interview, the facility failed to implement their abuse and neglect policies when staff failed to complete criminal background checks (CBCs) for two of ten sampled employees prior to their hire/start date in a facility with a census of 75. Review of the facility's Abuse Prohibition Protocol Manual (effective 11/28/2016) showed the following:-The facility must develop and implement written policies and procedures that: -prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of property;-It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check;-The facility will not hire an employee or engage an individual who was found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law;-A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation;-Regarding Background Checks: -The Family Care Safety Registry (FCSR) or the Employee Disqualification List (EDL) and Criminal Background Check (CBC) must be checked before the applicant/employee has any contact with residents. If you have received the EDL results and have made the CBC request, the applicant can start working at the facility. Once you receive the CBC results, you then have to evaluate the results. If the applicant/employee has a conviction on their criminal background check, Missouri facilities must check the Missouri Disqualifying Crimes list to determine if the conviction disqualifies them from employment. If the conviction is not specifically listed, the Administrator will review the file with the Quality Assurance Nurse or Director of Operations for a decision on hiring/retaining the applicant/employee. If the conviction is on the list, the applicant/employee cannot work or volunteer in the facility;-Always keep a hard copy of CBC request and the results for each employee. If you don't have these copies in the employees' files, the State will cite you. 1. Review of Dietary Aide (DA) U's employee record showed his/her hire date was 11/17/25. Staff documented a request for a CBC on 02/12/26. The facility did not document a completed CBC prior to 02/12/26 for DA U. 2. Review of Housekeeping (HK) V's employee record showed his/her hire date was 04/14/25. The facility did not document a completed CBC for HK V. 3. During an interview on 02/13/26, at 12:58 P.M., the Assistant Business Office Manager (Asst. BOM) said he/she was responsible for completing background checks on job applicants and providing education to new employees regarding abuse and neglect policies and procedures. The Asst. BOM said he/she had requested a CBC for DA U, but the results were not received. He/she said there was potentially some misinformation on the employee's request for inclusion on the FCSR that needed to be addressed by the employee or the Asst. BOM. When the state surveyor presented the list of sampled employees related to background checks, he/she had noted the uncompleted CBC and resubmitted a request on 02/12/26. HK V had requested inclusion on the FCSR, but the facility had not received a completed CBC back from them. The Asst. BOM said they had the availability of using a third-party investigation service for running background checks, but was told by a corporate manager not to enlist their services unless the facility did not get a response from FCSR. During an interview on 02/13/2026, at 1:03 P.M., the Director of Nursing (DON) and the corporate Quality Assurance Support Nurse (QA RN) said full background checks are to run, usually by the Asst. BOM, on all applicants prior to hire. The QA RN said he/she didn't think they should hire anyone until the CBC was done. Both staff said their screening policy says an employee cannot work with residents until the CBC is done to confirm there are no disqualifying indicators. The facility can use a third-party service to request a background check. During an interview on 02/13/26, at 1:22 P.M., the Administrator said the Asst. BOM had told him/her there had been some delays in response from the State's FCSR; occasionally taking up to five days to receive a clean report. The Administrator said the facility should use their available alternate investigative service to request a background check if there wasn't a quick response from FCSR. Staff can't work with residents until the background checks are done.

Based on observation, interview, and record review, the facility failed to maintain the medication storage refrigerator at the recommended temperatures, per manufactures recommendations, for multiple medications stored in the refrigerator for use. The facility census was 75.Review of the facility's policy titled Medications, Storage of, undated, showed the following:-Biologicals or medications requiring refrigeration must be kept in a separate, securely fastened refrigerator;-Drugs must be stored at appropriate temperature levels. Drugs stored in a refrigerator must be stored between 36 and 46 degrees Fahrenheit (F).Review of the Centers for Disease Control and Prevention (CDC) Guidelines for vaccines, dated 03/19/24, showed the following:-Never freeze refrigerated vaccines:-Ideal temperature of refrigerated vaccines is 40 degrees F;-Refrigerator temperature should be between 36 degrees F and 46 degrees F.Review of Lantus (insulin) package insert, dated December 2025, showed the following:-Keep unused Lantus pen or vial in refrigerator at 36 degrees F to 46 degrees F;-Do not freeze Lantus;-Store in use Lantus pen or vials in a refrigerator or at room temperature below 86 F.Review of the Novolog (rapid acting insulin) package insert, undated, showed the following:-Keep Novolog pen or vial in refrigerator at 36 degrees F to 46 degrees F;-Do not allow insulin to freeze.1. Observation on 02/11/26, at 9:31 A.M., of the medication refrigerator located in the medication room with Licensed Practical Nurse (LPN) A showed the following: -Five boxes of influenza vaccine for resident use with warning on box to store between 36 and 46 degrees;-Twenty-five pens of Lantus for resident use;-Twenty-five pens of NovoLog for resident use;-Fridge temperature measured 31 degrees.Review of the December 2025, January 2026, and February 2026 logs showed missing entries on 12/17/25, 12/18/25, 12/19/25, 12/22/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 01/02/26, 01/03/26, 01/24/26, 01/29/26, 01/30/26, 1/31/26, 02/06/26, 02/07/26, and 02/26/26.Observation on 02/12/26, at 11:26 A.M., of the medication refrigerator located in the medication room with Certified Medication Tech (CMT) B showed Keep refrigerator at 36 to 46 degrees written on refrigerator log on door of refrigerator.During an interview on 02/12/26, at 12:35 P.M., LPN C said the following:-Refrigerator temperatures are checked once a day by the night shift nurse;-He/she did not know what the temperature is supposed to be kept at but its listed on the refrigerator;-If temperatures are out of range nursing staff can adjust setting and notify the maintenance director.During an interview on 02/12/26, at 12:48 P.M., the Maintenance Director said the following:-Nursing staff will notify him/her if a refrigerator was not working correctly;-He/she can adjust setting and replace refrigerator if needed. During an interview on 02/12/26 at 2:32 P.M., LPN D said the following:-He/she is not sure what the temperature of the refrigerator should stay at but thinks it's 32 to 42 degrees F;-Night shift nurses check and maintain the temperature logs;-It is important to maintain proper temperature of the stored medication to insure it is working correctly.During an interview on 02/13/26, at 9:40 A.M., the Assistant Director of Nursing (ADON) said the following:-Refrigerator temperatures should be maintained at 36 to 46 degrees F;-Night shift nursing staff checks the temperatures and maintains an written daily log of all temperatures;-Nursing staff should notify the Maintenance Director if a refrigerator is not maintaining a proper temperature. -Nursing staff should consult with the pharmacist if a medication is stored in a temperature out of range because it may need to be replaced. During an interview on 02/13/26 ,at 11:46 A.M., the Director of Nursing (DON) said the following:-He/she expected nursing staff to notify him/her if any refrigerator is not operating correctly;-It was important to maintain proper temperature's because keeping them out of range can shorten the shelf life of the medication;-Thermostats and refrigerators can and will be replaced if needed.During an interview on 02/12/25, at 1:22 P.M., the Pharmacist said the following:-All medication stored in the refrigerator should be kept between 36 and 46 degrees F;-Staff should be checking and adjusting the temperature as necessary per facility policy;-He/she had made recommendations to the facility in the past to replace thermometers and to educate staff on proper storage of refrigerated medications;-It was important to maintain proper temperatures because failing to do so can destroy the medication or shorten the shelf life of the medication. During an interview on 02/13/26, at 3:20 P.M., the Administrator said the following:-He expected staff to follow facility policies in regards to storing refrigerated medication;-He expected staff to be monitoring the temperatures per policy.

Based on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use proper hand hygiene and Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during wound care for one resident (Residents #58) and medication administration for one resident (Resident #8) who had a feeding tube. Staff failed to complete proper hand hygiene during diabetic accu-checks (a point of care blood test) for one resident (Resident #1). A sample of 16 residents was reviewed. The facility census was 75.Review of the facility policy titled, Enhanced Barrier Precautions to Infection Control Guidance, undated, showed the following:-EBP is used to prevent the broader transmission of MDROs and to help protect patients with chronic wounds and indwelling devices;-EBP should be implemented for the period of their (the residents) stay or until wounds have resolved or indwelling medical devices have been removed; -EBP should be used when providing high contact resident care such as wound care, transferring, bathing, changing briefs and linens, caring for indwelling devices;-Gloves and donning and doffing of gown are required when conduction high contact resident care that are listed above. Review of the facility policy Standard and Transmission-Based Precautions, undated, showed the following: -Hand hygiene referred to hand washing with soap or using alcohol-based hand rubs that do not require water;-Hands shall be washed with soap and water whenever visibly soiled;-Wash hands after removing gloves;-Wear gloves and change as necessary during the care of a resident to prevent the cross contamination from one body site to another;-Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Review of the facility policy Diabetic Infection Control, undated, showed the following: -Gloves are to be worn when preforming finger sticks and changed between residents;-Preform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for the use on another resident. 1.Review of Resident #58 face sheet (a form that provides resident details) showed the following: -admission date of 09/26/25;-Current diagnoses included chronic venous ulcer and inflammation of the right lower extremity (a type of chronic wound to the right lower leg), pressure ulcer of unspecified part of back (a wound to the back), and pressure ulcer to the right buttock (a wound to the right buttock). Review of the residents' quarterly Minimum Data Set (MDS-federally mandated assessment tool administered by staff), dated 01/02/26, showed the following:-Cognitively intact with no memory concerns;-Needed partial assistance with lower body care;-Foley catheter (flexible tube inserted into the body to drain fluids (like urine));-Had pressure ulcers. Review of the residents' Physician Order Report, dated 02/13/26, showed the following: -An order, dated 11/03/25, for EBP related to catheter and pressure ulcer;-An order, dated 02/11/26, to cleanse the right buttock and apply collagen powder and Maxorb-alginate dressing (a type of wound dressing), cover with border gauze, and skin prep around wound bed. Review of the resident's care plan, revised 1/20/26, showed the following:-Risk for impaired skin integrity;-EBP due to high risk of infection. Observation of wound care on 02/10/26, at 11:02 A.M., by the Assistant Director of Nursing (ADON) and Director of Nursing (DON) showed the following:-Nursing staff washed hands, donned gloves, gathered supplies and entered the room. (The ADON and DON did not don gowns);-The DON completed wound care on resident's lower back, removed gloves, and donned new gloves;-Staff assisted resident to turn on his side removed brief and cleansed buttocks before starting wound care;-While assisting with turning the resident the ADON picked up and moved the foley catheter bag with gloved hands and then touched resident gown, covered the resident, and proceed to pick up pen and paper and moved them to the dresser before his/her changing gloves without performing hand hygiene. 2. Review of Resident #8's face sheet showed the following information:-admission date of 09/14/25;-Diagnoses included dominant /right side spastic hemiplegia and hemiparesis (weakness or paralysis) following a stroke, aphasia (difficulty with speech) following stroke, difficulty swallowing, gastrostomy status (feeding tube placed through an opening into the stomach), Type 2 diabetes, atrial fibrillation (a-fib; irregular heart rhythm), chronic obstructive pulmonary disease (COPD - breathing disorder, respiratory failure, acute bronchitis, cough, wheezing, obesity, disease of stomach (unspecified)z), cellulitis of lower limb (skin infection, occurs when bacteria enters a skin disruption such as injuries, wounds, surgical cuts, burns, etc.), pressure ulcer, kidney failure chronic pain syndrome, and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderately impaired cognition;-Impaired range of motion to upper and lower extremity, one sided;-Feeding tube in place while a resident with intake via tube 51% or more;-Incontinent of bowel and bladder;-Dependent on others for bed mobility and use of manual wheelchair. Review of the resident's care plan, last updated 01/20/26, showed the following:-EBP related to PEG tube (a soft, flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly);-Resident to be free of infection; -Ensure proper personal protective equipment is used;-Risk for infection related to PEG tube insertion site; -PEG site will remain clean, dry, and free from signs of infection; -Flush tube with prescribed amount of water before and after medications and every 4-6 hours. Review of the resident's Physician Order Sheet (POS), current as of 02/13/26, showed the following:-An order, dated 09/14/25, for NPO (nothing by mouth);-An order, dated 09/14/25, for enteral nutrition (tube feeding). The continuous feeding may be discontinued for up to one hour per day for bath and administration of medications;-An order, dated 09/14/25, flush tube with 30 milliliters (ml) of water before and after medications every shift;-An order, dated 01/06/26 for EBP related to PEG tube;-An order, dated 01/28/26, for Jevity (nutritional supplement) 1.5 calorie liquid food, 50 ml/hour (hr) per gastric tube with [NAME] water pump/bag, flush and Jevity both run at 50 ml/hr via pump. Review of the resident's electronic Medication Administration Record (eMAR), dated 01/01/26 to 02/13/26, showed staff documented administration of medications through the feeding tube per physician orders. Observation on 02/09/25, at 11:54 A.M., showed the resident's door indicated a need for EBP. Observation on 02/11/26, at 11:43 A.M., showed the resident's tube feeding pump audibly indicated a need for nurse assessment. The concurrent water bag was approaching empty. Observation on 02/12/2026, at 12:40 P.M., showed Licensed Practical Nurse (LPN) A utilized hand sanitizer gel and donned gloves, but did not don a surgical gown, and entered the resident's room. After explaining the procedure to the resident and stopping the feeding pump, LPN A used a syringe to instill air into the PEG tube and placed the bell of the stethoscope against the resident's skin to verify tube placement. LPN A then replaced the syringe with a graduate (funnel) and flushed the tubing with water. The tubing was clogged; The LPN massaged the tubing until he/she was able to advance the water through the tubing. LPN A poured premeasured medications into the graduate, allowing each to instill per gravity with the graduate held above the tube insertion site. LPN A added 30 ml of water to flush the medications through the tubing. The LPN removed the graduate, reconnected the tube feeding, and restarted the pump running at 50 ml/hr. 3. During an interview on 02/12/26, at 11:08 A.M., Certified Nurse Aide (CNA) I said the following: -EBP means staff are to wear a gown and gloves when entering the room;-It was to protect the resident and us from infections. During an interview on 02/12/26, at 11:15 A.M., CNA J said EBP was for residents with catheters and means we are to wear a gown and gloves when entering that room. During an interview on 02/12/26, at 12:35 P.M., LPN C said EBP the following: -EBP was used to protect residents that have wounds and foley catheters;-Staff should use gown and gloves when taking care of EBP residents. During an interview on 02/12/26, at 2:32 P.M., LPN D said the following:-EBP was for all residents with open wounds, or foley catheters;-He/she expected all staff to wear gown and gloves for EBP residents while completing patient care. During an interview on 02/12/26, at 1:15 P.M., Registered Nurse (RN) K said staff should follow EBP for working closely to residents with wounds, indwelling catheters, or tubing of any kind, such as tube feeding. He/she said EBP should be used when administering medications through a PEG tube. During an interview on 02/13/26, at 9:40 A.M., the ADON said the following:-Any resident with open wounds, or indwelling devices will be placed on EBP precautions;-Staff should wear a gown and gloves when performing direct resident care;-He/she expects all staff to follow EBP. During an interview on 02/13/26, at 11:46 A.M., the DON said the following:-EBP was to protect residents and staff from infections;-All residents with foley cath, IV, history of MRSA (a MDRO), or indwelling devices can be placed on EBP;-Gown and gloves are required depending on task;-If there is resident contact, contact with bodily fluids, staff should be wearing gown and gloves;-He/she expected all staff to follow EBP precautions. During an interview on 02/13/26, at 3:20 P.M., the Administrator said he expected all staff to be following EBP precautions including during wound care; 4. Review of Resident #1 face sheet showed the following: -admit date [DATE];-Diagnoses included diabetes (a disease where the body fails to regulate blood sugar levels). Review of the residents' physician order report, dated 02/13/26, showed and order for humalog insulin (fast acting insulin to lower blood sugar levels) to give 3 units subcutaneous (under the skin) three times a day. Staff to hold if blood sugar level was less than 120 milligram/deciliter (mg/dL). Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Observation on 02/11/26, at 11:16 A.M., showed the following: -CMT H donned gloves without performing hand hygiene; -CMT H completed the accu-check (blood sugar check), doffed gloves, obtained insulin, and donned gloves without performing hand hygiene;-CMT H completed insulin administration, doffed gloves, and charted results without performing hand hygiene. 5. During an interview on 02/12/26 at 11:08 A.M., CNA I said staff should wash hands before and after entering a room and when changing gloves. During an interview on 02/12/26, at 11:15 A.M., CNA J said staff should wash hands before and after contact with a resident. During an interview on 02/12/26, at 12:35 P.M., LPN C said all staff should wash hands before and after contact with a resident and when changing gloves. During an interview on 02/12/26, at 2:32 P.M., LPN D said he/she expected all staff to wash hands before and after contact with a resident and when changing gloves. During an interview on 02/13/26 at 9:40 A.M., the ADON said the following:-He/she expected all staff to wash hands before and after patient contact, when going from dirty surface to clean, and when changing gloves;-He/she expects all staff to follow handwashing precautions. During an interview on 02/13/26, at 11:46 A.M., the DON said all staff should wash hands before and after resident contact and when changing gloves. During an interview on 02/13/26 at 3:20 P.M., the Administrator said he/she expected all staff to wash hands before and after resident contact and when changing gloves.

Based on observation, interview, and record review, the facility failed to complete a comprehensive and individualized care plan for one resident (Resident #10). The care plan failed to include monitoring and interventions for the following: high fall-risk; insulin (a medication that lowers the level of glucose in the blood for treatment of diabetes), for an anticoagulant (prevent or reduce the ability of the blood to clot) medication; and toileting needs. The facility census was 75.Review of the facility's (undated) policy titled, Care Plan Comprehensive, showed the following:-The purpose of an individualized comprehensive care plan includes measurable goals and time frames developed to meet the resident's highest practicable physical, mental, and psychosocial well-being.-The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff).-Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition.-A well-developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence. -Managing risk factors to the extent possible or indicating the limits of such interventions. -Addressing ways to try to preserve and build upon resident strengths. -Applying current standards of practice in the care planning process. -Evaluating treatment of measurable goals, timetables and outcomes of care. -Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. -Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. -Involving the direct care staff with the care planning process relating to the resident's expected outcomes. -Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting.-The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: -When a significant change in the resident's condition has occurred. -At least quarterly. -When changes occur that impact the resident's care. The facility did not provide a specific policy for the monitoring of the anticoagulant medication Eliquis (a prescription blood thinner used to treat and prevent blood clots). 1. Review of Resident #10's face sheet (brief resident profile sheet) showed the following information:-admitted to the facility on [DATE];-readmitted to the facility on [DATE];-Diagnoses included weakness; other reduced mobility; atrial fibrillation (heart rhythm disorder that causes the heart to beat fast and inefficiently, often leading to palpitations, dizziness, and fatigue. It increases the risk of blood clots and stroke); hypertension (high blood pressure); fracture of left femur (bone extends from the hip to the knee); diarrhea; constipation; insomnia (a sleep disorder that causes difficulty getting or staying asleep); depression; encephalopathy (any diffuse disease of the brain that alters brain function or structure); type 2 diabetes. Review of the current physician order report showed the following: -Order dated 08/12/25, Eliquis 2.5 milligrams (mg), 1 tablet, twice per day;-It did not show any orders for oxygen for the resident. Review of the resident's bowel/bladder assessment, dated 08/13/25 showed the following:-Always incontinent of bowel;-Constipation present;-Always incontinent of urine;-Staff did not assess the resident for a urinary toileting program;-Resident never aware of toileting needs. Review of the resident's fall risk assessment, dated 08/13/25 showed the following:-History of one or more falls within the previous 6 months;-Urgency, frequency and incontinence with elimination;-On one high fall risk drug;-Required assistance or supervision for mobility, transfer, or ambulation;-Altered awareness of immediate physical environment, impulsive, and lack of understanding of one's physical and cognitive limitations;-Staff identified resident at high risk for falls. Review of the physician order report showed the following:-Order dated 09/16/25, Novolog FlexPen U-100 Insulin, 100 unit/3 milliliter (mL) per sliding scale, before meals and at bedtime: -If blood glucose is 140 to 199, give 2 units; -If blood glucose is 200 to 249, give 4 units; -If blood glucose is 250 to 299, give 6 units; -If blood glucose is 300 to 349, give 8 units; -If blood glucose is greater than 349, give 10 units. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Severe cognitive impairment;-Always incontinent of bowel and bladder;-Required extensive to total assistance from staff with bed mobility, transfers, toileting and locomotion (movement from one place to another);-Resident had two or more falls since admission/entry or reentry;-Insulin injections;-Anticoagulant use. Review of the resident's care plan revised/reviewed on 01/06/26, showed the following:-Problem start date of 01/06/26, showed impaired gas exchange related to chronic respiratory failure;-Administer two-six liters per minute of oxygen through a nasal cannula as ordered;-Supplemental oxygen can help maintain oxygen saturation at a normal level.-Avoid high concentrations of oxygen for patients with chronic obstructive pulmonary disease (COPD, a progressive lung disease that causes obstructed airflow, leading to severe breathing difficulties).-Staff did not address the resident's diagnosis of diabetes, signs and symptoms to monitor for problems related to diabetes.-Staff did not address the resident's toileting abilities, needs, or a toileting plan.-Staff did not address the resident's anticoagulant use and/or any signs and symptoms related to it's use.-Staff did not address the resident's high fall risk or any interventions to prevent falls. Review of the medication administration record (MAR) dated 02/01/26 - 02/12/26 showed the following:-Staff administered Eliquis 2.5 mg, one tablet, twice a day;-Staff administered Novolog FlexPen insulin according to the orders on the sliding scale. Staff administered the insulin at least daily. During an interview on 02/12/26, at 4:45 P.M., NA T said the following:-He/she would look for the resident's toileting plan in the care plan.-Staff should offer to toilet residents every two hours.-Resident #10 will only go to the bathroom when offered, will not ask, and does need to be prompted.-The aide did not know of any specific toileting plan for the resident.-He/she is usually incontinent, and his/her brief is usually wet.-He/she would not expect for the resident to be dry for an entire shift.-The resident's toileting information should be on the care plan.-The aide did not know if the resident was at risk for falls.-NA T would look on the care plan to find out if a resident was at-risk for falls.-NA T was not sure how to know if a resident was on a blood thinner.-NA T would look on the resident's care plan to find out if he/she was a diabetic. During an interview on 02/13/26, at 8:46 A.M., LPN C said the following:-Resident #10 was absolutely a fall risk.-The resident has had several falls but did not remember the number of falls.-LPN C would not leave the resident in his/her room because he/she would try to get up.-He/she did not know if the resident was on a blood thinner.-LPN C knew the resident was a diabetic.-He/she would expect insulin information to be on the resident's care plan.-LPN C did not know for sure if the resident had been on oxygen while at the facility. During an interview on 02/13/26, at 10:38 A.M., the Director of Nursing (DON) said the following:-She would expect residents at risk for falls and any fall interventions to be on the care plan.-Residents on an anticoagulant should have monitoring for signs/symptoms of bleeding on the care plan.-She would expect staff to monitor residents on an anticoagulant for bruising or any change of condition.-She would like to see anticoagulant monitoring on the care plan. She thought it was on the care plan if a resident was on specific anticoagulants like warfarin or Lovenox, but she did not think it was on care plans for medications that did not require regular blood laboratory tests.-She would expect staff to monitor all diabetic residents for symptoms of sweating, shaking, anything like that and to report it to the nurse.-She would expect for oxygen use not to be on a resident's care plan if the resident did not use oxygen or have oxygen ordered.-MDS coordinator X usually updates the care plans, but he/she was on vacation at this time. During an interview on 02/13/26, 11:35 A.M., MDS Coordinator W said the following:-The long-term care MDS coordinator X was on vacation. He/she is the MDS Coordinator for the rehabilitation section of the facility.-He/she would complete a resident's care plan by reviewing the physician orders, communicating with staff at the interdisciplinary team meetings (IDT - a group of professionals with expertise in different areas that coordinate care) every morning, at the weekly Medicare meetings, and at care plan meetings.-The long-term care MDS coordinator X; the social worker; the resident and their family, all share and collect information about each resident's needs.-He/she completes the sections of the MDS and the Care Area Assessments (CAAs - identifies the underlying causes, contributing factors, and risks related to the triggered area, helps to determine if a care plan intervention is necessary).-He/she would assess the resident as a whole and look at progress notes.-He/she would add to a care plan if a specific need was recognized and was not triggered on the CAA.-He/she expects anticoagulant medication monitoring to be on a care plan.-He/she expects residents at risk for falls and the interventions to be on the care plan.-He/she would expect for a diabetic diagnosis, insulin use, signs/symptoms of low blood glucose and high blood glucose, and the interventions to be on a care plan.-He/she would assess a resident's toileting abilities and plan by reviewing daily notes, the activities of daily living documentation by the CNAs and at the weekly Medicare meeting.-He/she would expect residents' toileting needs to be on the care plan. During an interview on 02/13/26, at 3:20 P.M., the Administrator said the following:-He would expect a toilet plan or assistance with toileting to be on a resident's care plan. It would ensure they maintain dignity, resident comfort and help prevent urinary tract infections (UTIs).-The MDS coordinator is ultimately responsible for the care plans.-Staff use IDT formatting, pull information from point of care (POC) charting completed by the CNAs, first person interviews, and nursing notes to make residents' care plans.-It would depend on the type of anticoagulant medication on whether it should be on the care plan. The care plan might need to have signs of bleeding and bruising on the care plan.-He would expect for a diabetic diagnosis, insulin use, and monitoring for signs/symptoms of high glucose and low blood glucose to be on a care plan.-All of the residents' needs and desires should be on the care plan to ensure the needs are met.

Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to provide assessments after falls in accordance with their change in condition policy and neurological assessment sheet (evaluation of the functioning of the nervous system, identifying any abnormalities or neurological deficits.) for two residents (Resident #12 and Resident #45) after each resident sustained a fall with potential for head injury. The facility census was 75.Review of the facility policy titled, Condition change, resident (observing, recording, and reporting) (includes falls), undated, showed the following:-After all residents fall, injuries or changes in physical or mental function, monitor the following: Observe for lacerations, swelling, discoloration, convulsions, headache, pain, personality changes, alterations in consciousness, incontinence, sensory disorder, weakness, speech disorder, gait change, stiff neck, reflexes, vital signs, bleeding, unequal pupils, flushing; -Monitor the resident's condition frequently until stable;-Complete incident, accident, risk management and report to the resident's responsible party and the physician; The facility did not provide a policy specifically covering neurological checks after fall. Review of the facility provided work sheet for neurological checks, undated, showed that neurological checks should be completed every 15 minutes times 4, every 30 minutes times 2, every hour times 2, every shift for 72 hours and that nurses' notes should reflect neurological assessments with each note. 1. Review of Resident #45's face sheet (a form that provides resident details) showed the following: -admission date of 10/21/25;-Diagnoses include chronic kidney disease, retroperitoneal hematoma (a potentially life-threatening collection of blood behind the abdominal lining caused by trauma), diabetes (a disease where the body fails to regulate blood sugar);-Resident is self-responsible. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/26/26, showed the following:-No cognitive impairment;-Depressed mood;-Used a walker for mobility;-Multiple falls since admission. Review of the resident's current care plan, revised on 01/19/26, showed at risk for falls due to muscle weakness and gait instability. Review of the resident's nursing progress notes, dated 11/23/25 at 3:20 P.M., showed Licensed Practical Nurse (LPN) D documented the resident fell (unwitnessed) and staff started neurological checks. Review of the resident's nursing progress notes, dated 12/04/25 at 06:06 A.M., showed LPN G documented the resident fell (unwitnessed) and staff started neurological checks. Review of the neurological assessment sheet dated 12/03/25 at 11:45 P.M., showed staff did not complete a neurological assessment on the 12/05/25, 10-6 shift, 12/06/25, 10-6 shift.Review of the resident's nursing progress notes, dated 12/11/25 at 07:49 A.M., showed Registered Nurse (RN) F documented the resident fell (unwitnessed) and staff started neurological checks. Review of the neurological assessment sheet dated 12/11/25, at 7:00 A.M., showed staff did not complete a neurological assessment on the 12/11/25, 10-6 shift, 12/12/25, 6-2 shift, 12/12/25, 10-6 shift, 12/13/25, 10-6 shift, 12/14/25, 6-2 shift. Review of the resident's nursing progress notes, dated 01/19/26 at 5:23 P.M., showed LPN E documented the resident fell (unwitnessed) and staff started neurological. Review of the neurological assessment sheet dated 01/19/26, at 5:00 P.M., showed staff did not complete a neurological assessment on the 01/21/26, 6-2 shift, 01/21/26, 2-10 shift, 01/21/25 ,10-6 shift, 01/22/25, 6-2 shift. During an interview on 02/12/26, at 12:35 P.M., LPN C said the following:-Nursing staff start neurological checks on all residents with an unwitnessed fall;-Nursing staff use neurological checks to monitor for changes in a resident with a potential head injury. During an interview on 02/12/26, at 2:32 P.M., LPN D said the following:-Nursing staff complete neurological checks on any resident with an unwitnessed fall;-Neurological checks are important to identify changes in a resident which could indicate a brain bleed. During an interview on 02/13/26 at 9:40 A.M., the Assistant Director of Nursing (ADON) said the following:-Nursing staff start neurological assessments on all residents with an unwitnessed fall;-Neurological assessments are important to help identify possible brain bleeds and changes in condition in residents with a head injury;-He/she expected nursing staff to complete all neurological checks. During an interview on 02/13/26 at 11:46 A.M., the Director of Nursing (DON) said the following:-He/she expected nursing staff to document in the nurses notes all falls and changes in condition;-Nursing staff complete neurological checks for all residents with an unwitnessed fall or a known fall with head injury. During an interview on 02/13/26 at 3:20 P.M., the Administrator said the following:-He/she expected nursing staff to start neurological assessments on residents with an unwitnessed fall or fall with head injury;-Neurological assessments are important to help staff identify possible brain injuries;-He/she expected nursing staff to complete all neurological assessments and document those assessments in the progress notes. 2. Review of Resident #12's face sheet showed the following:-admission date of 06/24/25;-Diagnoses included dementia, history of hip fracture, history of neck fracture, and head injury. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/10/26, showed the following:-Significant memory loss and severe cognitive decline;-Required touch, or partial assistance for transfers (such as moving from a chair to a bed);-Used a manual wheelchair independently;-Fell resulting in major injury in the past three months, while at the facility. Review of the resident's care plan, last updated 01/19/26, showed the following;-Unrealistic perception of abilities;-At risk for falls related to altered mental status and confusion;-At risk for falls due to a past hip fracture;-Impaired transfer ability. Review of the resident's John Hopkins Fall Risk Assessment, dated 01/21/26, showed staff assessed the resident at high fall risk (score of 18. The risk assessment for the resident had a score of 18, which is considered high fall risk. Review of the resident's progress notes, dated 12/17/25m showed staff documented the resident fell while getting out of his/her bed. The resident obtained a cut on the back of the hand. Staff did not complete neurological checks after the unwitnessed fall. Review of a fall report, dated 12/17/25, showed staff staff documented the resident fell in his/her bedroom, and the fall was unwitnessed by staff. The report directed staff to complete neurochecks on the resident for 72 hours since the fall was unwitnessed – per facility protocol, and to document appropriately. The same report showed body and pain observations. Staff left the neurological check section blank. Review of the resident's progress notes, dated 12/19/25 (two days after the fall), showed staff documented the resident's pupils equally reactive and responsive to light (PERRL). Staff did not document other assessments in the 72 hours (3 days) following the resident's unwitnessed fall. During an interview on 02/13/26 at 9:55 A.M., LPN C said he/she was unable to find that staff had completed ongoing assessments on the resident following the resident fall on 12/17/25. 3. During an interview on 02/12/26, at 12:35 P.M., LPN C said the following:-Nursing staff start neurological checks on all residents who have an unwitnessed fall;-Neurological checks are used to monitor for changes in a resident with a potential head injury;-It is important to complete the neurological assessments to know if the resident has had any changes. During an interview on 02/12/26, at 2:32 P.M., LPN D said the following:-Neurological checks were to be completed on any resident who has an unwitnessed fall;-Neurological checks were important to identify changes in a resident. During an interview on 02/13/26, at 9:40 A.M., the Assistant Director of Nursing (ADON) said the following:-Nursing staff were to start neurological assessments on all residents who have an unwitnessed fall;-Neurological assessments are important to help identify possible brain bleeds and changes in condition in residents with a head injury;-He/she expected nursing staff to complete all neurological checks. During an interview on 02/13/26, at 11:46 A.M., the Director of Nursing said the following:-He/she expected nursing staff to document in the nurses notes all falls and changes in condition;-Neurological checks were to be started and completed by nursing staff for all residents with an unwitnessed fall or a known fall with head injury. During an interview on 02/13/26 at 3:20 P.M., the Administrator said the following:-He/she expected nursing staff to start neurological assessments on residents with an unwitnessed fall or fall with head injury;-Neurological assessments were important to help staff identify possible brain bleed type injuries;-He/she expected nursing staff to complete all neurological assessments and documents those assessments in the progress notes.

Based on observation, interview, and record review, the facility failed ensure all residents maintained acceptable standards of nutritional status when staff failed to consistently encourage fluid intake for one resident (Resident #10) whose intake was less consistently that recommended by the registered dietician (RD) The facility census was 75.Review of the facility's policy titled Hydration, undated, showed the following:-The amount is based on careful assessment. Fresh water is to be distributed each shift, with glasses within reach of the resident;-Assistance will be given by staff for residents unable to drink independently;-Between-meal hydration programs, such as juice carts and related activities promote fluid intake;-The following conditions should be considered included dehydration, confusion or disorientation, concentrated urine, total dependence and other conditions at the discretion of the nurse. 1. Review of Resident #10's face sheet (brief resident profile sheet) showed the following information:-admission date of 7/16/25;-Diagnoses included weakness, other reduced mobility, encephalopathy (any diffuse disease of the brain that alters brain function or structure), and type 2 diabetes.Review of the resident's initial nutritional assessment completed by the Registered Dietician (RD), dated 07/17/25, showed fluid intake of need of 2000 plus cubic centimeters (cc's) suggested per day and staff to continue efforts encourage the resident.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/24/25, showed severe cognitive impairment.Review of the resident's care plan, dated 01/06/26, showed the following:-At risk for inadequate oral intake;-Observe for adequate intake of food/fluids, obtain and update food/beverage preferences, and to offer snacks between meals.Review of the resident's intake and output report for the following dates showed:-On 02/01/26, a total of 1420 cc's input;-On 02/02/26, a total of 1220 cc's input;-On 02/03/26, a total of 1460 cc's input;-On 02/04/26, a total of 2400 cc's input;-On 02/05/26, a total of 1130 cc's input;-On 02/06/26, a total of 1300 cc's input;-On 02/07/26, a total of 1460 cc's input;-On 02/08/26, a total of 860 cc's input;-On 02/09/26, a total of 480 cc's input.Observation on 02/10/26 showed the following:-At 9:26 A.M., the resident sat in the wheelchair in the day room watching tv, without any drinks by the resident;-At 9:31 A.M., the resident sat in the wheelchair in the common TV room, without any drinks by the resident;-At 9:58 A.M., the resident sat in the wheelchair in the day room watching tv, without any drinks by the resident;-At 10:17 A.M., the resident sat in the wheelchair in the day room, in the same spot, with his/her eyes closed and head leaned down, without any drinks by the resident;-At 10:44 A.M., the resident sat in the wheelchair in the day room, in the same spot with his/her head down, and chin on chest, without any drinks by the resident;-At 11:09 A.M., the resident sat in the wheelchair in the day room with his/her head down and chin on chest, without any drinks nearby;-At 11:21 A.M. and 11:24 A.M., the resident sat in the wheelchair in the day room with his/her eyes open, head up, and watching tv, without any drinks nearby;-At 11:25 A.M., the resident sat in the wheelchair in the day room without any drinks nearby;-At 11:32 A.M., Licensed Practical Nurse (LPN) A checked the resident's blood glucose. The nurse did not offer the resident a drink. The resident continued to sit in his/her wheelchair in the day room;-At 11:37 A.M., the resident sat in the wheelchair in the common TV room, without any drinks nearby;-At 11:40 A.M., the resident continued to sit in the same spot in the day room, without any drinks nearby;-At 11:51 A.M., the resident sat in the same spot/position in the common TV room. No drink offered, provided or beside the resident;-At 11:54 A.M., the resident continued to sit in the wheelchair in the same spot in the day room, without any drinks nearby;-At 11:58 A.M., Certified Nursing Assistant (CNA) I wheeled the resident from the day room to the dining room table. He/she did not offer the resident a drink;-At 12:03 P.M., the resident sat in the wheelchair in the dining room. The resident had drinks in front of him/her;-At 12:07 P.M., the resident sat at the dining table, with two drinks, a Kool-Aid, coffee and a shake supplement placed in front of him/her;-At 12:11 P.M., the resident continued to sit in the wheelchair at the dining room table;-At 12:25 P.M., the resident continued to sit at one of the assist tables. The resident drank and ate a couple of bites of food on his/her own;-At 12:29 P.M., the resident continued to eat without assistance;-At 12:31 P.M., staff assisted the resident to eat;-At 12:39 P.M., the resident ate all of his/her dessert. Staff came over to prompt/cue the resident to eat lunch;-At 12:44 P.M., staff continued to assist the resident with eating.-At 12:57 P.M., the resident ate some bites of corn nugget without staff assist. Staff offered and cut hotdog into bites for the resident;-At 1:05 P.M., the resident continued to sit in the wheelchair in the dining room eating lunch. LPN N cued the resident to eat at times;-At 1:09 P.M., the LPN N continued to prompt/cue the resident to eat. He/she ate a few bites of the hot dog. The LPN N asked the resident about not eating much lunch and the resident said not very hungry. The resident drank all of the shake supplement, two-thirds cup of Kool-Aid drink, and all of the coffee;-At 1:15 P.M., LPN N wheeled the resident to the activity room for a church activity. The resident did not have any drinks nearby;-At 1:28 P.M., the resident sat in the wheelchair in the activity room for the church activity. The resident did not have any drinks nearby;-At 1:58 P.M., a visitor came to visit the resident and sat beside him/her. The resident did not have any drinks nearby;-At 2:08 P.M., the resident sat in the wheelchair in the activity room. The resident did not have any drinks nearby;-At 2:26 P.M., the Bible study finished. The visitor and the resident continued to sit in the activity room. The resident did not have any drinks nearby;-At 2:41 P.M., the resident continued to sit in the wheelchair in the activity room. Staff explained the rules of the game to the group. Staff did not offer a drink. The resident did not have any drinks nearby.Oservation and interview on 02/10/26, at 2:52 P.M., showed the following: -CNA O said he/she usually took the resident to the restroom about now. The CNA went to the resident in the activity room and asked to take him/her to the bathroom;-CNA O and Nurse Assistant (NA) P assisted the resident to the bathroom. The brief appeared dry. CNA O said his/her brief was clean and dry. CNA O assisted the resident off the toilet and pulled up the resident's brief and pants. The urine was dark and concentrated. The aides transferred the resident back to his/her wheelchair. CNA O asked the resident if he/she wanted to go back to the activity, the resident said no. CNA O asked if he/she wanted to go to the TV room. The resident did not answer. Staff wheeled the resident to the common TV area and did not offer the resident a drink. The resident did not have any drinks nearby.Review of the resident's intake and output report for 02/10/26 showed a total input of 1190 cc's of fluid.During an interview on 02/10/26, at 2:10 P.M., CNA Q said the following:-The resident usually gets up for meals and goes to most of the activities;-The resident usually lays down after breakfast and lunch but did not today;-The resident can say if he/she needs a drink but will not initiate.During an interview on 02/10/26, at 2:18 P.M., CNA M said the following:-The night shift staff usually get the resident up for breakfast;-The resident does not like to lay down after meals;-The resident will not initiate any activities, such as drinking. -The resident does need to be prompted.During an interview on 02/10/26, at 2:23 P.M., CNA Student R and CNA Student S said the following:-The aides said their shift started after lunch;-They are allowed to provide the following cares to resident: nail care, pass water, change briefs, help in the bathroom, and about anything else.During an interview on 02/12/26, at 4:45 P.M., NA T said the following:-Hydration needs and plan should on the care plan;-The resident needed encouragement to drink;-Staff should offer the resident fluids every two hours;-The resident can drink on his/her own but needs to be offered. He/she will not ask.During an interview on 02/13/26, at 8:46 A.M., LPN C said the following:-He/she expected every resident to be offered a drink at least every two hours;-The CNAs document fluid intake every shift in the vitals section of the electronic medical record (EMR);-He/she would not expect the resident to be dry for an entire shift. The staff should push fluids if the resident was found dry.During an interview on 02/13/26, at 10:38 A.M., the Director of Nursing (DON) said the following:-The staff should give residents drinks at least every two hours;-She would expect the CNAs and nurses to document input and output during each shift;-She would not expect for the resident to be dry if he/she had not been toileted for an entire shift;-If the resident was dry for the entire shift, the physician should be told because there should be some urine output for the resident;-The DON would assume the resident was at risk for dehydration.-She did not know the resident very well and did not know if the resident could ask for a drink on his/her own;-She would expect staff to offer fluids any time they pass him/her. During an interview on 02/13/26, at 3:20 P.M., the Administrator said the following:-He would expect the staff to check on residents every two hours;-He would expect the staff to pass ice water every shift, if not more often, which would include the residents that are in the day room or activity room.

Based on observation, interview, and record review the facility failed to obtain a physician order, care plan the use of and monitor one resident's (Resident #1) cardiac life vest (a portable device that monitors and protects individuals at risk for sudden cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness)) out of a sample size of 7 residents. The facility census was 78.Review of the facility policy titled, Physician Orders, undated, showed a current list of orders must be maintained in the clinical record of each resident to avoid confusion and errors. Physician orders must be reviewed and renewed. Review of the facility policy titled, Care Plan Comprehensive, undated, showed the following:-An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest well-being;-The comprehensive care plan will be based on a thorough assessment;-A well-developed care plan will be oriented to preventing avoidable declines in functioning; managing risk factors to the extent possible; applying current standards of practice in the care planning process; evaluating treatment of measurable goals, timetables and outcomes of care; and assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs;-Involve the direct care staff with the care planning process relating to the resident's outcomes,-The interdisciplinary team (IDT) is responsible for updating of care plans when changes occur that impact a resident's care. Review of the [NAME] (manufacturer of the cardiac life vest) website showed the following:-The life vest is designed to detect certain life-threatening rapid heart rhythms and, if needed, deliver a treatment shock to save a person's life;-While wearing the life vest, a patient may hear an alert. It is important to know what the alert means and how to respond;-Patients should always wear the life vest, including when sleeping;-The life vest should only be removed when showering or bathing;-It is important to care for the life vest by charging the battery and a second battery every day;-The life vest should be washed every one to two days. 1. Review of the Resident #1's face sheet (document that gives a resident's information at a quick glance) showed the following:-admission date of 09/16/25; -Diagnoses included congestive heart failure (CHF - chronic condition in which the heart does not pump blood as well as it should) and chronic obstructive pulmonary disease (COPD - a group of kung diseases that block airflow and make it difficult to breathe).Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), showed the resident had moderate cognitive impairment. Review of the resident's admission assessment, dated 09/16/25, showed staff did not address the use of a cardiac life vest. Review of the resident's nursing progress note, dated 09/16/25, showed the resident had a life vest on to monitor heart rate and rhythm. Review of the resident's care plan, dated 09/17/25, showed staff did not address the use of a cardiac life vest. Review of the resident's nursing progress note, dated 09/18/25, showed the resident reported the life vest's Velcro was scratchy. Review of the resident's physician progress note, dated 09/22/25, showed staff did not document if the resident was utilizing a cardiac life vest. Review of the resident's physician progress note, dated 09/24/25, showed no documentation regarding the use of the cardiac life vest.Review of the resident's physician progress note, dated 09/28/25, showed no documentation regarding the use of the cardiac life vest. Review of the resident's current Physician Order Sheet (POS) showed staff did not obtain and document orders related to the resident's cardiac life vest, including when to apply, change the battery, cleanse, or monitor the resident's cardiac life vest. During an interview on 10/07/25, at 10:40 A.M., Licensed Practical Nurse (LPN) E said the facility had no current residents that utilized a life vest. He/she had sent the resident out to the hospital recently and he/she was wearing a life vest. He/she did not have experience with cardiac life vests and had no training on the use of it. The resident cared for the vest and would ask nursing staff if a battery change was required. A resident should have orders to wear a cardiac life vest. An order for a life vest should include skin assessments under the vest and battery checks. Nurses should be responsible for the life vest monitoring and battery changes. A cardiac life vest should be included in the care plan. During an interview on 10/07/25, at 11:05 A.M., Certified Nurse Assistant (CNA) A said the facility had a resident that wore a cardiac life vest recently. He/she did not work on the hall of the resident the wore the life vest resided on. A cardiac life vest should be in the care plan for the nursing staff to be aware of it. During an interview on 10/07/25, at 11:11 A.M., LPN B said he/she was responsible for physician orders, allergies, and diagnoses upon resident admission. The nurses working on the floor are responsible for the clinical admission assessment. There are no current residents with a cardiac vest at the facility. He/she was unsure if the resident had a life vest. Cardiac life vests should have orders to monitor the vest is in place, assess the skin underneath the vest, and monitor and change the battery. Nurses are responsible for the life vest. A cardiac life vest should be included in the care plan. During an interview on 10/07/25, at 11:15 A.M., Registered Nurse (RN) C said he/she does not recall a resident utilizing a life vest. He/she remembered the resident wearing a back brace. He/she had never cared for a resident that wore a life vest and did not know about them. A cardiac life vest should have an order. Nurses should assess that the vest was in place and the skin underneath the vest every shift. A life vest should be included on the care plan. During an interview on 10/07/25, at 11:20 A.M., LPN D said the facility does not admit residents that require the use of a cardiac life vest. He/she did not care for the resident. A resident with a life vest should have an order to ensure it is in place, to check the skin under the brace, make sure the battery is charged, and ensure a backup battery is available. Nurses should be aware of a cardiac life vest, and it should be included on the care plan. The nurse is responsible for the care and monitoring of a resident wearing a cardiac life vest. During an interview on 10/07/25, at 11:25 A.M., Certified Medication Technician (CMT) F said the resident was supposed to wear some type of brace around the waist but was unsure what it was. A brace should be included in the care plan, so staff are aware of it. During an interview on 10/07/25, at 12:15 P.M., the MDS Coordinator said he/she used information from the progress notes and resident diagnoses to create the care plan. He/she updates the care plan with new resident information discussed in the morning meeting or the nurse will notify him/her. He/she heard the resident had a life vest through discussions with the nurses and aides after the resident was admitted . A cardiac life vest should have a physician order and be included on the care plan. He/she she did not see the life vest mentioned while reviewing notes to create the resident's care plan.During an interview on 10/07/25, at 12:20 P.M., the Assistant Director of Nursing (ADON) said one resident utilized a cardiac life vest. He/she thinks the resident's use of a life vest was mentioned by the hospital during the resident's referral to the facility. The resident informed him/her that he/she utilized a cardiac life vest after admission to the facility. Life vests should have an order d be included on the care plan. This was his/her first experience with a cardiac life vest, and he/she did not receive education about the life vest from the facility. Facility should educate nurses on the care and use of a cardiac life vest. He/she was unable to find order or information in the care plan on the resident use of a life vest. During an interview on 10/07/25, at 12:00 P.M., the Director of Nursing (DON) said no current residents utilized a cardiac life vest. He/she learned of the resident's use of a cardiac life vest when he/she was transferred to the hospital. The nurse reported to him/her the resident was wearing a life vest during the hospital transfer. The life vest should have been noted upon the resident admission to the facility. Nurses should be educated on the use of a cardiac life vest. Life vests should have physician orders. The order should contain battery changes and monitoring and skin assessments under the vest. The nurse should monitor the life vest and battery. The nurse should have notified the physician and obtain an order if a resident was found wearing a cardiac life vest. During an interview on 10/07/25, at 12:43 P.M., the Administrator said the resident was admitted to the facility without a life vest on. The life vest was delivered with the rest of his/her belongings a few minutes after he/she arrived. The resident did not have any orders to utilize the life vest. The life vest should have a physician order prior to use and included on the care plan. Nursing staff should be educated on the use of a cardiac life vest.Complaint #2633767

