Every finding on record at Southgate Living Center

Based on observation, interview, and record review, the facility failed to follow infection control precautions by failing to implement Enhanced Barrier Precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms resistant to one or more classes of antimicrobial agents) or residents with a chronic wound and/or indwelling medical device) for two residents (Residents #2 and #8) out of three sampled residents. The facility census was 58.Review of the facility's policy titled, Enhanced Barrier Precautions, dated 2024, showed: - EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown, and gloves use during high contact resident care activities; - High contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, wound care, and care of central lines, urinary catheters, feeding tubes, and tracheostomy/ventilator tubes. 1. Review of Resident #2's clinical record showed the resident had a gastrostomy tube (G-tube - a tube surgically inserted into the stomach to provide hydration, nutrition, and medications), which qualified the resident for EBP. Observation on 06/04/26 at 9:46 A.M., of medication administration and a water flush through Resident #2's G-tube showed:- EBP signage was posted on the resident's door;- Licensed Practical Nurse (LPN) F entered the resident's room;- LPN F performed hand hygiene and wore gloves but did not wear a gown;- LPN F administered medications and performed a water flush through the resident's G-tube;- LPN F removed gloves, performed hand hygiene, and exited the room. 2. Review of Resident #8's clinical record showed the resident had a unstageable pressure wound – Slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined. Observation on 06/04/26 at 2:28 P.M., of Resident #8's transfer using a gait belt (device used to transfer residents from one position to another) showed:- EBP signage was posted on the resident's door;- Certified Nurse Aide (CNA) A and Nurse Aide (NA) B entered the resident's room;- CNA A and NA B performed hand hygiene and wore gloves but did not wear gowns;- CNA A leaned against the resident's bed while assisting the resident to sit on the side of the bed;- CNA A and NA B placed a gait belt around the resident's waist and transferred the resident from the bed to a wheelchair;- CNA A and NA B removed gloves, performed hand hygiene, and exited the room. During an interview on 06/04/26 at 11:00 A.M., LPN F said he/she should have worn a gown while providing G-tube care because Resident #2 required EBP due to the G-tube.During an interview on 06/04/26 at 2:45 P.M., CNA A and NA B said they knew Resident #8 required EBP based on the sign posted on the resident's door. CNA A and NA B stated they did not believe EBP required gown use during resident transfers. During an interview on 06/04/26 at 2:56 P.M., LPN C said staff should wear gowns and gloves while providing G-tube care, catheter care, and wound care, but stated gowns were not required during resident transfers or linen changes. During an interview on 06/04/26 at 3:05 P.M., the Director of Nursing (DON) said staff should wear gowns and gloves while performing transfers for residents who required EBP. During an interview on 06/05/26 at 12:00 P.M., the Administrator and DON said they expected staff to wear gowns and gloves while administering medications and performing water flushes through a G-tube for residents requiring EBP.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 25 opportunities with two errors made, for an error rate of 8.00%, which affected two residents (Residents #2 and #35) out of eight sampled residents. The facility census was 58.Review of the facility policy titled, Administering Medications, dated April 2019, showed:- Medications are administered in accordance with prescriber orders;- The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. Review of the facility policy titled, Medication and Treatment Orders, dated July 2016, showed:- Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. 1. Observation on 06/04/26 at 8:33 A.M., of Resident #35's medication administration showed:- Certified Medication Technician (CMT) E could not find the resident's sodium bicarbonate medication (a fast-acting antacid used to relieve occasional heartburn, acid indigestion, and sour stomach) card;- The facility failed to administer the resident's sodium bicarbonate. Review of the resident's physician order sheet (POS), dated 06/05/26, showed:- An order for sodium bicarbonate 650 milligram (mg) two times a day per gastrostomy (G-tube - a tube surgically inserted into the stomach to provide hydration, nutrition, and medications), dated 05/20/26. During an interview on 06/04/26 at 8:45 A.M., CMT E said the sodium bicarbonate for Resident #35 had to be reordered. He/She said it was the CMTs' and the nurses' responsibility to make sure medications were reordered. Medications should be ordered when they run out. 2. Observation on 06/04/26 at 9:46 A.M., of Resident #2's medication administration showed:- Licensed Practical Nurse (LPN) F administered five tablets of vitamin D 400 units for a total of 2,000 units through the resident's G-tube;- The facility failed to administer the Vitamin D 5,000 units as ordered. Review of the resident's POS, dated 06/04/26, showed:- An order for Vitamin D 5,000 units via gastrostomy one time a day for vitamin D deficiency, dated 02/05/26. During an interview on 06/04/26 at 2:48 P.M., LPN F said he/she did not do the math correctly when figuring out the number of tabs of vitamin D that Resident #2 should have been administered. During an interview on 06/04/26 at 2:23 P.M., CMT D said nurses were responsible for reordering narcotic medications. CMTs were responsible for ordering all other medications from the pharmacy. Medications should be ordered when the number of tablets left fell into the reorder area marked off on the medication cards. During an interview on 06/04/26 at 2:48 P.M., LPN F said the pharmacy made daily deliveries during the week and as needed on the weekends. During an interview on 06/05/26 at 12:00 P.M. the Administrator and the Director of Nursing (DON) said they would expect the medication error rate to be under five percent.