Based on observation, record review, and interview, the facility failed to ensure pharmacy services in place that established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, that ensured drug records were in order, and ensured an account of all controlled drugs was maintained and periodically reconciled when staff had medications that could not be returned to the pharmacy stored and not destroyed in timely manner for 73 residents, which included 159 cards of controlled substance medications, and failed to have a system of accountability for the 159 cards of unused controlled substance medications located in locked cabinets in two offices that were pending destruction. The facility census was 69.Review of the facility policy titled Destruction of Medications, undated, showed the following:-The facility will destroy and dispose of medication in a safe manner and in accordance to applicable law;-All mediation not returned to the issuing pharmacy will be destroyed;-Two licensed nurses or one licensed nurse and the facility pharmacist will destroy all medications, except controlled substances which will require Director of Nursing (DON) supervision;-Documentation of medication destruction will include date, name of medication, prescription (RX) number, amount of medication to be destroyed, method of destruction, and signatures of nurses and/or pharmacist;-Scheduled II to IV medications (under the Controlled Substances Act, have a potential for medication abuse) will be destroyed as stated above with the following exceptions:-The controlled medication count sheet will include the following information:-Signature of nurses and/or pharmacist destroying the medication;-Amount destroyed and date destroyed. Review of the facility policy titled Discontinued Medications, undated, showed the following:-When the attending physician discontinued a medication, it must be recorded in the resident's medical record and medication sheet;-The staff or charge nurse receiving the order to discontinue a medication is responsible for charting such information and must also notify the issuing pharmacy of such order;-The facility and/or the issuing pharmacy may destroy discontinued medications;-When medications have been discontinued and are not to be returned, refer to medication destruction guidelines;-The following will be the protocol for controlled medications:-When a medication has been discontinued, the nurse or certified medication technician (CMT) will discontinue the controlled medication on the physician order sheet (POS) and medication administration record (MAR);-The nurse or CMT will document the amount of controlled medication to be discontinued on the MAR;-The nurse or CMT will then log the controlled medication on the individual resident's destruction record to include the following Information:-Date medication discontinued, Rx number, and amount left on card or left in bottle;-The controlled medication will then be placed in the locked cabinet for destruction;-The controlled medication sheet will be maintained in the narcotic book under the discontinued narcotic tab and will be counted until destroyed; -When narcotics are destroyed, the nurses will document on the destruction record and narcotic records date destroyed, how medication was destroyed, and both nurses' names and titles;-Controlled medications will be destroyed at least weekly with DON supervision. 1. Review of Resident #1's medical record showed the following:-admission date of 02/22/25;-discharge date of 04/15/25;-Diagnoses included cerebral infarction (stroke), traumatic brain injury (TBI - damage to the brain caused by an external force, such as a bump, blow, jolt, or penetrating injury to the head), and chronic pain syndrome (persistent pain lasting longer than three months). Review of the resident's nursing notes dated 04/15/25, at 2:43 P.M., showed staff documented the resident was discharged home with his/her spouse via private vehicle with all of his/her possessions at 1:50 P.M. Discharge paperwork signed, and copies sent home with him/her along with all of his/her available medications. No new skin issues noted. He/she left with all his/her personal belongings. Nothing has been reported missing. Review of the resident's February 2025, March 2025, and April 2025 MARs showed the following:-An order, dated 02/26/25, for oxycodone (controlled drug used to treat moderate to severe pain) 15 milligrams (mg), administer one table every eight hours as needed for pain;-Staff documented administration of oxycodone medication almost every day with last dose administered on 04/14/25 at 8:52 P.M. Review of the resident's documents tab in the electronic medical record showed the following:-A Controlled Drug Receipt, Record, and Disposition form, dated 02/27/25, for oxycodone15 mg tablets, 30 tablets dispensed. Staff documented administration of the medication from 02/28/25 through 03/16/25;-A Controlled Drug Receipt, Record, and Disposition form, dated 03/04/25, for oxycodone 15 mg tablets, 30 tablets dispensed. Staff documented administration of the medication from 03/17/25 through 04/04/25;-No Controlled Drug Receipt, Record, and Disposition Form for oxycodone medication administered from 04/05/25 through discharge on [DATE]. Review of staff provided form titled Controlled Drug Receipt, Record, and Disposition Form, showed oxycodone 15 mg tablets, 30 tablets dispensed on 04/01/25 and signed as received at facility on 04/02/25. The form showed 16 tablets remained with the last dose documented as administered on 04/14/25, at 7:45 P.M.Review of the resident's February 2025, March 2025, and April 2025 MARs showed the following:-An order, dated 03/09/25, for clonazepam (controlled drug used to help reduce anxiety) 1 mg, administer 1 tablet every 12 hours as needed for anxiety or agitation;-Staff documented administration of clonazepam medication for 12 days in March 2025 and 10 days in April 2025 with last dose documented as administer on 04/14/25 at 8:52 P.M. Review of the resident's documents tab in the electronic medical record showed no Controlled Drug Receipt, Record, and Disposition Form for clonazepam administered from 03/09/25 through discharge on [DATE]. Review of staff provided form titled Controlled Drug Receipt, Record, and Disposition Form, showed clonazepam 1 mg tablets, 30 tablets dispensed on 03/13/25 and no signed date as received at the facility. The form showed 10 tablets remained and last dose documented as administered on 04/14/25, at 7:45 P.M. During an interview on 07/29/25, at 9:00 A.M., Licensed Practical Nurse (LPN) A said when a resident discharged to home, the remaining medications were sent home with the resident, except controlled substance narcotics. Once a resident had been discharged the narcotics were to be disposed of by two nurses as soon as possible. During an interview on 07/29/25, at 9:15 A.M., CMT B said when a resident discharged , the narcotics did not go home with the resident. The medication stayed in the cart and staff continued to count during each shift change until the nurses were ready to dispose of the medications. The Assistant Director of Nursing (ADON) and a second nurse to dispose of the narcotics. He/she did not know what the schedule was for destroying medications. During an interview on 07/29/25, at 9:45 A.M., Registered Nurse (RN) C said when a resident discharged to home any remaining narcotics were not sent with the resident. The narcotic cards that were not in use were sent to the DON for destruction. The controlled drug receipt, disposition form was sent to medical records for upload to resident charts. He/she did not know if there was a schedule time to destroy medications. During an interview on 07/29/25, at 10:00 A.M., the Social Service Director (SSD) said once a discharge date was set for a resident, he/she started the process for discharge including preparing home health visits, equipment needed at home, and scheduling physician appointments. The staff sent medications, except narcotics, home with residents. The doctor would write a new order for narcotics to get to the follow up appointment. The nursing staff entered the pharmacy data base what medications were sent home with the resident. The medications that needed destroyed were locked up in the DON and ADON office to be disposed. He/she did not know the schedule when they were destroyed. During an interview on 07/29/25, at 10:15 A.M., Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator said that once a resident was discharged home, he/she would get the resident paper records and ensure that all documents in the chart were uploaded to electronic medical record. This included controlled medication disposition papers. Narcotics were not sent home with the resident. He/she was not able to locate the April narcotic disposition paper for the resident. During an interview and observation on 07/29/25, at 10:30 A.M., the DON said that once a resident was discharged controlled substances were not sent with the resident. The left-over narcotics were destroyed, and the controlled substance disposition record was uploaded to the resident's electronic medical record. If she was not available, the narcotics were kept on the medication cart to continue to be counted each shift. Once the narcotic was given to her it was put into a locked cabinet in her locked office, it was not counted as it was behind two locks and no one else had access. When there was time two nurses destroyed the medications. Generally, the ADON and the DON destroyed the medications together, but there had not been an ADON for about two months. Additional overflow discontinued controlled substances were in the ADON office in a locked cabinet. The locked filing cabinet in the DON office contained two drawers filled with medications, containing 52 cards and 15 additional bottles of medications with the yellow disposition form folded on each item. Observation on 07/29/25, at 10:45 A.M., with the DON in the ADON office showed a locked desk drawer containing 84 medication cards with a yellow sheet of paper folder over each card. Review of the facility provided Controlled Drug Receipt, Record, and Disposition Forms, from the medications that were in the ADON and DON locked cabinets to be destroyed, showed the following:-Resident #1 - Clonazepam 1 mg, 30 tabs dispensed on 03/13/25, last given 04/14/25, 10 tabs remained and oxycodone 15 mg, 30 tabs dispensed on 04/01/25, last given 04/14/25, 16 remained;-Resident #2 - tramadol (used to treat moderate pain) 50 mg, 30 tabs dispensed 07/16/25, last given 07/18/25, 25 remained and tramadol 50 mg, 30 tabs dispensed 07/16/25, none given;-Resident #3 - hydrocodone/acetaminophen (APAP) (used to treat moderate to severe pain) 5/325 mg, 20 tabs dispensed on 07/07/25, last given 07/14/25, 14 remained; tramadol 50 mg, 30 tabs dispensed on 06/22/25, last given 07/07/25, 24 remained; and hydrocodone/APAP 5/325 mg, 30 tabs dispensed 07/08/25, none given;-Resident #4 - oxycodone 5 mg, 30 tabs dispensed on 6/30/25, none given; oxycodone 5 mg, 20 tabs dispensed on dated 6/28/25, none given; and oxycodone 5 mg, 30 tabs dispensed on 6/20/25, last given 07/13/25, four remained;-Resident #5 - oxycodone 5 mg, 30 tabs dispensed on 07/03/25, last given 7/15/25, 11 remained;-Resident #6 - tramadol 50 mg, 30 tabs dispensed on 03/20/25, last given 4/11/25, six remained; lorazepam (a controlled drug used to treat anxiety) 0.5 mg, 30 tabs dispensed on 04/02/25, none given; and tramadol 50 mg, 30 tabs dispensed on 04/0125, none given;-Resident #7 - oxycodone 5 mg, 30 tabs dispensed on 04/03/25, last given 04/14/25, 12 tabs remained;-Resident #8 - oxycodone 10 mg, 30 tabs dispensed on 06/11/25, last given 06/16/25, 26 tabs remained;-Resident #9 - oxycodone 5 mg, 20 tabs dispensed on 04/19/25, last given 04/24/25, 3 tabs remained;-Resident #10 - tramadol 50 mg, 20 tabs dispensed on 06/23/25, last given 07/01/25, 15 tabs remained and dipehn/atrop (diphenoxylate/atropine - used to treat diarrhea) 2.5 mg, 24 tabs dispensed on 06/09/25, last given 06/22/25, 18 tabs remained;-Resident #11 - tramadol 50 mg, 30 tabs dispensed on 06/04/25, last given 06/16/25, 12 tabs remained;-Resident #12 - zolpidem (a control drug, sedative) 5 mg, 30 tabs dispensed on 04/09/25, last given 04/23/25, 16 tabs remained;-Resident #13 - temazepam (a controlled drug, sedative) 30 mg, 14 tabs dispensed on 07/07/25, none given, 14 tabs remained; hydrocodone/APAP 5/325 mg, 30 tabs dispensed on 06/30/25, last given 07/08/25, 4 tabs remained; and hydrocodone/apap 5/325 mg, 30 tabs dispensed on 7/7/25, 30 tabs, none given;-Resident #14 - tramadol 50 mg, 26 tabs dispensed on 05/29/25, last given 06/28/25, 17 tabs remained and tramadol 50 mg, 30 tabs dispensed on 06/13/25, last given 07/02/25, 18 tabs remained;-Resident #15 - oxycodone 15 mg, 30 tabs dispensed on 03/19/25, last given 04/06/25, 11 tabs remained;-Resident #16 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/09/25, none given, 30 tabs remained; hydrocodone 5/325 mg, 30 tabs dispensed on 06/02/25, last given 07/08/25, 12 tabs remained; and hydrocodone 5/325 mg, 30 tabs dispensed on 06/09/25, none given, 30 tabs remained;-Resident #17 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/20/25, none given, 30 tabs remained;-Resident #18 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/27/25, last given 07/13/25, 4 tabs remained;-Resident #19 - hydrocodone 5/325 mg, 15 tabs dispensed on 04/14/25, none given, 15 tabs remained;-Resident #20 - lorazepam 2 mg/milliliter (ml) concentrate, 30 ml dispensed on 02/25/25, last given 04/08/25, 20 ml remained;-Resident #21 - lorazepam 2 mg/ml intensol 30 ml dispensed on 05/05/25, none given; lorazepam 2 mg/ml concentrate 30 ml, dated 05/07/25, last given 05/09/25, 29ml remained; morphine sulfate (controlled drug used to treat moderate to severe pain) solution 100/5 ml, 30 ml dispensed on 05/07/25, last given 05/09/25, 24.75 ml remained; fentanyl (controlled drug used to treat moderate to severe pain) 25 microgram (mcg)/hour (hr.) patch, 5 patches dispensed on 03/17/25, none given; fentanyl 75 mcg/hr patch, 5 patches dispensed on 05/01/25, none given; fentanyl 50 mcg/hr patch, 5 patches dispensed on 04/10/25, last given 05/07/25, 4 remained; fentanyl 75 mcg/hr patch, 5 patches dispensed on 05/01/25, none given; hydrocodone/apap 7.5/325 mg, 30 tabs dispensed on 04/10/25, last given 5/8/25, 24 remained; and hydrocodone/apap 7.5/325 mg, 30 tabs dispensed on 04/10/25, none given;-Resident #22 - lorazepam 2 mg/ml, 30 ml dispensed on 03/14/25, last given 04/09/25, 28ml remained;-Resident #23 - morphine 20 mg/ml, 17 ml remain, last given 04/21/25, no amount dispensed, no date dispensed or received. First given 04/12/25; lorazepam concentrate 2 mg/ml, 30 ml dispensed on 04/09/25, last given 04/21/25, 8 ml remained; morphine sulfate 100/5 ml, 30 ml dispensed on 04/11/25, none given; lorazepam concentrate 2 mg/ml, 30ml dispensed on 04/11/25, none given; lorazepam concentrate 2 mg/ml, 30ml dispensed on 04/09/25, none given; lorazepam 0.5 mg tab, 30 tabs dispensed on 04/02/25, none given; and tramadol 50 mg, 20 tabs dispensed on 04/01/25, none given;-Resident #24 - lorazepam concentrate 20 mg/ml, 30 ml dispensed on 04/14/25, last given 04/16/25, 25.5 ml remained and morphine sulfate solution 100/5 mg, 30 ml dispensed on 04/14/25, last given 04/16/25, 28 ml remained;-Resident #25 - lorazepam concentrate 20 mg/ml, 30 ml dispensed on 04/10/25, last given 06/13/25, 11.25 ml remained; morphine sulfate solution 100/5ml, 30 ml dispensed on 4/10/25, last given 6/13/25, 19.75 ml remained; lorazepam 0.5 mg tab, 30 tabs dispensed on 06/03/25, last given 06/04/25, 29 remained; tramadol 50 mg, 12 tabs dispensed on 06/06/25, last given 06/11/25, 5 remained; and oxycodone 5 mg, 30 tabs dispensed on 12/16/24, last given 04/04/25, 9 remained;-Resident #26 - morphine sulfate oral 20 mg/ml, 30 ml dispensed on 05/04/25, last given 05/07/25, 26ml remained and lorazepam intensol 20 mg/ml, 30 ml dispensed on 05/04/25, last given 05/07/25, 26 ml remained;-Resident #27 - lorazepam concentrate 20 mg/ml, 30ml dispensed 04/13/25, last given 04/17/25. 27.5 ml remained; morphine sulfate oral 20 mg/ml, 30 ml dispensed on 04/14/25, last given 04/17/25, 28 ml remained; and hydrocodone/apap 7.5/325 mg, 20 dispensed on 04/13/25, last given 04/16/25, 14 tabs remained;-Resident #28 - nayzilam spray (used to treat seizures) 5 mg, 2 dispensed on 10/01/24, none given; lorazepam intensol, dispensed on 03/03/25, no amount dispensed, last given 04/17/25, 0 remained; morphine sulfate solution 100/5 ml, 21 received on 08/06/24, last given 04/17/25, 2 remained; lorazepam 0.5 mg tab, 30 tabs dispensed on 08/07/24, none given; lorazepam 0.5 mg tab, 30 tabs dispensed on 08/06/24, none given; and lorazepam 0.5 mg tab, 5 tabs dispensed on 08/07/24, last given 08/21/24, 4 remained;-Resident #29 - morphine sulfate solution 100/5 ml, 30 ml dispensed on 05/13/25, none given; lorazepam intensol 2 mg/ml, 30 ml dispensed on 05/13/25, last given 05/21/25, 28.5 ml remained; morphine sulfate solution 100/5 ml, 30 ml dispensed on 05/13/25, last given 05/23/25, 23.5 ml remained; and lorazepam intensol 2 mg/ml, 30 ml dispensed on 05/13/25, none given;-Resident #30 - lorazepam concentrate 2 mg/ml, 30 ml dispensed on 04/24/25, none given; Ativan (used to treat anxiety) no strength, 30 ml dated 04/24/25, none given; lorazepam concentrate 2 mg/ml, 30 ml dispensed on 03/17/25, last given 04/30/25, 15.5 ml remained; and morphine concentrate 100/5 ml, 30 ml no date dispensed, last given 05/01/25, 15 ml remained;-Resident #31 - morphine solution 20 mg/ml, 30 ml dispensed on 07/09/25, last given 07/15/25, 25.5 ml remained; lorazepam intensol solution 1 bottle dispensed on 07/03/25, last given 07/15/25, 28.75 ml remained; morphine sulfate solution 100/5 ml, 30 ml dispensed 07/14/25, none given; tramadol 50 mg, 30 tabs dispensed on 06/10/25, none given; and tramadol 50 mg, 30 tabs dispensed on 06/10/25, last given 07/09/25, 16 remained;-Resident #32 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/26/25, last given 07/06/25, 21 tabs remained;-Resident #33 - oxycodone 5 mg, 30 tabs dispensed on 06/25/25, last given 07/24/25, 5 remained; and oxycodone 5 mg, 20 tabs dispensed on 07/21/25, none given;-Resident #34 - morphine concentrate, no strength noted, no dated received or dispensed, 30 ml dispensed, last given 07/09/25, 25.25 ml remained; and lorazepam concentrate 2 mg/ml, 30 ml dispensed on 07/03/25, last given 07/09/25, 22 remained;-Resident #35 - buprenorphin (used to treat pain and opioid disorder (dependence on narcotics) sublingual (SL - under the tongue) 2 mg, 30 dispensed on 06/23/25, none given; buprenorphin sublingual 2 mg, 30 dispensed on 06/23/25, none given; and buprenorphin sublingual 2 mg, 30 dispensed on 06/23/25, last given 06/26/25, 16 remained;-Resident #36 - morphine sulfate solution 20 mg/ml, 1 bottle dispensed 05/07/25, last given 07/20/25, 20.5 ml remained;-Resident #37 - lorazepam 0.5mg tab, 30 tabs dispensed 02/08/25, last given 03/31/25, 15 remained;-Resident #38 - clonazepam ODT tab 0.25 mg, 30 tabs dispensed 04/16/25, last given 05/08/25, 10 remained and tramadol 50 mg, 30 tabs dispensed 04/16/25, last given 05/06/25, 18 remained;-Resident #39 - hydrocodone/apap 5/325 mg, 30 tabs dispensed on 06/07/25, 17 tabs remained and modafinil (used to treat a sleep disorder) 100 mg, 28 dispensed on 06/08/25, last given 06/12/25, 25 remained;-Resident #40 - oxycodone 5 mg, 30 tabs dispensed 04/27/25, last given 05/10/25, 8 remained;-Resident #41 - oxycodone 5 mg, 20 tabs dispensed on 05/23/25, last given on 05/30/25, 2 tabs remained;-Resident #42 - oxycodone 5 mg, 20 tabs dispensed on 04/23/25, last given 05/05/25, 11 tabs remained;-Resident #43 - tramadol 50 mg, 30 tabs dispensed on 06/03/25, last given 06/05/25, 29 tabs remained;-Resident #44 - oxycodone 10 mg, 30 tabs dispensed on 05/20/25, last given 06/06/25, 7 tabs remained and buprenorphin sublingual 2 mg, 14 tabs dispensed on 05/07/25, last given 06/05/25, 4 remained;-Resident #45 - zolpidem 5 mg, 30 tabs dispensed on 05/23/25, none given; zolpidem 5 mg, 14 tabs dispensed on 06/01/25, none given; zolpidem 5 mg, 10 tabs dispensed on 04/23/25, last given 05/28/25, 4 remained; buprenorphin sublingual 2 mg, 20 tabs dispensed on 05/23/25, last given 06/01/25, 19 remained; and buprenorphin sublingual 2 mg, 20 tabs dispensed on 05/23/25, last given 06/23/25, 12 remained;-Resident #46 - triazolam (used to treat anxiety) 0.25 mg, 14 tabs dispensed on 04/24/25, none given;-Resident #47 - oxycodone 5 mg, 12 tabs dispensed on 04/22/25, none given and oxycodone 5 mg, 30 tabs dispensed on 04/26/25, none given;-Resident #48 - phenobarb (used to treat seizure activity) 32.4 mg, 1 tab dispensed 07/07/25, last given 07/25/25, 1 tablet remained; chlordiazepam (used to treat anxiety) 5 mg, 28 caps dispensed on 07/07/25, last given 07/24/25, 3 remained; oxycodone 5 mg, 30 tabs dispensed on 06/09/25, last given 07/25/25, 12 tabs remained; oxycodone 5 mg, 30 tabs dispensed on 06/12/25, last given 07/19/25, 6 tabs remained; oxycodone 5 mg, 20 tabs dispensed on 07/21/25, none given; phenobarb 32.4 mg, 30 tabs dispensed on 07/07/25, none given; and oxycodone 5 mg, 30 tabs dispensed on 06/10/25, none given;-Resident #49 - clonazepam 1 mg, 30 tabs dispensed on 04/18/25, last given 05/12/25, 11 remained and clonazepam 0.5 mg, 30 tabs dispensed on 05/13/25, last given 06/02/25, 1 remained;-Resident #50 - tramadol 50 mg, 30 tabs dispensed on 05/12/25, none given and tramadol 50 mg, 30 tabs dispensed on 04/11/25, last given 06/02/25, 4 remained;-Resident #51 - hydrocodone/apap 5/325 mg, 30 tabs dispensed on 05/12/25, last given 5/18/25, 27 remained;-Resident #52 - tramadol 50 mg, 20 tabs dispensed on 04/18/25, last given 04/20/25, 19 tabs remained;-Resident #53 - tramadol 50 mg, 30 tabs dispensed on 02/19/25, last given 04/11/25, 11 remained;-Resident #54 - tramadol 50 mg, 20 tabs dispensed on 05/28/25, last given 06/05/25, 7 remained;-Resident #55 - tramadol 50 mg 30 tabs dispensed on 04/28/25, last given 05/07/25, 26 remained and oxycodone 5 mg, 30 tabs dispensed on 04/28/25, last given 05/06/25, 21 tabs remained;-Resident #56 - buprenorphin sublingual 2 mg, 15 tabs dispensed on 05/10/25, none given and buprenorphin sublingual 2 mg, 15 tabs dispensed on 05/10/25, none given;-Resident #57 - oxycodone 5mg, 10 dispensed on 01/21/25, last given 05/04/25, 8 remained;-Resident #58 - buprenorphin sublingual 2 mg, 30 tabs dispensed on 05/02/25, none given; buprenorphin sublingual 2 mg, 30 tabs dispensed on 05/02/25, none given; and buprenorphin sublingual 2 mg, 30 tabs dispensed on 05/02/25, last given 05/26/25, 12 remained;-Resident #59 - Oxycontin ER (controlled pain medication) 10 mg, 14 tabs dispensed on 04/21/25, last given 04/23/25, 10 remained; hydrocodone/apap 10/325 mg, 30 tabs dispensed 04/26/25, last given 05/02/25, 21 remained; and diphen/atrop tab 2.5 mg, 30 tabs dispensed on 04/15/25, none given;-Resident #60 - hydrocodone/apap 5/325mg, 30 tabs dispensed 04/14/25, last given 04/26/25, 5 remained and oxycodone 5 mg, 30 tabs dispensed 03/24/25, last given 04/25/25, 26 remained;-Resident #61 - oxycodone 5 mg, 30 tabs dispensed on 03/24/25, last given 04/25/25, 26 remained;-Resident #62 - oxycodone 5 mg, 30 tabs dispensed on 04/07/25, last given 04/24/25, 11 remained; oxycodone 5 mg, 30 tabs dispensed on 04/21/25, none given; oxycodone 5 mg, 30 tabs dispensed on 04/07/25, last given 04/24/25, 1 remained; and oxycodone 5 mg, 30 tabs dispensed on 04/21/25, none given;-Resident #63 - oxycodone 5 mg, 30 tabs dispensed on 04/18/25, last given 04/23/25, 20 remained; tramadol 50 mg, 20 tabs dispensed on 03/03/25, last given 03/11/25, 10 remained; and oxycodone 5 mg, 30 tabs dispensed on 04/18/25, last given 04/23/25, 20 remained;-Resident #64 - tramadol 50 mg, 30 tabs dispensed on 07/20/25, none given and tramadol 50 mg, 10 tabs dispensed on 07/20/25, last given 07/20/25, 9 remain;-Resident #65 - oxycodone 5 mg, 30 tabs dispensed on 06/27/25, last given 07/03/25, 14 remained;-Resident #66 - oxycodone 5 mg, 20 tabs dispensed on 07/14/25, last given 07/28/25, 1 tabs remained;-Resident #67 - oxycodone 5 mg, 30 tabs dispensed on 03/26/25, last given 04/08/25, 18 tabs remained;-Resident #68 - oxycodone 5 mg, 30 tabs dispensed on 04/15/25, last given 04/19/25, 27 remained;-Resident #69 - oxycodone 5 mg, 30 tabs dispensed on 04/02/25, last given 04/05/25, 26 remained;-Resident #70 - oxycodone 5 mg, 30 tabs dispensed on 04/25/25, last given 04/29/25, 16 remained;-Resident #71 - oxycodone 20 mg, 30 dispensed on 04/11/25, last given 4/28/25, 2 remained and oxycodone 10 mg, 30 dispensed on 04/10/25, last given 4/27/25, 5 remained;-Resident #72 - hydrocodone/apap 5/325 mg, 30 dispensed on 04/24/25, last given 05/03/25. 25 remained;-Resident #73 - oxycodone 5 mg, 30 dispensed on 05/27/25, last given 6/8/25, 25 remained. During an interview on 07/29/25, at 11:30 A.M., the Administrator said narcotics were not commonly sent home with residents on discharge. The remaining medications were kept locked up and counted in the medication cart until two nurses could remove them and destroy them. The medication should be destroyed in a timely manner, ideally within 30 days. He was aware that staff had gotten behind with destroying narcotics. He was not aware that there were 159 cards of narcotics dating back to April 2025 waiting to be destroyed. Complaint 2560530

Based on observations, interviews, and record review, the facility failed to ensure nursing staff supervised residents during medication administration to ensure medications were taken as prescribed and medications were not left unattended in residents' rooms for four residents (Residents #51, #33, #46, and #7) of nine sampled residents reviewed for accidents and hazards. The facility also failed to identify and investigate a fall for one resident (Resident #48) of three sampled residents reviewed for falls. 1. Review of the facility policy titled, Medications, Storage Of, undated, showed the following: -All medications for residents must be stored at or near the nurses' station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts. Review of the facility policy titled Medication Administration, undated, showed the following: -Remain in room while the resident takes the medication. 2. Review of Resident #51's Resident Face Sheet showed an admitted [DATE] with the most recent readmitted [DATE]. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 02/01/24, showed the resident was cognitively intact. Observation on 03/18/24, at 9:48 A.M., showed a cup that contained three white pills in the resident's room. Upon return to the room, after getting a nurse, the pill cup was empty. The resident said they had just taken the medications. During an interview on 03/18/24, at 10:12 A.M.,, the resident said nursing staff normally remained with them while they took their medications and did not normally leave them at their bedside. The resident indicated they were sleepy that morning and fell asleep before taking all of their medications. 22445 3. Review of Resident #33's Resident Face Sheet showed the following: -admitted [DATE]; -Diagnoses that included essential hypertension (high blood pressure), cognitive communication deficit, and unspecified macular degeneration (a disease that affects a person's central vision). Review of the resident's quarterly MDS, with an ARD of 01/15/24, showed the resident had moderate cognitive impairment. Observation on 03/18/24, at 9:38 A.M., showed a medication cup that contained a small blue-gray tablet and four white tablets in the resident's room. The resident said the nurse brought the pills into their room that morning about 9:00 A.M. and left the medications in the room for them to take as they wanted. During an interview on 03/18/24, at 9:54 A.M., Licensed Practical Nurse (LPN) #4 said she did not leave the medications in the resident's room and indicated Certified Medication Technician (CMT) #5 had given the medications to the resident. LPN #4 said the medications should not have been left in the resident's room. During an interview on 03/18/24, at 9:56 A.M., CMT #5 said he/she had been taught that medications should not be left in residents' rooms; however, he/she left the resident's medications in their room, because he/she trusted the resident would take them. CMT #5 identified the tablets observed in the resident's room as Tylenol 325 milligrams (mg), two tablets of vitamin C 500 mg tablets, one tablet of amiodarone (a medication to treat an irregular heartbeat), and Sinemet (a medication for Parkinson's disease). CMT #5 said the danger of leaving the medication in the resident's room could be another resident or visitor taking the medications, or if the resident waited too long to take the medications, there was a risk of double-dosing some of the medications. 46863 4. Review of Resident #46's Resident Face Sheet showed the following: -admitted [DATE]; -Diagnoses included allergic rhinitis (inflammation and swelling of the mucous membrane of the nose), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), acute and chronic respiratory failure with hypercapnia (increased carbon dioxide levels in the bloodstream), altered mental status, respiratory failure, and vascular dementia with behavioral disturbance. Review of the resident's quarterly MDS, with an ARD of 02/11/24, showed the resident had moderate cognitive impairment. Observation on 03/18/24, at 9:25 A.M., showed medications were at the resident's bedside on the resident's rolling tray table. The medications included a three-ounce (oz) bottle of antifungal powder, fluticasone propionate nasal spray 60 milligrams (mg), and an Advair Diskus inhaler. During an interview at the time of the observation, the resident said they did not know why the antifungal powder was in their room. The resident said staff helped them administer the nasal spray and that staff did not put it away that day. During an observation and interview on 03/18/24, at 9:51 A.M., LPN #7 observed the medications at the resident's bedside and said the medications were not supposed to be left at a resident's bedside. LPN #7 said another resident could wander into the resident's room and get into the medications. 5. Review of Resident #7's Resident Face Sheet showed the following: -admitted [DATE]; -Diagnoses included pain in the left hip, unspecified skin changes, altered mental status, pain in the leg, and chronic pain syndrome. Review of the resident's quarterly MDS, with an ARD of 03/04/24, showed the resident was cognitively intact. Observation on 03/18/24. at 10:19 A.M., showed medications were at the resident's bedside. A 1.25-ounce (oz) tube of muscle rub cream and two 3 oz tubes of a lidocaine topical pain reliever were observed on the resident's rolling tray table, and an opened, unsealed individual 5 gram, single-use pack of skin ointment and a tube of antifungal ointment were observed on the resident's nightstand. During an observation and interview on 03/18/24, at 10:30 A.M., LPN #7 observed the medications at the resident's bedside. The LPN said the muscle rub and topical pain relievers should be in the treatment cart instead of the resident's room. 6. During an interview on 03/19/2024, at 1:23 P.M., LPN #1 said he/she had seen medications in cups left unattended in residents' rooms before. Staff became overwhelmed at times with their workload and when staff left medications with a resident to take, they normally went back to ensure the resident took them. There was no way to ensure residents safely took medications that were left with them or if they threw them away, flushed them, or if another resident took the medications. During an interview on 03/19/24, at 1:55 P.M., CMT #3 said if a resident was cognitively intact, he/she sometimes left medications with them to take on their own. He/she had found cups of medications on tables in the dining room. If medications were left unattended, a different resident could potentially take them. During an interview on 03/20/24, at 11:15 A.M., the Director of Nursing (DON) said the danger of leaving medications at a resident's bedside was that staff would not know if the resident took their medications, and the resident could have an adverse event. Someone else could take the medications. The DON expected staff administering medications to stay with the resident until they took all medications unless there was an emergency. Cups of medications should not be left in residents' rooms and indicated all unattended medications should be locked in a medication cart, a medication room, or if a resident could keep medication at their bedside. She expected them to be kept locked so that no other resident could have access. During an interview on 03/21/24, at 9:23 A.M., the Administrator said he expected CMTs and nurses to follow the facility's policies and procedures for medication administration and said if something was not appropriate to have at a resident's bedside, staff should not leave it unattended. 7. Review of the facility policy titled, Event Investigation, undated, showed the following: -Purpose to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed. To identify any injuries after a resident sustains an event; -Interview the resident to determine cause of any conditions identified; -Interview any witnesses to determine cause of any condition identified; -Implement preventive measures as appropriate; -Complete a Report of Event Form as soon as possible whenever there is an unusual, unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor. Examples of when a form should be completed include fall or person found on the floor; -Any staff member who discovers, witnesses, or is involved in an event should immediately report the event to the nurse in charge. The charge nurse is responsible for completion of the Report of Event Form and forwarding to the DON as soon as possible. Review of Resident #48's Resident Face Sheet showed the following: -admitted [DATE] with most recent readmission on 12/25/23; -Diagnoses included COPD with acute exacerbation (worsening or increase in symptoms), anxiety disorder, type two diabetes mellitus with hyperglycemia (increased blood glucose levels), peripheral vascular disease, iron deficiency anemia, and chronic congestive heart failure. Review of the resident's quarterly MDS, with an ARD of 02/18/24, showed the resident had moderate cognitive impairment. The resident required supervision or touching assistance for chair/bed-to-chair transfers. Review of the resident's Care Plan showed revealed a Problem area, with a start date of 02/14/23, that indicated the resident was at risk for falls due to COPD exacerbation. During an interview on 03/21/24, at 9:03 A.M., LPN #7 said on 03/06/24 the resident reported they got tangled up in their oxygen tubing and went down on one knee, but was able to get themselves up and into the bed from the floor. The resident indicated the incident occurred overnight the night before the resident reported it to LPN #7. Despite the resident's description of what happened, he/she did not consider the incident a fall because the resident only went down on one knee. LPN #7 said to be considered a fall, both knees would have needed to go down on the floor. LPN #7 said when a resident had a fall, the facility's process was to check the resident's vital signs, conduct neurological assessments, check the resident's range of motion, notify the resident's medical doctor and resident representative, and document information about the fall in the resident's progress notes. Review of the resident's Resident Progress Notes showed staff did not document regarding a fall on 03/06/24. During an interview on 03/21/24, at 10:35 A.M., the DON said following a fall, he/she expected staff to assess the resident, ensure their safety, notify the physician , resident representative, and the DON, document in the resident's electronic medical record (EMR), and create a fall event in the EMR. An event report should be completed for each fall. The DON said she ran event reports off on a weekly basis and reviewed them daily, along with interventions. The DON was not aware of a fall involving the resident on 03/06/24. If a resident's knee went to the ground, it was considered a fall, and staff should initiate a fall assessment and follow the facility's fall process. During an interview on 03/21/24 at 3:12 P.M., the Administrator said if a resident reported their knee went down to the ground, he expected staff to investigate the incident as a fall. He said a fall investigation involved interviewing the resident and gathering additional statements to determine what happened. MO00232950

Based on interviews, and record review, the facility failed to resolve a grievance and document full resolution of the grievance for one resident (Resident #8) of two residents reviewed for grievances. Review of an undated facility policy titled Resident Grievances showed the following: -The coordinator (or designee) shall conduct an investigation of the complaint to determine its validity. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint; -The coordinator will maintain files and records of the facility, relating to such grievances; -The coordinator will issue a written decision on the grievance no later than 30 days after its filing. 1. Review of Resident #8's Resident Face Sheet showed the following: -admitted [DATE]; -Diagnoses included chronic diastolic (congestive) heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs), acute kidney failure, anemia (a condition in which the body does not have enough healthy red blood cells), type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), and chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 03/05/24, showed the resident was cognitively intact. Review of the resident's current Care Plan showed the following: -As of 12/22/21, the resident had a problem telling staff what they want or understanding staff instructions due to being hard of hearing, and the resident wore bilateral hearing aids; -Intervention directed staff to answer the resident's questions and repeat them as necessary, observe the resident to see if they understand, and allow the resident time to respond and give the resident cues/reminders if needed. Review of a facility document titled Concern/Grievance Report, dated 02/05/24, showed the following: -The resident initiated a grievance due to $200.00 being misplaced; -On 02/09/24, the facility resolved the grievance and noted, $100 was found in residents personal wallet continue search of other misplaced funds. During an interview on 03/18/24, at 11:00 A.M., the resident said they had $200.00 go missing at the facility. The Director of Nursing (DON) located $100 in their room during a search. The resident said a $100.00 was still missing, and the facility did nothing else. During an interview on 03/21/24, at 10:35 A.M., the DON said she had filed a report with the state agency as a result of the resident's grievance filed on 02/05/24. The DON indicated that they were finished with the investigation after locating some of the missing money. During an interview on 03/21/24, at 2:15 P.M., the Social Worker (SW) said she worked as the facility grievance coordinator. When she received a report of a concern or a grievance form, she interviewed the person who filled out the grievance form. She took the investigation data that was gathered to the head of the department and let them come up with a solution. She then shared the resolution with the Administrator and then with the family members verbally over the phone. The resident reported they were missing $200 cash in February (2024). The DON informed her of the grievance for the missing money. The SW oversaw this grievance and worked with the DON. The SW looked in the resident's wallet the day that the $200.00 cash was reported missing, and there was no money in the resident's wallet. Some of the money was located, but she was unaware of who had located it. After locating some of the money, they stopped the investigation.

Based on observations, record review, and interviews, the facility failed to ensure staff assessed one resident (Resident #30), of two sampled residents reviewed for self-administration of medications, to determine if they were clinically appropriate and safe to self-administer medications before allowing them to administer their own medication. Review the facility policy titled, Medications, Self-Administration, Self Storage, Leave At Bedside, undated, showed the following: -The resident has a right to self-administer medication unless the interdisciplinary team has determined that this practice is unsafe for an individual resident; -If a resident expresses a desire to self-administer medication, the interdisciplinary team must assess the resident's cognitive, physical, and visual ability to carry out this responsibility. The mental status and any psychiatric diagnoses must be taken into account. The 'Evaluation Assessment to Self-Administer Medications will be used for this purpose; -When the resident self-administers medications, the resident will be re-assessed on an ongoing basis for continued safety of this practice. The evaluation assessment will be completed annually or with significant change by nursing and reviewed by the interdisciplinary team to determine if the resident is still capable of self-administer medications; -The physician's order sheet will reflect the current status of the resident's self-administering medications. 1. Review of Resident #30's Resident Face Sheet showed the following: -admitted [DATE], with the most recent readmitted [DATE]; -Diagnoses included acute respiratory failure with hypoxia (decreased oxygen level) and hypercapnia (increased carbon dioxide level in the bloodstream typically caused by inadequate respiration) and acute bronchitis. Review of a resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 03/07/24, showed the resident had moderate cognitive impairment. Review of the resident's current Care Plan showed the following: -Start date of 08/19/19, indicated the resident had an alteration in respiratory status due to anemia and asthma; -The care plan directed staff to administer the resident's medications as ordered. (The staff did not care plan regarding the resident's ability to self-administration of any medications.) Review of the resident's Observation History, dated 02/19/23 through 03/20/24, showed staff did not document completion of a self-administration of medication evaluation for the resident. Review of the resident's Physician's Order Report, dated 02/20/24 through 03/20/24, showed the following: -An order, dated 09/22/19, for an albuterol sulfate aerosol inhaler (used to treat difficulty breathing), two puffs by inhalation every six hours for asthma. The order included, Special Instructions: May keep at bedside; however, the resident's Physician Order Report did not reflect orders for self-administration of their albuterol inhaler. Observations and interview on 03/20/24, at 9:01 A.M., showed a Ventolin inhaler (the name brand for albuterol) at the resident's bedside. The resident said the inhaler stayed in their room all the time. The resident said the nurses were aware the inhaler was in their room since the nurses were the ones that brought the inhaler to the room for the resident's use. During an interview on 03/20/24, at 10:30 A.M., Certified Medication Technician (CMT) #6 said he/she was aware the resident had an order to keep their inhaler at bedside. He/she thought the resident had been assessed for self-administration and acknowledged the resident administered their inhaler independently. During an interview on 03/20/24, at 11:17 A.M., the Director of Nursing (DON) said prior to a resident being allowed to self-administer medication a self-administration assessment had to be completed and an order for self-administration obtained from the physician. The DON said assessments for self-administration of medications was completed quarterly and with any change in a resident's condition and could be found in the electronic medical record (EMR) under the observation history. The DON stated there were no residents in the facility that had been approved to self-administer medications.