Based on interview and record review, the facility failed to ensure three nurse aides (NAs) (NA B, NA C, and NA D) completed a nurse aide training program within four months of his/her employment at the facility. The facility's census was 58. Review of the facility's policy titled, Nurse Aide Qualification and Training Requirements, revised August 2022, showed: -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise unless: that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in 483.150 9 (a) and (b) of the requirements of participation; - Nursing Assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. 1. Review of NA B's personnel file showed: - A hire date of 07/24/24; - NA B completed the nurse aide program, but did not test; - The facility failed to ensure the completion of the program within four months of the hire date. 2. Review of NA C's personnel file showed: - A hire date of 05/29/24; - NA C completed the nurse aide program, but did not test; - The facility failed to ensure the completion of the program within four months of the hire date. 3. Review of NA D's personnel file showed: - A hire date of 05/01/24; - NA D completed the nurse aide program, but did not test; - The facility failed to ensure the completion of the program within four months of the hire date. During an interview on 03/06/25 at 10:00 A.M., the Director of Nursing (DON) said NA B, NA C, and NA D had completed the nurse aide training, but had not tested yet. All three were working in the nurse aide positions. The DON did not know why the NAs had not tested in a timely manner. During an interview on 03/06/25 at 3:45 P.M., the Administrator said she expected NA's to be certified within four months of hire.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted practices. This had the potential to affect all residents. The facility census was 58. Review of the facility policy titled, Medication Labeling and Storage, revised February 2023, showed: - If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Medications are stored separately from food and are labeled accordingly; - Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum the medication name, prescribed dose, strength, expiration date, when applicable, resident's name, route of administration, and appropriate instructions and precautions; - For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains the medication name, strength, quantity, accessory instructions, lot number, and expiration date (if applicable); - Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the Insulin Aspart Manufacturer's Instructions showed: - Keep at room temperature or refrigerated for up to 28 days; - Dispose after 28 days, even if there is insulin left in the vial. 1. Observation on 03/05/25 at 3:20 P.M., of the medication cart on 400 Hall showed: - One opened, unlabeled, and undated glargine (long-acting insulin) insulin pen; - Two opened and undated Fiasp (rapid-acting insulin) insulin pens; - One opened and undated Tresiba (long-acting insulin) insulin pen; - One opened and undated basaglar (long-acting insulin) insulin pen; - One glucagon (medication used to treat low blood sugar) 1 milligram container with an expiration date of 10/24/24, and one glucagon 1 milligram container with an expiration date of 01/10/25. Observation on 03/05/25 at 3:30 P.M., of 100/200 Hall storage rooms showed: - One opened insulin aspart multidose vial, dated 01/14/25; - Two Vitamin B Complex bottles an expiration date of 11/26/24. During an interview on 03/05/25 at 4:01 P.M., Licensed Practical Nurse (LPN) K said insulin should be discarded 30 days after being opened and should be labeled with the resident's name and the date when it was opened. During an interview on 03/06/25 at 3:45 P.M., the Administrator and the Director of Nursing (DON) said they would expect insulin should be labeled and dated appropriately and multi-dose vials discarded 28 days after opened.

Based on observation, interview, and record review, facility staff failed to provide activities of daily living (ADL's) when staff failed to provide assistance with eating for one resident (Resident #15) of three sampled residents, who was assisted with meals by another resident (Resident #21). The facility census was 58. Review of the facility policy titled, Activities of Daily Living, Supporting, dated March 2018, showed: - Residents will be provided with care, treatment and services to ensure their ADL's do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADL's are unavoidable; - Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; - Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care; - A resident's ability to perform ADL's will be measured using clinical tools, including the Minimum Data Set (Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility). Functional decline or improvement will be evaluated in reference to the assessment reference date (ARD). 1. Review of Resident #15's medical record showed: - An admitted [DATE]; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (DM - abnormal blood sugar) , genetic torsion dystonia (causes shaking or tremors), unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), major depressive disorder (long-term loss of pleasure or interest in life), and morbid obesity (excess body fat); - An order for controlled carb diet with regular texture and regular/thin consistency, order start date 06/03/24. Review of the resident's Care Plan, undated, showed: - The resident experienced tremors of hands and made it difficult at times to complete ADL's or participate in activities; - Interventions of assisting as needed and administering Parkinson's (disorder of the nervous system affecting movements and causing tremors) medications as ordered. Review of the resident's annual MDS, a federally mandated assessment instrument completed by the facility staff, dated 01/17/25, showed: -Section GG showed no impairment of upper or lower extremities, supervision or touching assistance with eating; -Section V showed care area triggered for ADL functional/rehabilitation potential and nutrition status. Observation of on 03/04/25 at 12:35 P.M., showed the resident sat up in bed with a tray table over his/her lap attempting to eat meatloaf with a regular spoon in his/her right hand. The resident's plate had