Based on observation, interview, and record review, the facility failed to ensure two (Resident #12 and Resident #72) of 2 residents reviewed for activity of daily living (ADL) care received services to maintain grooming/personal hygiene. Specifically, the facility failed to ensure staff provided nail care and shaved facial hair for Resident #2 and #72. In addition, the facility failed to assist Resident #72 with a bath/shower twice weekly in March 2024 per the facility's shower schedule. Review of a facility policy titled Activities of Daily Living (ADL), undated, showed the purpose of the policy was to assist resident in achieving maximum function. (The policy did not addressed assisting residents with shaving or nail care. Review of the facility's Certified Nursing Assistant (CNA) Job Description, dated May 2006, showed the following: -CNA provides personal hygiene needs, including bath (complete, partial, tub/shower, Sitz and skin care); -CNA provides other duties as assigned; -CNA must have the ability to provide personal care for the frail elderly and for acute, chronic, and terminally ill patients. 1. Review of Resident #12's Resident Face Sheet showed the following: -admitted [DATE]; -Diagnoses included weakness, personal history of transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke), chronic pain, rash, and aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking). Review of Resident #12's Admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 02/09/24, showed the following: -Resident dependent on staff for a shower/bathing and required partial/moderate assistance with personal hygiene (including shaving and washing/drying the face and hands); -Resident had upper and lower extremity impairment on one side; -Resident exhibited no behavior symptoms of rejection of care. Review of the resident's current Care Plan, dated 02/03/24, showed the following: -Resident at risk for pressure ulcers related to immobility, incontinence, and the need for extensive assistance with transfers; -Staff to keep the resident clean and as dry as possible. (Staff did not care plan regarding the resident's personal hygiene needs or preferences.). Review of the facility's shower schedule showed the resident was scheduled to receive a shower every Tuesday and Friday. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated February 2024 and March 2024, showed the following: -Staff were required to document whether the resident's toenails needed to be trimmed; -There was no specific area that prompted staff to document whether the resident was shaved or their fingernails were trimmed; -Staff wrote on the 03/07/24 shower form that the resident was shaved and their nails were cleaned and trimmed; -The resident's last documented shower was on 03/14/24. Staff did not document regarding the resident's nails or shaving of the resident on that day. During an interview on 03/18/24, at 11:16 A.M., the resident nodded their head to indicate yes when asked if they would like to be shaved and if they would like their nails to be shorter. Observations on 03/19/24, at 8:03 A.M. and 10:53 A.M., showed the resident had facial hair and long that needed to be trimmed. During an interviews on 03/19/24, at 11:15 A.M., CNA #13 said the resident liked to be shaved, noting the last time he/she provided the resident a shower was on 03/04/24 (15 days prior). At that time the CNA had shaved the resident and trimmed their nails. The resident did not refuse ADL (activities of daily living - dressing, grooming, bathing, eating, and toileting) care. During an interview on 03/20/24, at 11:40 A.M., Licensed Practical Nurse (LPN) #16 said he/she did not think the resident refused showers/bathing, noting staff should make sure the resident's nails were trimmed and facial hair was shaved. 2. Review of Resident #72's Resident Face Sheet showed the following: -admitted [DATE]; -Diagnoses included pain, other reduced mobility, personal history of TIA, osteoarthritis (a type of arthritis that happens when the cartilage that lines the joints is worn down and bones rub against each other) of hip, scoliosis (a sideways curve of the spine), other intervertebral disc degeneration and radiculopathy (a range of symptoms produced by the pinching of a nerve root in the spinal column) of the lumbar region, and age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Review of the resident's admission MDS, with an ARD of 01/03/24, showed the following: -Resident had intact cognition; -Resident needed setup or clean-up assistance from staff with showers/bathing and personal hygiene (including shaving and washing/drying the face and hands); -Resident had upper and lower extremity impairment on one side and exhibited no behavior symptoms of rejection of care. Review of the resident's current Care Plan showed the following: -An area, dated 01/11/24, for the resident's ability to complete ADLs, including, in part, maintaining personal hygiene, had deteriorated related to a recent health decline. (Staff did not care plan interventions to ensure the resident's personal hygiene needs were met.) Observation and interview on 03/18/24, at 10:57 A.M., showed the resident had long fingernails and facial hair. The resident said their nails were too long and they did not like having a beard. The resident said they received a shower once a week. During an interview on 03/19/24, at 2:03 P.M., the resident said they did not get a shower the previous day as scheduled, noting it had been quite a few days since they had a bath or shower. Observation and interview on 03/20/24, at 11:12 A.M., showed the resident continued to have long facial hair and long fingernails. The resident said they would like to have their face shaved and nails trimmed when they got a shower/bath, but staff did not offer. Review of the facility's shower schedule showed the resident was scheduled to receive a shower on Mondays and Thursdays. The instructions showed for staff to mark who received a shower or refused, complete shower sheet, and put in shower book in alphabetical order by last name. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated March 2024, showed the following: -Staff documented they assisted the resident with a bed bath on Monday, 03/04/24; Monday, 03/11/24; and Tuesday, 03/19/24; -Staff did document assisting the resident with a shower on Thursday, 03/07/24; or Thursday, 03/14/24; -Staff did not document regarding shaving the resident or trimming his/her fingernails. During an interview on 03/20/24, at 11:14 A.M., Registered Nurse (RN) #12 said the resident did not always like to take a shower, but staff could provide an adequate bed bath, trim their fingernails, and shave their facial hair. During an interview on 03/20/24, at 11:24 A.M., CNA #13 said he/she had never assisted never assisted the resident with a shower, but typically made sure to offer to shave the resident and trim their nails. During an interview on 03/20/24 at 11:34 A.M., CNA #15 said he/she gave the resident a bed bath on 03/17/24, but failed to complete a shower sheet. He/She stated he/she did not offer to trim the resident's nails and did not offer to shave the resident, but he/she should have offered the services to the resident. During an interview on 03/20/24, at 11:40 A.M., Licensed Practical Nurse (LPN) #16 said the resident refused showers at times, but most of the time, the resident would allow staff to provide a bed bath. Staff should also ensure the resident's facial hair was shaved and nails were trimmed per the resident's preferences. 3. During an interview on 03/20/24, at 11:14 A.M., RN #12 said staff should complete a shower sheet after a bath or shower. The shower or bath process should include shaving and nail care. Staff were also supposed to shave all residents and trim their nails when needed. 4. During an interview on 03/20/24, at 11:24 A.M., CNA #13 said that showers were provided twice per week, noting residents should be shaved and have their fingernails trimmed when needed. 5. During an interview on 03/20/24, at 11:34 A.M., CNA #15 said showers and bathing should include shaving a resident and trimming the resident's nails, noting staff should complete a shower sheet. If a resident refused a bath or shower, he/she would document the refusal on the shower sheet. 6. During an interview on 03/20/24, at 11:27 A.M., CNA #14 said shaving and trimming nails were part of a bath or shower. Shower sheets were completed and placed in a binder at the nurses' station. Staff should offer to trim the residents' nails and shave them when providing baths/showers. 7. During an interview on 03/20/24, at 2:45 P.M., CNA #17 said when providing a shower or bath, staff should offer to shave facial hair and trim the residents' fingernails. 8. During an interview on 03/20/24, at 11:40 A.M., Licensed Practical Nurse (LPN) #16 said shower sheets should be completed for baths and showers. Staff were to offer to trim residents' nails and shave the residents when providing showering assistance. 9. During interviews on 03/20/24, at 8:22 A.M. and 2:52 P.M., the Director of Nursing (DON) said she expected staff to provide two showers weekly and, on alternating days, staff should provide a bed bath. She expected residents' nails to be trimmed and clean and for staff to offer to shave residents' faces every day. 10. During an interview on 03/20/24, at 3:03 P.M., the Administrator said he had high standards and expected residents to be well groomed and bathed. He said he expected staff to offer to shave residents and trim their nails as needed, particularly when long or dirty.

Based on record review, and interviews, the facility failed to monitor and document the bruit (a whooshing sound that can be heard with a stethoscope) and thrill (gentle vibration caused by blood flow) of a resident's arteriovenous (AV) shunt for one resident (Resident #61) of one sampled resident reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services. Review of a facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed the following: -Purpose to utilize the following guideline to provide care for a resident that is receiving dialysis; -Care of the AV shunt/fistula/graft specified, feel for the thrill sensation daily; -Checking the thrill sensation specified nurses will check the thrill daily and document daily. This will be documented on the resident's treatment record; -At the AV site feel for a pulse. The pulse is the blood flow through the access; -If no thrill sensation is felt notify the physician. 1. Review of Resident #61's Resident Face Sheet showed the following: -admitted [DATE] with a readmitted [DATE]; -Diagnoses included end stage renal disease (ESRD), anxiety, and type two diabetes mellitus with diabetic nephropathy (the chronic loss of kidney function occurring in those with diabetes mellitus). Review of a quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 01/02/24, showed the following: -Resident was cognitively intact; -Received dialysis services while a resident of the facility. Review of the resident's current Care Plan showed the following: -A focus area, with a start date of 09/28/22, showing the resident had an alteration in kidney function related to ESRD; -Resident received hemodialysis each Monday, Wednesday, and Friday; -Encourage the resident to go to dialysis as ordered per the facility van, administer medications as ordered, check the resident's dialysis access site daily for signs or symptoms of infection, and to notify the physician of significant changes. (Staff did not care plan related to checking the bruit or thrill of the resident's AV shunt.) Review of the resident's Active Orders and Order History showed the following: -An order, dated 09/28/22, for staff to monitor the resident's AV site for signs and symptoms of infection every shift; -An order, dated 06/10/23, for dialysis three times per week on Mondays, Wednesdays, and Fridays. (There was no order to check the resident's AV shunt for bruit and thrill until 03/19/24, during the survey.) Review of the resident's Medication Administration Record, dated 03/01/24 to 03/19/24, showed staff did not document monitoring the bruit and thrill of the resident's AV shunt prior to 03/19/24. During an interview on 03/19/24, at 1:23 P.M., Licensed Practical Nurse (LPN) #1 said the resident currently had an AV shunt for dialysis access. Staff observed the resident's AV shunt daily for any redness or other changes, but did not check the bruit and thrill. If staff were supposed to check the bruit and thrill, there would be orders prompting them to do so. LPN #1 confirmed he/she had not been checking the bruit and thrill for the resident's AV shunt. During an interview on 03/19/24, at 2:39 P.M., the resident said their AV shunt was in their left arm. Per the resident, nursing staff felt around the shunt site periodically, but did not routinely assess their AV shunt site using a stethoscope. During an interview on 03/19/24, at 3:39 P.M., LPN #2 said when a resident was received dialysis, nursing staff checked the resident's AV shunt site for any swelling or bleeding and also checked the bruit and thrill to ensure blood was flowing and the AV shunt was functioning properly. It was important to check the bruit and thrill of an AV shunt, because it could alert nursing staff if something was wrong with the shunt. After reviewing the resident's orders, LPN #2 confirmed there was no order directing staff to check the bruit and thrill, but indicated he/she did so anyway out of habit. During an interview on 03/21/24, at 9:21 A.M., the Director of Nursing (DON) said when a resident was on dialysis and had an AV shunt, she expected nursing staff to check the bruit and thrill every shift to ensure proper blood flow. The DON was unaware there was no order directing staff to check the resident's bruit and thrill prior to 03/19/24. During an interview on 03/21/24, at 9:23 A.M., the Administrator said he expected an order to be in place for nursing staff to monitor and document the bruit and thrill of a dialysis resident's AV shunt.

Based on observation, interview, and record review, the facility failed to ensure the physician reviewed and acted upon medication irregularities reported by a Consultant Pharmacist in a timely manner for one resident (Resident #16) of five residents reviewed for unnecessary medications. Review of facility guideline titled, Drug Review, undated, showed the following: -All medications given to each resident will be reviewed on a monthly basis in order to review drug interactions, ensure adherence to stop orders. ensure accuracy in administration, and evaluate medications appropriate to diagnosis; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas. The report lists any problems noted, the date, and signature of reporter; -Medications should not show unnecessary or excessive use and should have a diagnosis to support them; -Problems identified shall be addressed according to need in consultation with physician; -Follow up on problems needs either the Director of Nursing's (DON) or pharmacist's signature to show that the problem has been addressed; -Any order changes are handled in the proper manner and changes conveyed to pharmacy. 1. Review of Resident #16's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 01/22/24, showed the following: -admitted [DATE]; -Diagnoses included non-Alzheimer's dementia and unspecified disorientation; -Resident was unable to complete the interview to determine cognition; -Resident rejected care and had verbal behavioral symptoms directed toward others; -In the prior seven days or since admission, the resident had taken antipsychotic, hypnotic, and opioid medications; -There was a documented indication for use of the medications. Review of the resident's Care Plan, dated 01/16/24, showed the following: -Resident received psychotropic medications and had a potential for drug-related complications associated with the use of Seroquel (quetiapine - an antipsychotic medication) and lorazepam (a sedative, antianxiety medication); -Interventions directed staff to monitor for side effects and indicated the doctor and the pharmacist would review the resident's medications monthly for possible problems and to determine if the resident could take a lower dose. Review of the resident's Physician Order Report, dated 01/01/24 through 01/31/24, showed the following: -An order, dated 01/16/24, for oral lorazepam intensol 2 milligrams (mg)/milliliter (mL), providing 0.5 mL (1 mg) by mouth every four hours as needed (PRN) for unspecified dementia at an unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; -An order, dated 01/16/24, for delayed-release divalproex (Depakote - anticonvulsant, migraine headache preventer, and bipolar therapy agent) 125 milligrams (mg) daily, oral, at bedtime for a diagnosis of other specified health status; -An order, dated 01/19/24, for lorazepam intensol 2 mg/mL, provide 1 mL (2 mg) for agitation PRN every four hours with a diagnosis identified as unspecified dementia at an unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. (Staff did not document discontinuation of the 01/16/24 order.); -A current order for Robitussin Cough+Chest Congestion DM (dextromethorphan-guaifenesin) liquid, 5-100 mg/5 mL, providing 10 mL by mouth for acute cough PRN. (The order did not indicate how often staff could administer the medication.) Review of the resident's Pharmacist's Recommendation to Prescriber forms, with a recommendation date of 01/31/24, showed the following: -The resident had two PRN orders for lorazepam intensol, one directing staff to provide one mg every four hours as needed (ordered 01/16/24) and one directing staff to provide two mg every four hours as needed (ordered on 01/19/24). The pharmacist indicated the orders must specify when to give the 1 mg dose and when to give the 2 mg dose; -The pharmacist indicated the PRN lorazepam intensol orders lacked a stop date and that the Centers for Medicare and Medicaid Services (CMS) required for PRN orders for psychotropic drugs be limited to 14 days unless the prescriber documented the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order in the medical record; -The consultant pharmacist asked the prescriber to consider particular clarifications pertaining to the lorazepam intensol orders/diagnosis; -There was no documentation the prescribing physician reviewed/acted upon the pharmacy recommendations from 01/31/24 until 03/18/24, after the survey was initiated. Review of the resident's Pharmacist's Recommendation to Prescriber forms, with a recommendation date of 01/31/24, revealed the following: -The resident had an order for PRN Robitussin Cough+Chest Congestion DM that lacked a PRN dosing interval. The pharmacist documented that the order was incomplete without the PRN dosing interval. The pharmacist recommended the prescriber consider clarification of the dosing interval to every four hours PRN for cough or chest congestion; -There was no documentation the prescribing physician reviewed/acted upon the pharmacy recommendation from 01/31/24 until 03/18/24, after the survey was initiated. Review of the resident's Pharmacist's Recommendation to Prescriber forms, with a recommendation date of 01/31/24, showed the following: -The resident was receiving divalproex acid (Depakote) for dementia with behavioral disturbance. The pharmacist recommended the prescriber consider one of the following: obtaining laboratory (lab) tests that included a complete blood count (CBC), comprehensive metabolic panel (CMP), and a valproic acid (Depakote) level on the next routine lab day; obtaining a valproic acid level only on the next routine lab day; or denoting that lab tests were not necessary at the time due to hospice/clinical goals; -There was no documentation the prescribing physician reviewed/acted upon the pharmacy recommendations from 01/31/24 until 03/18/24, after the survey was initiated. Observation on 03/18/24, at 9:45 A.M., showed the resident had their eyes closed while in bed. Observation 03/18/24, at 10:30 A.M. showed the resident was sleeping. Observation on 03/19/24, at 9:00 A.M., showed the resident had their eyes closed in a wheelchair in front of a television by a day room. During an interview on 03/18/24, at 2:00 P.M., the resident's representative said during every visit they had with the resident, the resident was sleeping, and it was difficult to awaken the resident. During an interview on 03/20/24, at 9:00 AM, the Pharmacy Consultant said all residents' medications regimens were reviewed monthly. If there was an urgent recommendation, she contacted the facility immediately and, if the recommendation was not urgent, she emailed the recommendations to the DON and prescribing physician. The resident's 01/31/24 recommendations were emailed to facility staff on 02/19/24. She stated when she completed another resident review on 02/29/24, the physician had not addressed some of the recommendations; however, she did not address that with the facility. During an interview on 03/19/24, at 3:26 P.M., the Medical Director said he had not seen the pharmacy recommendations for the resident from 01/31/2024. The Pharmacy Consultant normally emailed the recommendations, and he typically addressed those recommendations within seven to ten days. During an interview on 03/20/24, at 10:46 A.M., the DON said the Pharmacy Consultant emailed medication regimen recommendations to the DON and Medical Director. Pharmacy recommendations should be sent to the facility within a few days of the consultant pharmacist's review. The DON was not aware that the Medical Director had not addressed the Pharmacy Consultant's recommendations for the resident. During an interview on 03/20/24, at 9:29 A.M., the Administrator said he had not received any concerns from the Pharmacy Consultant or other staff that the Medical Director was not addressing pharmacy reviews/recommendations.

Based on observation, record review, and interviews, the facility failed to ensure an expired medication was not stored in a resident's room for one resident (Resident #8) of 21 sampled residents. Review of the facility policy titled, Medications, Storage of, undated, showed the following: -All medications for residents must be stored at or near the nurses' station in a locked cabinet, a locked medication room, or one or more locked mobile medication carts; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. 1. Review of Resident #8's Resident Face Sheet showed an admitted [DATE]. Observations on [DATE], at 11:18 A.M., showed a tube of hydrocortisone cream in the resident's room. The cream had an expiration date of [DATE]. During an interview on [DATE], at 11:22 A.M., Licensed Practical Nurse (LPN) #1 said the hydrocortisone cream in the resident's room had an expiration date of [DATE]. He/she had not previously seen the cream in the resident's room. During an interview on [DATE], at 11:15 A.M., the Director of Nursing (DON) said she was not aware that the resident had expired hydrocortisone cream in their room. Certified nurse assistants (CNAs) periodically looked for medications in residents' rooms and said she expected them to remove and report any items they found.

Based on observations and interviews, the facility failed to ensure a privacy curtain was in place between two residents (Resident #16 and Resident #17) who resided in one of 48 semi-private rooms in the facility. 1. Observations on 03/18/24, at 11:59 A.M., showed Resident #16 and Resident #17 shared a semi-private room. The privacy curtain between their beds was missing. Observations on 03/19/24, at 12:04 P.M., and on 03/20/24, at 10:35 A.M., showed the privacy curtain between the two residents was missing. During an interview on 03/20/24, at 12:09 P.M., Certified Nurse Assistant (CNA) #9 said he/she had been employed at the facility for approximately one year and did not recall if there had ever been a privacy curtain between the residents' beds. He/she did not think the privacy curtain was a concern due to the poor cognition of both residents. During an interview on 03/20/24, at 12:19 P.M., Licensed Practical Nurse (LPN) #8 said he/she was not aware of the missing privacy curtain in residents' room. If it had been brought to his/her attention, he/she would have contacted housekeeping or maintenance staff to address the concern. During an interview on 03/20/24, at 12:40 P.M., the Environmental Supervisor said a floor technician took the privacy curtain down from the residents' room on 03/17/24 to wash it. A replacement curtain should have been hung when it was taken down to wash; however, the Environmental Supervisor said the facility had a limited supply of replacement curtains available and was unsure if a replacement was available on 03/17/24. During an interview on 03/21/24, at 9:30 A.M., the Director of Nursing (DON) said semi-private rooms should have privacy curtains to provide privacy for the residents. The cognitive status of the residents was irrelevant and indicated all residents should have privacy curtains. During an interview on 03/21/24, at 10:30 A.M., the Administrator said semi-private rooms should have privacy curtains to provide privacy for the residents. The Administrator was not aware of a limited supply of privacy curtains and indicated if a curtain was taken down, a replacement curtain should be hung immediately.

Based on observations, interviews, and record review, the facility failed to provide protective oversight to one resident (Resident #1), when staff failed to place foot rests on the resident's wheelchair, and the resident subsequently fell out of the wheelchair sustaining a facial laceration and a broken nose. The facility census was 78. Review of the facility policy titled, Use of Wheelchair, undated, showed the following: -Purpose to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living; -Apply brakes to lock wheels of wheelchair and fold footrests up out of the resident's way for safety; -Do not remove footrests unless resident uses feet on floor to enable mobility; -Pad seat of wheelchair with pressure-reducing cushion; -Assist resident to dress in appropriate clothing with proper footwear; -Assist resident into wheelchair, using proper transfer techniques; -Lower footrests and place resident's feet on footrests if used; -Position feet and legs in good body alignment; -Elevate legs as ordered. 1. Review of Resident #1's face sheet showed: -Original admitted [DATE]; -Re-admitted [DATE]; -Diagnoses included dementia, laceration to head, reduced mobility, history of traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), and repeated falls; -Currently on hospice services. Review of the resident's current care plan showed the following: -Resident has a risk for falls due to dementia; -On 06/21/22, resident fell and staff sent resident to emergency room , Resident was admitted to the hospital with a subarachnoid hemorrhage; -On 10/22/22, resident slipped out of wheelchair; -On 11/04/22, resident placed in a geri-chair (a medical recliner on wheels); -On 12/03/22, resident found on floor and had a nose bleed and some bruising; -On 03/31/23, resident sitting on the floor in his/her room with no injury; -On 04/30/23, resident slid onto the floor from bed with no injuries; -Assess the resident for pain, administer medication as ordered, and observe for effectiveness; -Assess that the resident's wheelchair is the right size and in good working condition; -Encourage the resident to wear non-skid shoes and keep the resident bed in low position; -Remind resident to call for assistance; -Fall mats in floor on the sides of the bed. Review of the resident's fall risk assessment tool, dated 8/30/23, showed the following: -History of one or more falls within the previous six months; -Required assistance or supervision with mobility, transfers; -Lack of understanding of one's physical and cognitive limitations; -High fall risk. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 10/11/23, showed the following: -Diagnoses of non-traumatic brain dysfunction, hypertension (high blood pressure), dementia, dysphagia (difficulty swallowing), and pain; -Severe cognitive impairment; -Functional limitations in range of motion to bilateral (both sides) upper and bilateral lower extremities; -Wheelchair for mobility device; -Dependent on staff for assistance with eating, showering, dressing, personal hygiene, and transfers; -Always incontinent of bowel and bladder; -Resident has fallen since admission. Review of the resident's occupational therapy (OT) evaluation and plan of treatment, dated 10/26/23, showed the following: -Reason for referral: Resident is receiving hospice care and was referred to OT service due to multiple choking episodes; -Resident warrants skilled OT for wheelchair positioning, range of motion (ROM)/mobilization of neck, core strengthening, and staff education with proper positioning to help reduce factors contributing to choking due to poor position. Review of OT treatment encounter notes, dated 11/10/23, showed the following: -Provided education to four certified nurse assistants (CNA), two charge nurses, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and MDS Nurse regarding resident's proper sitting posture and wheelchair configuration; -Resident using comfort saddle gel cushion. Resident scooted back in the wheelchair with maximum assistance of two staff. Resident immediately stated, I am so much more comfortable. I love it; -OT placed bilateral foot rests and adjusted length to ensure that patient knees are aligned with hips. Provided right half tray (arm rest tray) to decrease right side leaning and improve sitting alignment at midline. Review of the resident's progress note dated 11/11/23, at 1:33 P.M., showed a nurse documented the following: -Called to the dining room by the CNA stating the resident was on the floor. Resident found face down on the floor in the dining room with a large amount of blood on the floor. The resident did not lose consciousness. Staff applied pressure to the large laceration, cleansed and covered areas, applied ice, and administered Tylenol as ordered. Staff placed call to hospice to alert of the situation and verbal consent given to send the resident to the emergency room . Staff placed call to to the resident's responsible party and updated on the incident. Staff notified the resident's physician who gave new orders to send the resident to the emergency room for evaluation and treatment. Staff left message for the administrator on call. Staff notified emergency medical services (EMS) of need to transport the resident. Staff called report to the emergency room nurse. Staff initiated neurological assessments at the time of the fall and continued until EMS arrived to transport the resident out of the building at 1:30 P.M. Review of the resident's physician order report, dated 10/20/23 to 11/20/23, showed an order, dated 11/11/23, to send the resident to the emergency room for evaluation and treatment. Review of the resident's event report dated 11/11/23, at 1:41 P.M., completed by a facility nurse, showed the following: -Fall with injury in the dining room; -Resident sitting in his/her wheelchair waiting on lunch to be served in the dining room at his/her table; -Complained of pain to head, rated as a 5 on a pain intensity scale of 0-10. (0= no pain, and 10= excruciating pain, worst possible); -Right forehead laceration, area cleansed, pressure applied, ice applied, and neurological checks initiated, Review of the resident's hospital discharge instructions, dated 11/11/23, showed diagnoses of closed head injury, forehead laceration, and nasal bone fracture. Review of the resident's progress not, dated 11/11/23, at 8:11 P.M., showed a nurse documented the following: -The resident returned from the hospital via ambulance with diagnoses of closed head injury, forehead laceration, and fractured nasal bone. The resident's physician is aware of the resident's return and gave orders for Ultram (a pain medication) for the resident, as the resident complained of head pain. Staff assisted resident with supper and responsible party at bedside. Call light in reach. Staff completed frequent checks due to the resident's inability to use the call light. Hospice aware of the resident's return. Sutures to be removed in 7 days. Review of the resident's OT treatment encounter note, dated 11/12/23, showed the following: -OT was informed the resident had a fall yesterday. After standing, he/she fell and hit his/her face on the floor. Resident was hospitalized and required stitches on his/her forehead. Facility staff and the resident's responsible party asked OT to address fall prevention. OT educated and trained three weekend/evening CNA's that it is absolutely necessary for the resident to be scooted all the way back in the wheelchair with attention to pelvic positioning and ensuring the resident is scooted all the way back. Resident has tendency to continue sliding forward. Because the resident is using a saddle cushion, if patient is sitting on the higher front part of the cushion. It sits him/her higher and makes standing easier. However, resident is unable to stand or walk functionally and only falls forward. Staff educated with two person technique to reposition resident on the chair. OT reiterated that the resident must have bilateral leg rests and left half tray at all times for positioning. Facility informed OT the resident did not have bilateral leg rests on wheelchair at the time of fall and was also sitting farther forward on the wheelchair. Review of the resident's weekly skin assessment, dated 11/14/23, completed by a facility nurse showed resident had a recent fall and has stitches noted to the right forehead that are intact with no signs/symptoms of infection noted and also bruising that is healing yellow purplish in color to bilateral eyes and underneath eyes. Review of the resident's physician order report showed an order, dated 11/18/23, to monitor incision to right forehead daily for signs/symptoms of infection until resolved. Review of the resident's updated care plan intervention, dated 11/20/23, showed staff to place the resident in a high back wheelchair with foot rests when out of bed for comfort. During an interview on 11/20/23, at 10:45 A.M., CNA A said the following: -The resident fell approximately two weeks ago out of his/her wheelchair; -The nurse reported a CNA forgot to place the footrests on his/her wheelchair. During an interview on 11/20/23, at 10:48 A.M., Registered Nurse (RN) B said the following: -The resident fell on Saturday, 11/11/23. One of the CNA's took the resident into the dining room for lunch and approximately five minutes later, staff yelled for help. This nurse entered the dining room and the resident was lying face down on the floor. The resident had a significant amount of blood coming from a laceration to his/her forehead. The nurse held pressure to get the bleeding stopped, applied a dressing and an ice pack. The nurse notified the appropriate staff, physician, and responsible party and sent the resident to the hospital for evaluation; -Staff had just recently, a few days prior, started placing the resident into a high-backed wheelchair; -The resident had previously used a geri-chair, but was having swallowing issues in the reclined position; -The OT inserviced some of the staff on proper wheelchair positioning for the resident, prior to the fall; -On the day of the fall, the CNA forgot to place the resident's footrests on the wheelchair. During an interview on 11/20/23, at 11:50 A.M., Occupational Therapist (OT) C said the following: -Approximately one week before the resident's fall on 11/11/23, hospice provided a high back wheelchair for the resident's use; -The resident had previously used a geri-chair, but was having swallowing issues and therapy thought this wheelchair would place the resident in a more upright position during meals; -The OT educated staff during the week of 11/06/23 to 11/10/23 about proper positioning in the wheelchair and the necessity for footrests to prevent the resident from falling; -The OT returned to the facility on [DATE] and was informed by staff that the resident had fallen out of the wheelchair because staff failed to place the resident's footrests on his/her wheelchair; -The resident's fall on 11/11/23 was due to or related to staff not placing the footrests on the wheelchair; -At the time of the fall, the OT did not have a documented plan for the resident's wheelchair positioning, for staff to use because he/she did not yet have an approved contract through hospice to work with the resident. Observation in the facility dining room on 11/20/23, at 12:28 P.M., showed the following: -The resident seated at a table in a high back wheelchair, with bilateral foot rests in place with non-skid shoes on his/her feet; -The resident had a healing linear scar to his/her forehead approximately 4-5 centimeters in length and fading purple bruises to his/her right and left cheeks. During an interview on 11/20/23, at 12:40 P.M., CNA D said the following: -He/she was responsible for providing direct care to the resident during the day on 11/11/23; -He/she assisted the resident into his/her wheelchair before lunch, but failed to place the footrest on the resident's wheelchair; -The CNA said he/she was not aware the resident had footrests and he/she did not see foot rests in the resident's room; -The resident should have had foot rests on his/her wheelchair; -Staff later found the foot rests in the resident's closet. During an interview on 11/20/23, at 1:47 P.M., CNA F said the following: -On 11/11/23, the CNA was in the dining room assisting another resident, when he/she heard the resident fall and turned to see the resident fall and hit the floor; -The CNA was unsure exactly how the fall occurred, but the resident did not have foot rests on his/her wheelchair and he/she knew the resident was supposed to have them on the chair; -The CNA said the facility did not instruct him/her on the resident's wheelchair/positioning, prior to the fall on 11/11/23, but staff place foot rests on most of the wheelchairs for proper positioning of the residents; -The CNA said he/she did not assist the resident to the dining room on 11/11/23. During an interview on 11/20/23, at 1:30 P.M., the MDS coordinator (RN E) said the following: -He/she was a little behind on adding fall interventions to resident care plans; -He/she updated the resident's care plan today, on 11/20/23, to show the resident should be up in a high-back wheelchair with bilateral footrests. During an interview on 11/20/23, at 1:35 P.M., the DON said the following: -The OT came to the facility on [DATE] after the resident fell on [DATE] and investigated the cause of the fall and found the staff failed to place the resident's foot rests on his/her wheelchair; -Staff should have updated the care plan with the new wheelchair and proper positioning in the chair; -All parts of the resident's wheelchair are important for positioning. Complaint #MO00227438

Based on observation, interview and record review, the facility failed to identify, assess, notify the physician, and implement treatments and interventions for one resident (Resident #2), at high risk for pressure ulcer development. The resident developed one Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable (does not turn white when pressed indicating tissue damage)), two Stage II (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) pressure ulcers, one unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and one deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin usually initially presents a dark purple color and can quickly deteriorate) to his/her feet, not identified by the facility. A sample of 14 residents was selected in a facility with a census of 86. Record review of the facility's pressure ulcer, care and prevention of policy, dated March 2016, included the following information: -Purpose: To prevent and treat further breakdown of pressure ulcers; -treatment of [REDACTED]. -The nurse is responsible for implementing measures to prevent pressure ulcers and for carrying out the treatment as ordered by the physician; -Observe skin. Any persistent reddened areas that remains after pressure is relieved is a high risk area for a pressure ulcer to begin; -Use pressure relieving devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences; -Use elbow and heel protectors if needed. 1. Record review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/07/17, showed the following information: -admitted to the facility on [DATE]; -Dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing; -Used a wheelchair for mobility; -[DIAGNOSES REDACTED]. -One Stage III (full thickness skin loss involving damage or death of subcutaneous tissue that may extend down to but not including the bone) pressure ulcer; -Skin and ulcer treatments included: Pressure reducing device for bed and chair. Review of the resident's Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower review forms showed the following information: -On 07/07/17, a CNA documented skin tear on the resident's left foot and pressure ulcer on the resident's buttocks. The charge nurse documented see above regarding an assessment of the areas and treatment in place. The Assistant Director of Nursing (ADON) signed she reviewed the form on 07/18/17. -On 07/14/17, a CNA documented pressure ulcer on the resident's buttocks and right foot. The charge nurse documented see above on the assessment portion of the form and treatment in place. The ADON signed she reviewed the form on 07/17/17. -On 07/18/17, a CNA documented pressure ulcer on the resident's buttocks and right foot. The charge nurse documented treatment to coccyx (tailbone) in place, right heel reddened but blanches (turns white when pushed). The ADON signed she reviewed the form on 07/18/17. Record review of the resident's medical record showed no documentation or assessment of the resident's feet. Record review of the resident's weekly skin assessment, dated 07/21/17, showed a nurse documented the resident's bilateral (both) lower extremities were intact (healthy skin in which there are no breaks, scrapes, cuts, or abnormal openings) with reddened areas that staff treat with skin prep (a liquid film forming skin protectant which can be used on intact or damaged skin to help prevent irritation caused by friction in high-risk areas). Record review of the resident's medical record showed no documentation of a skin assessment for 07/28/17. Record review of the Resident's Skin Monitoring: Comprehensive CNA Shower review forms showed the following information: -On 07/28/17, a CNA documented dryness to both of the resident's feet. The charge nurse documented see above regarding an assessment of the areas and treatment in place. The ADON signed she reviewed the form on 07/31/17. -On 08/04/17, a CNA documented no new skin issues. Record review of the resident's medical record showed no documentation of a skin assessment for 08/04/17. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Significant Change MDS, dated [DATE], included the following differences from the previous assessment (06/07/17); -One Stage IV (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) pressure ulcer. Record review of the resident's care plan, last reviewed/revised on 08/11/17, showed the following information: -The resident had a pressure ulcer to his/her coccyx with risk for further breakdown due to immobility and dependence on staff for care; -Complete weekly skin/wound assessments; -Encourage the resident to reposition side to side when in bed; -Float the resident's heels using a heel riser (a cushion to aid in floating heels) as needed; -Low air loss mattress; -Cushion in wheelchair for pressure relief Record review of the resident's weekly skin assessment, dated 08/13/17, showed a nurse did not document regarding any areas on the resident's feet. An observation on 08/16/17, at 9:30 A.M., showed CNA N and MDS Coordinator O assisted the resident to bed. The resident laid on a low air loss mattress. After staff provided incontinence care, they positioned the resident on his/her left side and placed a pillow between his/her knees. (The staff did not float the resident's heels or feet off of the mattress.) An observation on 08/16/17, at 12:15 P.M., showed the resident in bed without his/her heels or feet floated off of the mattress. CNA N removed the sock covering the resident's right foot and showed three reddened areas, approximately 1 cm in diameter, on the left side of his/her great toe. CNA F removed the sock covering the resident's left foot and showed an area of black eschar (dead tissue), approximately 1 cm in diameter, on the right side of his/her great toe. Observations on 08/17/17 showed the following information: -At 10:40 A.M., the resident laid in bed without his/her heels or feet floated off of the mattress; -At 11:00 A.M., Licensed Practical Nurse (LPN) B removed the sock covering the resident's right foot and showed three reddened areas, approximately 1 cm in diameter, on the left side of his/her great toe and one non-blanchable reddened area, approximately 1 cm in diameter, and one blanchable reddened area on the right side of his/her foot. The LPN removed the sock covering the resident's left foot and showed an area of black eschar, approximately 1 cm in diameter, on the right side of his/her great toe. -At 11:30 A.M., after LPN B and the ADON completed wound care to the resident's coccyx, inner knee and back they positioned the resident on his/her right side and placed a pillow between the resident's knees. (The nurses did not float the resident's heels or feet off of the mattress.) Record review of the resident's medical record showed no documentation of the reddened areas on the resident's right and left feet or the black eschar on the resident's left great toe. An interview and observation on 08/18/17, at 11:10 A.M., showed the following: -The resident laid in bed while a hospice nurse conducted a routine visit. The hospice nurse removed the blankets covering the resident's feet and showed one reddened area and two fluid-filled blisters on the left side of his/her right great toe (two of the same areas that were reddened on 08/16/17 and 08/17/17 now presented as blisters), an area of black eschar, approximately 1 cm in diameter, on the right side of his/her right great toe, a dime-sized non-blanchable reddened area on the right side of his/her right 5th toe and a dime-sized non-blanchable reddened area on the left side of his/her left mid foot. -The hospice nurse said the resident needed heel protectors. The resident has had the reddened areas and black eschar on his/her feet since he/she started seeing the resident two weeks ago. The reddened areas appear worse and the eschar appears a little better. During an interview on 08/18/17, at 2:45 P.M., CNA N said the following: -Interventions for a resident at risk or who has pressure ulcers include repositioning, placing pillows between knees and behind his/her back and floating/positioning feet off of the mattress. If staff observe a new open area on a resident's skin, the staff member reports the area to the charge nurse; -Resident #2 has had the areas on his/her feet for quite a while. The CNA reported the areas to the nurses who said there was nothing they could do for those areas but to apply Sure Prep (a type of skin prep). During an interview conducted on 08/18/17, at 3:25 P.M., the ADON said the following: -She is responsible for ensuring staff complete weekly skin assessments. -CNAs report all newly observed wounds/pressure ulcers to the charge nurse. The charge nurse assesses the wound/pressure ulcer and documents the assessment in the nurse progress notes. The nurse who assesses the new wound/pressure ulcer notifies the physician and family and also notifies the wound nurse. The wound nurse measures wounds every week and documents the measurements on the weekly wound assessment. -The ADON becomes aware of new wounds when she reviews the nurses' progress notes and CNA bath sheets. Sometimes the nurses also tell her of new wounds. When the ADON becomes aware of a new wound, she tells the wound nurse. -The charge nurses complete the weekly skin assessments based on the schedule created by the ADON. If the charge nurse finds a new wound when completing the weekly skin assessment, he/she assesses the wound, documents the assessment, notifies the physician and family and notifies someone in management. -Pressure ulcer interventions include repositioning every two hours and floating heels off of the mattress. -The ADON did not know the resident #2 had reddened areas on his/her feet or an area of eschar on his/her left great toe. During an interview conducted on 08/18/17, at 4:05 P.M., the Director of Nursing (DON) said they could not apply Posey Boots (padded foot protector held in place by a Velcro strap) on the resident's feet due to the manufacturer's instructions, but staff could float the resident's heels to decrease pressure. During an interview conducted on 08/18/17, at 4:20 P.M., CNA H said if a CNA notices a new area/wound on a resident, he/she reports the new area to the charge nurse. The resident has not had the reddened areas on his/her feet for very long. They have been there about a week, maybe a little longer. The CNA did not report the areas to the charge nurse because he/she thought someone already did. Every time the aides transfer the resident to bed, they apply Sure Prep to his/her feet. The CNA did not know the resident had a black area on his/her left foot; he/she only observed the reddened areas. Record review of the resident's August 2017 physician's orders [REDACTED]. During an interview conducted on 08/18/17, at 5:00 P.M., LPN P said the following: -The charge nurses complete the residents' weekly skin assessments. -If staff report to or if the nurses find a new wound/pressure ulcer, they assess the wound/pressure ulcer and document the assessment in the nurse progress notes and on the weekly skin assessment form, and notify the physician. The nurses also document they found a new wound/pressure ulcer on the 24-hour report sheet. Every morning the DON, ADON and wound nurse reviews the 24-hour report sheet and discusses any issues or problems the nurses have had; -The resident has an abrasion on his/her right toes and redness on his/her ankle. The black area on the resident's left great toe is a scab; the resident caught it on his/her toenail. Review of the resident's weekly skin assessment, dated 08/18/17 at 5:21 P.M., showed a nurse documented he/she was notified by the previous shift's nurse of areas to the resident's feet. The resident had an abrasion (scrape) to both of his/her great toes, and redness on his/her left ankle; the nurse would apply Sure Prep to the redness on the resident's ankle. The nurse notified the physician. An observation and interview on 08/18/17, at approximately 5:30 P.M., the DON and physician said the following: -The DON did not know the resident had pressure ulcers on his/her feet. The DON described the resident's wounds as the following: two open blisters on the right medial great toe, blanchable reddened area on the right medial great toe, dark unstageable pressure ulcer on the left medial great toe; -The physician described the resident's wounds as the following: deep tissue injury on the left lateral 5th toe and left lateral mid-foot. -The physician said the wounds were probably caused by pressure from the resident's leg turning inward. The physician did not know the resident had any pressure ulcers on his/her feet. During an interview on 08/18/17, at 6:05 P.M., the DON and administrator said the following: -The DON said charge nurses complete residents' weekly skin assessments per a set schedule. -The DON said CNAs complete a skin monitoring bath sheet for each resident they bathe. They give the bath sheet to the charge nurse for review, the nurses give their copy to the ADON. When staff identifies a new wound, the nurse immediately assesses the wound, documents the assessment in the nurse progress notes and notifies the physician. The charge nurses should let the DON know when they have identified a new wound and write it on the 24-hour report sheet. The DON, ADON and administrator reviews the 24-hour report sheets during their daily morning meeting. The wound nurse works Saturday, Sunday, Monday and Tuesday and tracks the wounds on the days she works; the ADON tracks wounds on the days the wound nurse is not working. The DON tells the wound nurse when a resident has a newly identified wound; the wound nurse sets-up and completes the weekly wound assessments; -The DON said interventions for residents with or at high risk of developing pressure ulcers include posy boots, low air loss mattresses, positioning devices such as wedges and cushions, and turning and repositioning. The MDS coordinator, ADON or unit supervisor updates care plans with pressure ulcer interventions as needed. -The administrator said nurses can also update care plans with new interventions. Record review of the resident's pressure ulcer assessment, completed by the ADON on 08/18/17, showed the following information: -Right medial great toe: open area that measured 0.7 cm (diameter) with a scant amount of serous (clear, thin, watery drainage made of protein and fluid) drainage; -Right medial great toe: reddish scab (located above the open area) that measured 0.4 cm x 0.5 cm; -Base of right great toe: Fluid-filled blister that measured 1.5 cm x 1.7 cm, red perimeter; -Left medial 1st metatarsal head (bone in the foot just behind the big toe): Unstageable wound covered with eschar that measured 0.7 cm (diameter); -Left lateral 5th toe: Stage I pressure ulcer that measured 0.9 cm x 1.2 cm; -Left lateral mid foot: deep tissue injury that measured 1.2 cm x 1.7 cm.

Based on observation, interview, and record review, the facility staff failed to provide protective oversight and supervision and nursing care in accordance with the resident's condition for one sampled resident (Resident #3) diagnosed with [REDACTED]. The resident had one fall in his/her room on 7/19/12. The resident left the facility, unknown to staff, on 07/22/12 at 3:30 A.M., and re-entered the building with injuries including facial/head injuries from an un-witnessed fall. The staff implemented interventions of a security bracelet, that they did not activate. The resident left the building the next morning on 7/23/12, but was retrieved by staff. The facility staff did not notify the resident's physician when the resident had a significant decline in mental and physical functioning. On 7/25/12, dialysis sent the resident to the hospital, and the results of a CT scan showed a large subdural bleed (bleeding in the brain). The hematoma measured 2.6 cm in greatest dimension and caused a 1 cm midline shift (pressure from the accumulation of blood that causes a shift of the brain past its center line). The facility staff failed to comprehensively assess and develop an individualized interdisciplinary care plan with interventions to instruct staff on how to keep the resident, safe from injury from falls. In addition, staff failed to provide adequate supervision when one resident (Resident #16) exhibited verbal, physical and inappropriate behaviors directed at his/her roommate (Resident #20). Thirteen residents were sampled, with the addition of five residents out of a facility census of 67. 1. Record review of Resident #3's hospital records, prior to admission to the facility, showed the following information: -On 07/08/12, the resident was brought to the emergency room after being found unable to take care of him/herself; -The resident was dehydrated; -The resident was diagnosed with [REDACTED].g. malaise "general feeling of being unwell", weight loss, poor self-care that can be seen in elderly individuals); -On 07/09/12, the resident fell when he/she tried to get up and go to the bathroom without alerting the staff for assistance; -The resident really cannot take care of self at this point and needs a skilled nursing facility; -Orders included skilled nursing and physical therapy; -The hospital faxed a nursing assessment that showed the resident needed help from staff with feeding (set-up), dressing, toileting, bathing and walks with assistance; and -On 07/11/12, the resident was transferred to the facility. During an interview on 08/20/12, 3:25 P.M., a family member said the following: -The resident was admitted to the facility for rehabilitation due to muscle weakness and at this time he/she was unable to live on his/her own without assistance; -The resident had hoped to get stronger with therapy and return to living more independently as he/she had been prior to being admitted to the facility. -The resident was alert and oriented with mild confusion; and -The resident had two falls at home that resulted in a fractured rib and fell at the hospital right before being admitted to the facility. Record review of an admission Clinical Health Status form (a form a nurse completes on admission that includes a fall risk assessment and an elopement risk assessment) completed on 07/11/12, showed the following information: -Staff admitted the resident to the facility on [DATE]; -The resident was alert and oriented; -The resident was blind in his/her left eye; -The resident's hearing was highly impaired; -The resident had a history of [REDACTED]. -The resident had 1-2 falls in the past three months; -The resident had a balance problem while standing and walking; and -The resident scored a 9 on the fall risk assessment ("total of 10 or more deems resident at risk for falls"). During an interview on 8/22/12 at 3:25 P.M., RN D said the nurses completed the elopement assessments with the admission assessment then with readmission and if triggered by behaviors. Record review of the resident's immediate care plan (initial care plan completed by the nurse on admission) dated 07/11/12, showed the following information: -Staff identified dehydration as a problem area and put interventions in place. -Staff identified the resident at risk for falls; -The resident fell in the past 30 days; -The only interventions documented in the care plan regarding falls were for one staff to assist in transfers with a transfer belt and assist with mobility; needed wheelchair; -Staff failed to address the resident's general weakness; and -Staff failed to address the resident's wandering/elopement risk in the care plan. During an interview on 8/24/12 at 1:15 P.M., the MDS/care plan coordinator said the following:-The initial care plan was completed by the nurse on admission. The nurses should add any new problems and interventions to the initial care plan until she completed the full care plan.-Staff should have been walking with the resident during ambulation. -If staff noted in the initial care plan that the resident needed a wheelchair, then staff should have been using a wheelchair and/or documenting if the resident refused the wheelchair. On 8/23/12 at 6:55 P.M., the director of nursing services (DNS) said the family reported the resident wandered but did not try to elope. This was discussed "orally" in a meeting, was not documented in the record. This should have been reflected in the care plan. Record review of the physical therapy plan of care dated 07/12/12, showed the following information: -The resident qualified for physical therapy due to a functional decline and treatment [DIAGNOSES REDACTED]. -Safety precautions included high risk for falls. -Unable to maintain balance while turning head or trunk; -Requires contact guard assistance from staff when going from a sitting position to a standing position, a standing position to a sitting position and while pivoting due to unsteadiness during the transfer; -Ambulates with a cane 125 feet with minimal assistance. -Routinely requires minimal assistance of staff to ambulate; -Short term goals included the resident safely performing all functional transfers with minimal assistance of staff, increasing standing balance to fair in order to ambulate safely with stand by assistance from staff, ambulate 150 feet with cane on even surfaces with stand-by-assist from staff. -Long term goals included to ambulate 300 feet safely with cane on even surfaces with no physical assistance of staff or verbal cues. -The resident was motivated to return home. During an interview on 8/23/12 at 4:30 P.M., physical therapy assistant (PTA) N and PTA O said:-The resident followed basic commands. At first he/she had a slow progression related to having diarrhea. Once his/her bowels stabilized he/she was up more and used a cane in therapy;-Therapy suggested the resident walk with staff assistance. The resident should never have been walking alone; and -The resident's gait was always unstable and cognition was not so good. During an interview on 8/24/12 at 10:25 A.M., the therapy director said the resident was pretty independent when he/she was admitted and at times resisted assistance with ambulation. The resident was pretty high functioning the first two weeks. The therapy director reviewed the admission MDS assessment. She said staff should be present when ambulating the resident. Therapy staff used a transfer belt and the cane. She said the resident should have had more assistance with ambulation. With long distance ambulation, the resident became more unsteady. Record review of the occupational therapy plan of care dated 07/12/12, showed the following information: -The resident qualified for occupational therapy due to a functional decline requiring significantly more assistance for completion of self care; -Required minimal physical assistance for grooming, dressing upper and lower body and bathing lower and upper body; -Unable to maintain balance while turning head or trunk when standing; -Able to maintain balance with handheld support and constant minimal assistance; -Contact guard assist (CGA): contact with resident due to unsteadiness for mobility and transfers; and -Safety precautions included high risk for falls. During an interview on 8/23/12 at 4:45 P.M.,the occupational therapist (OT) said on evaluation (7/12/12), the resident had slight confusion but good safety awareness. The resident was pretty oriented at first. Staff interviews showed the following: -On 8/22/12 at 3:25 P.M., RN D said the resident's family brought him/her to the facility because of weakness and to get rehab. The resident was alert and oriented on admission. -On 8/22/12 at 6:35 P.M., RN A said on the initial assessment, the resident was alert and oriented times three and had a slow gait. The RN spoke with the family who said the resident had a history of [REDACTED]. -On 8/22/12 at 5:30 P.M., RN B said the resident did go outside during the day hours and sit on the bench. RN B knew the resident from helping with the admission. The resident had some confusion, fed and dressed him/herself and walked around. On admission if a resident was disoriented or confused, the nurse could make a judgment to apply a wander guard. -On 8/21/12 at 5:05 P.M., RN C said the resident was very independent, walked at lib with a cane, gave history of his/her life, was a "walkie talkie", and had issues with insomnia. -On 8/21/12 at 5:45 P.M., RN G said the resident had general confusion and weakness. The resident could be redirected. His/her confusion would come and go, more confused on dialysis days and walked with a cane. -On 8/22/12 at 7:30 P.M., LPN K said on admission, the resident was alert and oriented during the day and declined at night. The resident was disoriented and confused. The resident refused medications and care at times. The resident did not want to be bothered, the confusion began early evening and continued. The resident would try to get up on his/her own. He/she needed the cane. The resident's pattern was to go outside and sit on the bench, there was no indication that he/she was leaving.-On 8/23/12 at 6:55 P.M., RN M said the resident walked unsteady with a cane and held the side rail. He/she was alert and oriented with periods of confusion. -On 8/23/12 at 4:15 P.M., LPN E said the resident was up constantly "wandering" going in and out the front door. The resident was cognitively impaired. The resident could go anywhere he/she wanted. Staff tried putting the resident in a wheelchair and he/she kept getting up. LPN E said he/she caught him/her three times and he/she almost fell . One time the resident was up walking and got caught up in the cane and one time was in the activity room. He/she told the resident's nurse, LPN J, that the resident was going to fall if staff did not watch him/her then he/she left and the resident fell . Record review of the resident's admission minimum data set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 07/16/18/12, showed in part the following information: -[DIAGNOSES REDACTED]. -Brief interview for Mental Status (BIMS) assessment showed a score of 12 which shows cognition was moderately impaired with poor decision making; supervision required; -Staff did not identify any behavioral concerns and identified "feeling tired or having little energy" as the only concern for mood assessment; -Needs limited assistance of one staff physical assist with bed mobility, dressing, toilet use, personal hygiene and transfers; -Needs supervision of one staff's physical assistance for ambulation. -Needs total assistance of staff with bathing. -Only able to stabilize with staff assistance when moving from a seated potion to a standing position, moving on and off the toilet and transferring from the bed to a chair or wheelchair; -Uses a cane for mobility; -Occasionally incontinent of urine and frequently incontinent of bowel; -Weight was 115 pounds; and -History of falls and a fracture related to a fall within the last six months. During interview on 8/23/12 at 6:55 P.M., the director of nursing services (DNS) said the resident was independent with dressing and toileting. The DNS saw the resident up ambulating with his/her cane and the resident had an unsteady gait. The resident needed standby assistance from staff. At times he/she was more confused before dialysis treatment and more unsteady after dialysis. It was not unusual for the resident to be up at night. Record review of the nurses notes dated 07/11/12 to 07/18/12, showed the following information: -The resident was alert and oriented; -The resident knew he/she needed help walking; -The resident recently fell in the hospital while walking to the bathroom; -On 07/12/12, at 2:59 A.M., staff noted the resident had been restless and asked for a sleeping pill. Restoril (sleeping medication) given to resident by licensed practical nurse (LPN), noted resident lying on the foot of bed with head propped on two pillows and a rolled up blanket. The resident had a midnight snack; -The resident suffered from insomnia; -The resident was ambulatory with a cane and one person assist. -The resident participates in physical therapy and occupational therapy; -On 07/14/12, at 4:27 A.M., staff noted resident had been up earlier out in the hall wanting more covers; -07/15/12, at 4:30 A.M., the resident had been awake during the night ambulating down the hallway and stated he/she just needed to stretch his/her legs; -On 07/16/12, at 4:46 A.M., the resident had been awake during the night sitting on the side of his/her bed, ambulating short distances in room without shoes, encouraged to put shoes or nonskid socks on before ambulating; -On 07/17/12, at 2:35 A.M., the resident was complaining of insomnia and medication was given per order at that time; At 2:54 A.M., staff noted the resident was resting quietly in bed; -On 7/17/12, at 9:38 A.M., the resident was independent with all activities of daily living (ADL); -On 07/18/12, at 1:41 A.M., the resident had been restless this shift, ambulating in hall with cane, has slow steady gait; At 4:54 A.M., staff noted the resident was complaining of insomnia and medication was given as ordered. The resident remained awake most of the shift. At 10:18 A.M., staff noted the resident needed minimal assistance with all ADLs; and -The staff noted throughout the notes during the overnight shifts the resident was restless, was awake most of the shift, sitting on the side of the bed, ambulated in his/her room without shoes and ambulated with a cane and/or walker throughout the facility. Record review of the resident's immediate care plan showed staff failed to address the resident's insomnia and his/her wandering/elopement risk. Record review of the physical therapy progress updated note dated 07/18/12, showed the following information: Current level of function: -The resident ambulated 125 feet with cane on even surfaces requiring minimal assistance of staff; -The resident demonstrates deficits in standing balance impacting the need for minimal assistance of staff to ambulate safely; -Required minimal assistance of staff to transfer safely; -The resident had excessive diarrhea for the past three days and was unable to report any increase or decrease in the resident's status due to the lack of therapy sessions at this moment; and -Safety precautions included high risk for falls. Record review of the occupational therapy progress note dated 07/18/12, showed the following information: -Minimal assistance and CGA with dressing; -Minimal assistance to stand by assistance required with bathing; -The resident had five skilled treatments since the last report; -The resident had improved activity tolerance and strength allowing for increase independence in dressing, bathing and clothing management; and -Safety precautions included high risk for falls. Record review of the nurses notes dated 07/19/12, showed the following information: -Staff heard a loud noise at 1:35 A.M., and found the resident sitting on the floor in front of his/her bed room door. -The resident was alert and oriented and denied any discomfort; -The resident had three new skin tears to the right hand, finger and right elbow. -Staff began neurological checks (assessment of neurological status such as pupils, hand grips, level of consciousness and other reflexes that could change when there is an increase of pressure inside the brain due to injury). Record review of the facility verification of investigation dated 7/19/12, showed in part the following information: -Description of event/allegation: resident found sitting on floor in doorway, stated he/she was going to bathroom and fell ; -Objective/underlying illness: history of falls, impaired safety awareness/judgement, neurological checks; -Causal/contributing factors: resident has had some generalized weakness. Resident walking without shoes or gripper socks; -Interventions prior to fall: change in footwear, toileting schedule, bed low position, call light in reach; and -Recommendations and interventions post fall: change in footwear. Record review of a form titled Change In Condition Report-Post Fall/Trauma dated 07/19/12, showed the following information: -Objective/underlying illness: history of falls, impaired safety awareness/judgement (the resident was very impulsive, independent and difficult to make understand that he/she needs some assistance when ambulating) and neurological checks;-At 1:35 A.M., the resident fell while ambulating without assistance in his/her room; -The resident was found sitting in the doorway of room with back against door; -The resident stated he had started to the bathroom and fell ; -Skin tear to right arm and right finger; -Interventions used prior to fall included change in footwear, toileting schedule, bed in low position and call light within reach; -Investigation summary showed the resident was ambulating in his/her room not wearing shoes or gripper socks and fell ; -Recommendations and interventions post fall: change in footwear; -Interdisciplinary Team and Recommendations were gripper socks and treatment initiated; -Care plan updated; and -Staff did not document additional interventions. Record review of the neurological checks dated 07/19/12-07/21/12, showed the following information: -Vital signs completed; -Pupil and Extremities: staff noted the resident's pupil size and reaction and the resident's extremities were strong; -Consciousness: staff noted the resident was oriented and restless on all the days; and -Speech: clear. Record review of the resident's care plan, dated 7/19/12, provided by the MDS/Care Plan Coordinator during interview on 08/24/12, showed the following: -At risk for falls related to: fell in the past 30 days, history of falls; -Assess for pain every shift; -Call light or personal items available and in easy reach or provide reacher; -Keep environment well lit and free of clutter; -Staff hand wrote on the care plan, the resident was found on the floor by his/her room door with two skin tears to the right hand (record review of the nurses notes showed staff noted the resident had three skin tears); -Staff documented a change in footwear to be placed as the intervention; - Record review of the 07/19/12, change in condition report showed staff noted change in footwear was an intervention used prior to the fall; -Staff did not note interventions to include toileting schedule and bed in low position as documented on the 07/19/12, change in condition report. -Staff did not document additional interventions; and -Staff failed to address the resident's insomnia and the resident's wandering/elopement risk in the care plan. Record review of the nurses notes dated 07/19/12 to 07/22/12, showed the following information: The resident was alert and oriented; -The resident suffered from insomnia and receives medication that is effective much of the time; -On 07/20/12, at 2:27 A.M., the resident had been awake during the night for brief times sitting on the side of his/her bed and needed minimal assistance with all activities of daily living (ADLs); -On 07/20/12 at 7:08 A.M., and 07/21/12, staff noted the resident was independent with most ADLs; -On 07/21/12, at 2:05 A.M., the staff noted the resident sitting in the recliner in the dayroom asleep and ambulatory with cane, at times with unsteady gait; -The resident was ambulatory with a cane and one person assistance; -The resident was up and about throughout facility with walker; and -The resident continues on physical, occupational, and speech therapy for gait training, self care training, safety, orientation and memory. During an interview on 8/23/12 at 5:24 P.M., the director of nursing service (DNS) said;-The resident was not an elopement risk. The resident did not actually have cognitive impairment but had impaired decision-making skills;-She completed the 7/22/12, clinical health status form. She did not review the 7/11/12, clinical health status form;-Surveyor showed the DNS the 7/11/12, clinical health status form where the nurse checked "yes, the resident had a history of [REDACTED]. The DNS said the staff should have implemented a care plan for elopement or wandering for whichever the check mark; and-Staff should place a wander guard if a resident made statements about leaving or if a resident attempted to leave. Record review of the nurses notes SBAR-(change of condition) dated 07/22/12, at 4:22 A.M., showed staff noted the following information: -Situation: Noted coming into the building through the 300 hall door, responded to door alarm. -Assessment: Abrasion with raised area to right forehead, 1 cm laceration to upper nose, abrasion to nose, dirt noted all over resident's clothes. The resident could not state how he/she fell , no complaints of pain. -Response: Assisted the resident to his/her room, injuries cleaned, a band-aid applied to nose, neurological checks started and notified Director of nursing services (DNS), executive director (ED), family and family nurse practitioner (FNP). Investigation began to determine how the resident exited the building unnoticed, wander guard applied. During an interview on 8/22/12 at 7:30 P.M., LPN F said the resident had taken to sleeping in the recliner or on the couch in the day room. On 7/22/12, The resident was up at 2:45 A.M. LPN F asked the resident if he/she wanted to go to bed and the resident said no. Then asked if the resident wanted a snack, the resident said he/she was an "insomniac" and this is just what he/she does. The resident would not sleep in his/her bed. During an interview on 8/22/12 at 6:35 P.M., RN A (worked as unit manager on the night shift on the back hall where the resident lived) said the following in regards to the incident on 07/22/12: - He/she had noticed the few nights before the resident fell that the resident got up and walked around the facility. -The front door was unlocked at the time of the fall (7/22/12). The front door was never locked, staff just came and went. He/she was not aware of the procedure for locking the doors before 7/22/12. He/she was not told of a specific time to lock the doors. -It was not that we were not paying attention, just got used to his/her routine and we assumed he/she was sitting in the recliner in the dayroom; did not know he/she went out or when; -He/she did not see the resident go out;-The alarm sounded on the 300 hall, RN A said he/she was at the nurse's station. The door was open and the resident was standing in the doorway with the alarm sounding. The resident had his/her cane when he/she came back into the building;-The resident had dust and dirt on his/her shirt and arms, hematoma (localized collection of blood outside the blood vessels, usually in liquid form within the tissue) on right side of forehead, abrasions on forehead and nose. We got the resident back to his/her room, assessed the resident and started neurological checks. The resident was more confused and irritable but re-directable;-He/she had staff complete witness statements and notified the Director of nursing services (DNS), Executive Director (ED) and the FNP;-RN A said he/she reported to the DNS, ED and FNP that staff saw the resident coming back in the door, about the resident's injuries and the hematoma. The resident denied being in any pain. The FNP did not tell him/her to do anything. The FNP asked if the resident needed an x-ray. RN A told the FNP he/she did not think the resident needed an x-ray and staff were following the neurological check protocol;-On 07/22/12, staff put interventions in place. The bed in the lowest position, fall mat by the bed, personal alarm and the wander guard was placed. Staff placed the wander guard (generic term for a bracelet device that locks a door on a resident's approach) immediately, but staff forgot to activate it; and-He/she was not sure how to activate the wander guard. He/she thought there was a button on the side for activation. During an interview on 8/22/12 at 7:30 P.M., LPN K (the nurse that worked the back hall where the resident lived) said RN A reported to LPN K what happened (on 7/22/12). LPN K was on break at the nurse's station. RN A told LPN K the resident was trying to come back in the 300 hall. The resident was very confused with scratches on his/her face. RN A reported that the alarm was going off. LPN K thought that was strange because he/she was at the desk and did not hear the alarm at all. RN A and CNA I assisted the resident back in. That was the first time the resident went outside at night. It was not appropriate for the resident to be out at 3:30 A.M. Prior to 7/22/12, LPN K thought the doors were locked at night. During an interview on 08/20/12, 3:25 P.M., a family member said the following: -The resident had only been at the facility a little under two weeks and staff called the family member around 4:00 A.M., (on 7/22/12) to inform him/her that the resident got out of the building and fell , hitting his/her forehead and bridge of his/her nose. The staff told the family member, 'It looked like the resident had been in a fight and didn't win.' The staff told the family member they were not sure why the door did not alarm. -The family member was very concerned about how the resident got out of the building at that time of night without being noticed and why the door did not alarm to alert the staff. Record review of a form titled Change In Condition Report-Post Fall/Trauma dated 07/22/12, showed the following information: -Objective/underlying illness: history of falls, impaired safety awareness/judgement (the resident walks with a cane, gait was unsteady at times and was resistant to assistance); -At 3:30 A.M., the resident fell while ambulating without assistance in corridor (entering door into 300 hall); -Injuries: Abrasion to the head, abrasion to the nose, hematoma to head and laceration to upper nose; -Interventions used prior to fall included change in footwear, pain assessment and call light within reach; -Investigation summary showed the resident was ambulating on his/her own, likes to go outside during the day for sun. Wanders through the facility went out the 100 hall on own and fell and came back in the 300 hall door sounding the alarm. Zero abuse/neglect; -Recommendations and interventions post fall: Bed/chair alarm; -Interdisciplinary Team and Recommendations were wander guard, front door to be locked after 9:00 P.M., Fifteen minute checks to be started in the A.M., physical therapy to assess for a possible walker and neurological checks; and -Care plan updated. Record review of the resident's care plan on 7/19/12, showed the following: (This was not in the resident's medical record or overflow of the record until 08/24/12, when the MDS/care plan coordinator gave the care plan to the surveyor.) -Staff hand wrote on 07/22/12, the resident fell outside; and -Interventions placed were the wander guard and a bed alarm. During an interview on 8/21/12 at 5:05 P.M., RN C said staff should check the wander guard and make sure it was activated before placing it on a resident. Record review of the computer generated Facility Verification of Investigation dated 7/22/12 at 3:30 A.M., received from facility staff on 8/21/12, showed in part the following information: -Description of event/allegation: Falls: Ambulating without assist in corridor, entering 300 hall door. Resident noted by RN A and certified nurse aide (CNA) I entering door through 300 hall, alerted by alarm; -Objective/underlying illness: history of falls; -Physical assessment of resident: anxious, irritable, change in ambulatory status, redness/swelling/bruising. Raised area on right forehead with abrasion, cut on upper nose with abrasions, "dirt on clothes". -Resident interview summary: the resident could not state how he/she fell , he/she thought it was outside, very irritable with staff, stating, "just let me go to bed". At 12:00 P.M., the resident did state that he/she went out the front door and just fell . Unable to say why he/she fell . Denied tripping or losing balance. At 12:45 P.M., the resident also stated he/she could not sleep (at the time of the incident) and wanted to get some fresh air and went for a walk; -Immediate resident protection: injuries cleaned and dressed, treatment initiated, wander guard placed; -Causal/contributing factors: Ambulates with cane at night, at times with unsteady gait, muscle weakness. Was assessed on elopement assessment 7/11/12, which showed resident was not at risk for elopement (record review of the elopement assessment, which is part of the Clinical health assessment dated [DATE], staff checked yes, the resident had a history of [REDACTED]. -Timeline was completed and determined that resident was last seen in the facility 15 minutes before being seen returning to facility (record review of the employee witness statements showed the last times staff saw the resident was at 3:15 A.M., in his/her room and then observed at 3:45 A.M., entering the facility, 30 minutes later); and -Summary of investigation findings: Investigation determines that while resident was walking outside to get fresh air he/she fell sustaining minor injuries. The resident, who is cognitively alert was correctly assessed to not be a risk for elopement prior to this. While resident states he/she was just going out for fresh air and returned to the facility on his/her own, staff re-assessed for elopement risk due to going outside before daylight and falling. A wander guard has been placed on the resident and will be reassessed in one week. Record review of a computer generated and handwritten Facility Verification of Investigation dated 7/22/12 at 3:30 A.M., and a computer generated Facility Verification of Investigation dated 7/22/12 at 3:30 A.M., received at the same time from the facility on 8/21/12, showed conflicting information from the report noted above: -Objective/underlying illness: history of falls, impaired safety awareness/judgement; -Recommendations and interventions post fall: bed/chair alarm. Staff hand wrote "front door to be locked at night" then marked a line through it; and -Summary of investigation findings: currently investigating. Resident goes outside for sun and walks on sidewalk. Walked out the front door while nurse was in a room, fell , came around to 300 hall door and held door until it opened. Record review of the nurses notes dated 07/22/12, showed the following information: -At 5:36 A.M., RN A documented the resident sitting on the side of his/her bed, confused, refuses to believe he/she is at facility;

Based on observation, interview and record review the facility staff failed to appropriately assess, monitor and document when one resident (Resident #3) who had a recent history of multiple falls within the last month had injuries that included abrasion and raised area to right forehead and laceration and abrasion to nose from an un-witnessed fall outside of the facility on [DATE] at 3:30 A.M. The staff failed to notify the physician in a timely manner when the resident had a significant decline in mental and physical functioning. The [MEDICAL TREATMENT] center sent the resident to the emergency roiagnom on [DATE]. Results of a CT scan on [DATE], showed a large subdural bleed (bleeding in the brain). The hematoma measured 2.6 cm in greatest dimension and caused a 1 cm midline shift (pressure from the accumulation of blood that causes a shift of the brain past its center line). Staff also failed to appropriately assess, monitor, document and notify the physician in a timely manner when one resident (Resident #16) was pale, lethargic, had tongue protrusion and slight droop in left corner of mouth and complained of chest pain on [DATE] at 6:15 A.M. Staff did not notify the resident's physician until five hours later at 11:45 A.M. Facility staff sent the resident to the emergency room and the resident was determined to have a high blood sugar, chronic pain, and decreased mental status. Staff also failed to follow treatments as ordered and provide ordered daily treatments to leg wounds for one resident (Resident #10) for two consecutive days. On [DATE], facility staff assessed the wound as green in color and foul smelling with numerous maggots on the resident's posterior calf. Staff also failed to contact the family and the wound clinic of the findings. Thirteen residents were sampled, with the addition of five (5) residents out of a facility census of 67. 1. Record review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated [DATE], showed in part the following information: -Admission to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Brief interview for Mental Status (BIMS) assessment showed a score of 12 which shows cognition was moderately impaired with poor decision making; supervision required; -Staff did not identify any behavioral concerns and identified "feeling tired or having little energy" as the only concern for mood assessment; -Needs limited assistance of one staff physical assist with bed mobility, dressing, toilet use, personal hygiene and transfers; -Needs supervision of one staff physical assist for ambulation. -Needs total assistance of staff with bathing. -Only able to stabilize with staff assistance when moving from a seated potion to a standing position, moving on and off the toilet and transferring from the bed to a chair or wheelchair; -Uses a cane for mobility; -Weight was 115 pounds; and -History of falls and a fracture related to a fall within the last six months. Record review of an admission Clinical Health Status form (a form completed by the nurse on admission to the facility) completed on [DATE], showed the following information: -The resident was alert and oriented; -The resident was blind in his/her left eye; -The resident had a history of [REDACTED]. -The resident had ,[DATE] falls in the past three months; and -The resident had a balance problem while standing and walking. Record review of the resident's immediate care plan (initial care plan completed by the nurse on admission) dated [DATE], showed the following information: -Staff identified the resident at risk for falls; -The resident fell in the past 30 days; -One staff to assist in transfers with a transfer belt and assist with mobility; needed wheelchair; and -There was no information regarding wandering/elopement risk in the immediate care plan. Record review of the nurses notes SBAR-(change of condition) dated [DATE], at 4:22 A.M., showed staff noted the following information: -Situation: Staff noted resident coming into the building through the 300 hall door; -Assessment: Abrasion with raised area to right forehead, 1 cm laceration to upper nose, abrasion to nose, dirt noted all over resident's clothes. The resident could not state how he/she fell , no complaints of pain. -Response: Assisted the resident to his/her room, injuries cleaned, a band-aid applied to nose, neurological checks started and notified Director of nursing services (DNS), executive director (ED), family and family nurse practitioner (FNP). Investigation began to determine how the resident exited the building unnoticed. Record review of a form titled Change In Condition Report-Post Fall/Trauma dated [DATE], showed at 3:30 A.M., the resident fell while ambulating without assistance in corridor (entering door into 300 hall): -Injuries: Abrasion to the head, abrasion to the nose, hematoma (localized collection of blood outside the blood vessels, usually in liquid form within the tissue) to head and laceration to upper nose. -Recommendations included fifteen minute checks to be started in the A.M., physical therapy to assess for a possible walker and neurological checks. -Care plan updated. Record review of the nurses notes dated [DATE], showed the following information: -At 5:36 A.M., RN A documented the resident was sitting on the side of his/her bed, confused, refuses to believe he/she is at facility; -The resident was unable to re-orient at this time; -The resident was refusing to let staff take vital signs; and -There was no documentation in the nurses' notes regarding notification of the DNS, FNP or the resident's physician. During an interview on [DATE] at 6:35 P.M., RN A said the following in regards to the incident on [DATE]: -He/she did not see the resident go out only that the resident came back in the 300 hall;-The resident had dust and dirt on his/her shirt and arms, hematoma on right side of forehead, abrasions on forehead and nose. We got the resident back to his/her room, assessed the resident and started neurological checks. The resident was more confused and irritable but re-directable;-RN A said he/she reported to the DNS, ED and FNP about the resident's injuries and the hematoma. The resident denied being in any pain. The FNP did not tell him/her to do anything. The FNP asked if the resident needed an x-ray. RN A told the FNP he/she did not think the resident needed an x-ray and staff were following the neurological check protocol; and-He/she did not call the FNP or physician after the 5:36 A.M., note regarding the resident. Record review of the neurological checks dated [DATE]-[DATE], showed the following information: -Vital signs completed; -Pupil and extremities: staff noted the resident's pupil size and reaction and a strong hand grasp; -Consciousness: staff noted the resident was disoriented throughout the checks, and on [DATE], staff assessed the resident at 4:45 P.M., and 5:15 P.M., as restless and at 9:15 P. M and on the 2:,[DATE]:00 P.M., as being drowsy; and -Speech: clear. Record review of the nurses notes dated [DATE], showed the following information: -At 2:32 P.M., RN D documented the resident was alert and oriented to self and surroundings; -The neurological checks were without deficit; -The resident was dozing in chairs during the day; -Left forehead abrasion was red and bandage across bridge of nose was intact; and -The resident used a cane for mobility and ambulated with a slow steady gait. Record review of the nurses notes dated [DATE], showed the following information: -At 2:55 A.M., RN A documented the resident was sleeping on the couch, has been pacing back and forth to room and staff continue to do 15 minute checks; -The resident was alert with some confusion; -The resident believed he/she was still at the facility he/she lived prior to coming to this facility; -The resident ambulated with a cane and was unsteady at times; -The resident was re-directed for scooting down to the floor from the couch and lying on a pillow; and -Nursing staff did not document again until 5:00 P.M., when a nurse documented the resident was alert and oriented to person with noted confusion. Record review of the physical therapy daily treatment notes dated [DATE], showed the following information: -The resident was unstable with cane, therapy staff had to correct loss of balance several times during gait, with maximum verbal cues for cane use and visual demonstration; and -Will trial walker until the resident demonstrates increased dynamic balance and a better understanding of safe technique. Record review of the nurses notes dated [DATE], showed the following information: -At 4:42 A.M., RN I documented that the resident refused to go to bed all night and staff was not able to re-direct; -At 8:00 A.M., RN C documented the resident has new onset of agitation and becomes agitated easily. -Staff did not document they notified physician and/or FNP. During an interview on [DATE] at 11:00 A.M., the FNP said she would expect the staff to report any change in a resident's condition. Record review of the neurological checks dated [DATE], showed the following information: -Vital signs completed; -Pupil and Extremities: staff noted the resident's pupil size and reaction and the resident's extremities were strong; -Consciousness: staff noted the resident was disoriented throughout and on [DATE], staff assessed the resident as restless and drowsy on the 10:00 P.M.-6:00 A.M., shift (no time documented); and -Speech: clear. Record review of the occupational therapy progress report dated [DATE], showed the following information: -The resident was making great progress toward plan of care but has had significant change in cognition in the last few days. -The resident was having difficulty following a command or answering a question with two choices. -Spoke with nursing about significant concern for the residents health and change of cognition; -The resident had a fall during this reporting period when he/she went outside in the middle of the night without staff being aware; and -Safety precautions included high risk for falls. Record review of the nurses notes dated [DATE], showed the following information: -At 4:04 A.M., RN I documented the resident had been awake the first half of the night and had been up several times; -At 8:50 A.M., RN C documented the resident refused to have blood pressure taken; -The resident was alert and confused this morning and will speak an occasional word/sentence that was reasonable in context; -The resident had a slow and unsteady gait; -The resident has new onset of agitation and becomes agitated easily. -The resident required minimal assistance with all ADLs and was able to feed self with meal set-up. -At 9:30 A.M., the resident left for [MEDICAL TREATMENT] appointment. Record review of the occupational therapy progress report and discharge summary dated [DATE], showed the following information: -This occupational therapist (OT) notified RN C on multiple occasions that the resident has had a significant medical change affecting performance; -OT documented that RN C decided not to speak to the physician when he/she was in the facility and to assess the resident after [MEDICAL TREATMENT]; -The residents changes occurred over multiple days; -The resident was having severe difficulty answering a question or making needs known; -The resident tried to eat a sweetener packet at breakfast; -Difficulty with word finding and alertness level; -The resident now in a wheelchair and was ambulating with a cane upon evaluation; -OT documented RN C had stated he/she believed the resident was probably just toxic and needed to go to [MEDICAL TREATMENT], despite OT disagreement, RN C continued to wait until after [MEDICAL TREATMENT] to assess the resident. During an interview on [DATE] at 4:45 P.M.,the OT said: -On [DATE], OT worked with the resident at breakfast and the he/she was trying to eat sugar packets; -OT said he/she reported to RN C his/her concerns regarding the resident's prior cognition and present cognition which was just not normal for this resident. -The physician was here at the time and needed to be told maybe the resident had a urinary tract infection; -OT said he/she had not put together yet that the resident had a fall, but had noticed a change over the past few days. -OT said when he/she went back to follow up RN C said the resident may be toxic and he/she was going to wait until after the resident went to [MEDICAL TREATMENT] to assess. Record review of the [MEDICAL TREATMENT] notes showed the following information: -On [DATE], the resident had [MEDICAL TREATMENT]; -Staff noted In the comments section the residents mental status decreased over the past ,[DATE] days. The resident was not able to tell staff the location of his/her family members. -The resident was agitated; -The nursing home had difficulty getting the resident to come to [MEDICAL TREATMENT] today; -The resident had a history of [REDACTED]. -The resident had an abrasion on the right elbow and old bruise on forehead; -Family member said when talking to the resident he/she was more confused; -The [MEDICAL TREATMENT] physician ordered the resident to be evaluated by the emergency room ; and -Nursing home and family notified. During an interview on [DATE], at 3:12 P.M., the RN [MEDICAL TREATMENT] unit manager said:-The resident arrived for [MEDICAL TREATMENT] treatment on [DATE], with bruising on the face and head with scrapes on his/her arm;-The facility said the resident was agitated and did not want to go to [MEDICAL TREATMENT] but the [MEDICAL TREATMENT] staff did not observe agitation when he/she arrived;-Staff did notice the resident was not following conversation well. When the [MEDICAL TREATMENT] manager interviewed the resident, he/she could not remember where his/her family lived. The RN [MEDICAL TREATMENT] unit manager said, "This was a big red flag for me" because the resident often spoke of his/her family and shared information of their lives including where they lived; and-He/she sent the resident to hospital #1 for an evaluation because, prior to [DATE], the resident was alert and oriented x 3 (to person, place and date/time). Record review of the nurses notes dated [DATE], showed the following information: -At 1:30 P.M., RN C documented staff from [MEDICAL TREATMENT] called regarding the resident's increased confusion; -Joining comparisons with [MEDICAL TREATMENT], both facilities were in agreement to have the resident further evaluated; -Physician notified and unable to reach family. Will call until contact was made; and -RN C gave report to hospital #1, located in the same town. During an interview on [DATE] at 5:05 P.M., RN C said: -On [DATE], the resident was somewhat different but not as bad a on [DATE];-On [DATE], he/she noticed a change in the resident. It was the resident's [MEDICAL TREATMENT] day, extremely confused and combative. He/she discussed his/her concerns with RN M;-The resident had bouts of confusion but [DATE], he/she was "totally not him/herself";-Staff decided to send the resident to [MEDICAL TREATMENT] on [DATE], to see if toxins had built up. The physician saw the resident [DATE], and RN C was not sure if staff reported any changes in the residents condition to the physician; and-The FNP was at the facility on [DATE]. During an interview on [DATE] at 11:00 A.M., the FNP said:-She was at the facility on Mondays (fall occurred early Sunday morning [DATE]) and the physician was at the facility on Wednesdays; -The facility staff gave her a list of resident to be see and RN M gathered the resident's records;-The FNP said she did not recall the residents cognition prior to the fall;-The staff called her at home after the resident fell and told her the resident was ok; -The staff did not tell her that the resident had abrasions or any injuries. -The FNP said she did not see Resident #3 on [DATE], the resident was not on her list; -FNP was not aware of any change in the resident's condition; -FNP would expect the staff to report any change in a resident's condition and agreed the staff should have notified her and/or the physician of this residents change in condition. Record review of a handwritten physician progress notes [REDACTED]. -The resident had exited the building last night ([DATE]), walked around the building and re-entered through a side door (record review showed the resident exited the facility on [DATE]); -The resident had a fall striking his/her face; -This morning the resident had a facial abrasion, no loss of consciousness; -Neurological checks through the night were normal; -The resident has some confusion but this was not a change from baseline; and -Plan: observation. Nursing notes on [DATE], showed the resident left for [MEDICAL TREATMENT] at 9:30 A.M. During an interview on [DATE] at 10:45 A.M., the medical director, who is also the resident's physician said:-RN M notified him the morning after the fall. He thought the fall occurred on [DATE];-He saw the resident the morning after the fall ([DATE]) (the fall actually occurred on [DATE]); -Staff should have notified the physician and/or the FNP if there was a change in the resident's condition. Record review of the physical therapy progress report and discharge summary dated [DATE], showed the following information: -The resident was discharged from therapy due to being sent to the hospital due to change in medical condition. -The resident had a significant decline in function, requiring him/her to ambulate with a wheelchair and/or use front wheeled walker with minimal assist. -End of care [DATE]. Record review of hospital #1's triage nurses notes dated [DATE], showed the following information:-Chief complaint: Here for evaluation due to increased falling and memory problems;-At 3:14 P.M., Alert and oriented, appears in no acute distress, no facial asymmetry noted, skin intact, (facility staff states the resident is here because "he/she has been acting abnormal, seems more confused" staff states resident just finished [MEDICAL TREATMENT] and [MEDICAL TREATMENT] nurse suggested the resident go to ER for evaluation); and-At 3:58 P.M., called the facility staff and the nurse (RN C) stated that "resident got out of the facility ([DATE]) Sunday night and at 3:30 A.M., in the morning, he/she was knocking in the door. We don't know how many times he/she fell when outside. Since then he/she has been acting strange with confusion, angry, anxious and flight of ideas." Record review of hospital #1's emergency room physician progress notes [REDACTED]. This started one week and is still present. Falling easily, seems more confused and weaker than normal. escaped nursing home and came back pounding on door. Unknown if fell per nursing home report but friend from [MEDICAL TREATMENT] called stating not acting right. He/she has had weakness and has had difficulty walking;-Alert, no distress;-Healing wounds on forehead and face;-The resident is disoriented to time and place, mood/affect normal, speech normal, finger-nose test mildly abnormal on the right and left; and-Skin: healing wounds on right hand and elbow and multiple locations but no swelling or with pain with range of motion except mild swelling to right hand. Record review of the CT (computed tomography) scan dated [DATE], showed the following information:-Clinical history: altered mental status;-Findings: examination reveals mixed attentuations (a dilution or thinning of a substance - in this case, blood) subdural bleed (bleeding into the space between the covering of the brain, the dura, and the brain itself) on the left side along the entire convexity, greatest dimension measuring 2.6 cm in thickness. There is a 1 cm midline shift (pressure from the accumulation of blood that causes a shift of the brain past its center line). -Impression: Large subdural bleed which had mixed attentuations with suggestion of acute on chronic change. This measures 2.6 cm in greatest dimension and causes 1 cm midline shift. Record review of hospital #1's emergency room physician progress notes [REDACTED]. Family called, resident transferred to hospital #2 (in a nearby larger city) where neurosurgeon is available; and-Clinical impression: acute subdural hematoma, multiple falls, right hand injury. During a telephone interview on [DATE] at 11:32 A.M., an emergency medicine specialist at hospital #1 on [DATE], said the following:-Subdural bleeding occurs between the brain and the skull from trauma;-It is unusual to see mixed attentuations with suggestion of acute on chronic;-Acute on chronic shows there was a bleed and a re-bleed;- The physician said it was would be impossible to know which fall caused the bleed. The scan indicates at least one fall prior to the [DATE], visit;-Chronic bleeds can present from days to weeks;-Acute bleed can just re-bleed, you would suspect the resident had another trauma;-The acute could have occurred from being hit in the head; and-A subdural hematoma should be on the top of the list for concerns with any head trauma. Record review of hospital #2 emergency department physician documentation dated [DATE], showed in part the following information:-History of present illness: the resident presents to the emergency department with complaints of head injury;-The resident's family reports subdural hemorrhage (bleeding); -Context of injury: the resident apparently fell at the nursing home a few days ago. The resident has had some mental status changes since that time. The resident was seen at hospital #1 and diagnosed with [REDACTED].; and-Disposition: intracranial bleed: subdural, problem is new, condition is unchanged, symptoms are unchanged. Record review of the hospital #2's Trauma Service Consult Progress Notes dated [DATE], showed the family has decided to withdraw care including [MEDICAL TREATMENT] and scheduled evacuation for the bleed (brain surgery to evacuate the hematoma). Record review of the Neurologic Problem Admission History and Physical dated [DATE], showed the neurosurgereon physician's assistant (PA) and the neurosurgereon noted in part the following information:-Chief complaint: resident at nursing home, fell several days ago striking his/her head. Now has mental status changes. Taken to hospital #1 today, found to have large left subdural hematoma, referred to hospital #2 for evaluation/treatment;-History of present illness: the resident presents with mental status changes. Associated symptoms consist with altered speech;-Neurologic physical examination: orientation: to person, altered level of consciousness-confused;-Radiology results: CT shows large left-sided fluid collection with compression of brain and midline shift;-Diagnosis: [REDACTED]. Family wishes to pursue non-intervention course. Explained likely time regarding eventual demise. Expect death in the ,[DATE] weeks. During a telephone interview on [DATE] at 9:05 A.M., the neurosurgereon physician's assistant (PA) said the following:-The resident had a large subdural hematoma with compression to one side. The brain pushes over to one side of the head;-This can create changes in personality, cognition and high functioning. Initially the basal function, your basic functions, will be affected, that is how a chronic subdural hematoma presents;-The cranial nerve function may present as normal, neurological checks may be normal at first;-Resident #3's subdural hematoma presented as a combination of trauma and his/her history. It can present from a combination of falls;-Chronic subdural hematoma will present with one signal.-Acute subdural hematoma has a different signal.-If a resident has a chronic and an acute subdural in the same area there is likely fresh and old blood.-Chronic subdural hematoma can develop over a few days to a few weeks;-Acute subdural hematoma is new bleeding from bridging veins between the brain. The veins can tear with a fall or a trauma. With age the brain can atrophy (shrink) and the brain can shift.-The mass can increase and a resident can have personality changes with a subdural hematoma. During an interview on [DATE], 3:25 P.M., a family member said the following: -The resident was admitted to the facility for rehabilitation due to muscle weakness and at this time he/she was unable to live on his/her own without assistance; -The resident had hoped to get stronger with therapy and return to living more independently as he/she had been prior to being admitted to the facility. -The resident was alert and oriented with mild confusion; -The resident had two falls at home that resulted in a fractured rib and fell at the hospital right before being admitted to the facility; -The resident had only been at the facility a little under two weeks and staff called the family member around 4:00 A.M., (on [DATE]) to inform him/her that the resident got out of the building and had fell hitting his forehead and bridge of his/her nose. The staff said, 'It looked like the resident had been in a fight and didn't win.' -The family member said after the fall he/she spoke with the resident around 7:00 A.M., that morning ([DATE]) and the resident was irritable and at that time wasn't concerned. -The family member called back on [DATE], and the resident could not complete a sentence, was babbling, "It was not dad/mom." The family member could not understand the resident; -From Sunday to Tuesday there was a drastic change; -The family member spoke with a nurse on [DATE], and informed the nurse of his/her concerns and said the resident was not acting right and there was something wrong. The nurse did not send the resident to the hospital. (record review of the medical record showed staff had not notified the FNP and/or physician of the family members concerns); -The next morning ([DATE]) the family member called and spoke with the [MEDICAL TREATMENT] clinic and informed the staff his/her concerns and asked for them to observe the resident and let him/her know if they noticed any change; -The staff at [MEDICAL TREATMENT] called to get permission to have the resident taken to have a CT scan. -Hospital #1 called the family member to inform him/her of the findings of the CT scan, the test showed the resident had a brain bleed and to get permission for the resident to be transported by ambulance to hospital #2; -The family member said the neurosurgeon from hospital #2 called and informed the family that the brain bleed would have to have surgery or the resident would die. The physician could not guarantee the resident would live through the surgery or that the surgery would fix the problem. -The family decided not to put the resident through any more procedures or surgeries. -The neurosurgeon from hospital #2 told the family member the resident had weeks to a month to live. At that time the family also discontinued the [MEDICAL TREATMENT] treatment. Record review of the facility's nursing notes showed the resident died on [DATE]. During an interview on [DATE] at 4:16 P.M., LPN J said prior to [DATE], he/she did not think the resident was that mobile, he/she sat in the chair or laid in bed during the day shift. The resident was hard of hearing. Staff should notify the physician if a resident had increased agitation and/or confusion. During an interview on [DATE] at 5:05 P.M., RN C said: -Prior to the fall the resident was very independent, walked at lib with a cane, gave history of his/her life, was a "walkie talkie", and had issues with [MEDICAL CONDITION]; and -On [DATE], hospital #1 called to get report, they were sending the resident to geriatric psychiatric unit. RN C reported to hospital #1 staff that the resident had multiple falls and mental status changes. During an interview on [DATE] at 5:45 P.M., RN G said:-The resident had general confusion and weakness. The resident could be redirected. His/her confusion would come and go, more confused on [MEDICAL TREATMENT] days;-Prior to the fall ([DATE]), the resident walked with a cane; and-Staff should contact the physician if a resident had a change in condition and/or a change in mental status. During an interview on [DATE] at 3:25 P.M., RN D said:-On [DATE], he/she does not recall getting report. Staff use a 24 hour report sheet and he/she checks the vital sign sheet and checks with the charge nurse;-RN D read the note for [DATE] at 5:36 A.M., RN D said he/she was not aware of the resident having agitation;-On [DATE], the resident slept all day;-RN A mentioned that he/she was going to call the physician because the resident was "drowsy" and said,"I think he/she needs a CT scan". RN D was not sure if RN A called the physician. During an interview on [DATE] at 5:30 P.M., RN B said:-On [DATE] (day shift), the resident did not look right, not up walking like normal, eating but needed cueing;-The resident had some confusion, fed and dressed him/herself and walked around;-On [DATE], as him/her and LPN E were leaving for the day, he/she told RN A to call the FNP. RN B even offered to come back later and call the FNP. RN A said, 'No, no, I can do it' and that he/she had a good rapport with the FNP. RN B came in the next day did not hear so did not know what happened;-He/she was concerned because it was a "quick" change in the resident's function and ability, "just not acting right";-She also told the day shift nurse RN D that the resident was not acting right;-On [DATE], all the staff were keeping an "eye" on the resident. He/she was weak. RN B knew the resident was up all night and wondered at first, if the resident was just tired. -The resident progressed to the wheelchair. He/she could not remember to use the cane;-After [DATE], while eating the resident would start and forget. Later the resident needed to be fed by staff;-On [DATE], he/she told the oncoming nurse RN A that the resident was not acting right and may need to call the physician, maybe he/she has a "bleed". Staff did not know how the resident fell or what he/she hit;-RN B said with his/her past nursing experience he/she "always thinks the worse", and a subdural hematoma can come on slowly;-If the FNP or physician were notified that the resident was not acting right they would have sent the resident out, they are very good about that;-FNP comes to the facility on Mondays and the physician comes on Wednesdays;-After the [DATE], fall RN B and the FNP di