a small amount of meatloaf left. The spinach and mashed potatoes were not touched. The resident's shirt had a large amount of the meatloaf on the front of it. The resident said his/her roommate was not available today to help feed him/her. The resident had a Sip-A-Mug (a specialty cup with a lid) on the tray table next to his/her tray. Resident #15 asked for assistance with his/her meal multiple times during the observation. Observation on 03/05/25 at 12:45 P.M., showed Resident #21 stood beside Resident #15 as he/she sat up in bed. Resident #21 cut up and fed Resident #15 a chili dog. During an interview on 03/03/25 at 11:50 A.M., Resident #21 said he/she helped feed Resident #15 all the time. Resident #15 needed help eating meals because of his/her shaking. Resident #21 said he/she was aware he/she was not supposed to feed Resident #15, but none of the staff would help him/her, and Resident #15 needed to eat. Resident #21 said he/she has had to assist Resident #15 since they had become roommates, which had been months now. During an interview on 03/03/25 at 11:52 A.M., Resident #15 said he/she needed help eating because he/she can't do it himself/herself. He/She can't cut up his/her food and was difficult to eat most things due to his/her shaking. Staff hardly assisted him/her with feeding and he/she did not have any special utensils for eating. Most meals were brought to his/her room to eat. During an interview on 03/05/25 at 12:51 P.M., the Dietary Manager said he/she was not aware Resident #15 needed assistance or had difficulty eating. The resident did shake sometimes but did not have any difficulty eating as far as he/she knew. During an interview on 03/06/25 at 8:19 A.M., Certified Nurse Assistant (CNA) L said Resident #15 received assistance with eating each meal due to his/her shaking. The resident had a normal spoon but a special cup to drink from that the resident had requested. The resident would probably do better if he/she had a built-up spoon to use. CNA L said Resident #21 tries to feed Resident #15 sometimes and take care of Resident #15 and had informed Resident #21 that it is not ok to feed Resident #15. During an interview on 03/06/25 at 9:02 A.M., Occupational Therapist (OT) M said the resident was screened in the past and did not need any assistive devices or have difficulty eating even though the resident shook some. When the resident became upset, then his/her shaking worsened. He/She monitored the weight loss list and watched eating in the dining room at least once a month to see what residents might need to be evaluated. Resident #15 had not really lost weight and mostly ate in his/her room. During an interview on 03/06/25 at 1:48 P.M., Licensed Practical Nurse (LPN) K said therapy had assessed the resident before and he/she did not need assistive devices. The specialty cup the resident had was something the resident wanted on his/her own because another resident had one. If the resident did need help eating, then staff could provide the assistance. Other residents were not supposed to feed other residents and was aware Resident #21 had tried to feed and fed Resident #15. When that happens, staff try to redirect the residents and explain why that was not acceptable. During an interview on 03/06/25 at 3:45 P.M., the Director of Nursing (DON) and the Administrator said they would expect residents who need assistance to eat or perform ADL's to be given that assistance by staff. They assess the residents need for assistance at least quarterly, with significant change, or as needed in order to meet or maintain the residents' needs. Residents were not allowed to feed other residents, were aware Resident #21 feeds Resident #15, and had told the residents not to feed each other and if they need help to just ask and staff will assist.

Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months from February 2024 through January 2025. The facility's census was 58. Review of the facility's policy titled, Surety Bond, revised March 2021, showed: - A surety bond is an agreement between the facility, the insurance company, and the resident or the state acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, accounts for, safeguards, and manages; - This facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents; - All funds (including refundable deposits) entrusted to the facility for a resident are covered by the surety bond; - The purpose of the surety bond is to guarantee the facility will pay the residents for losses occurring from any failure by the facility to hold, account for, safeguards, and manage the residents' funds (i.e., losses occurring as a result of acts or errors of negligence, incompetence or dishonesty); - Inquiries concerning the financial security of personal funds managed by the facility should be referred to the Administrator. Review of the Residents' Personal Funds Account for the last 12 consecutive months from February 2024 through January 2025, showed: - The facility's approved bond amount equaled $99,000.00; - The average monthly balance of the residents' personal funds equaled $66,606.98; - An average monthly balance of $66,606.98 rounded to the nearest thousand equaled $67,000.00, at one and one-half times would equal the required bond amount of at least $100,500.00. During an interview on 03/05/25 at 11:22 A.M., the Business Office Manager said he/she had not been checking to ensure the bond was correct because he/she had never been told to do that. They had a corporate person that he/she assumed was supposed to do that. During an interview on 03/06/25 at 3:45 P.M., the Administrator and the Director of Nursing (DON) said they would expect the bond to be sufficient to cover the residents' funds.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions to meet the highest practicable physical, mental, and psychosocial well-being for two residents (Residents #15 and #30) out of 15 sampled residents. The facility's census was 58. Review of the facility's policy titled, Comprehensive Person - Centered Care Plans, revised March 2022, showed: - The care plan is person-centered and includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs; - Describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. 1. Review of Resident #15's medical record showed: - An admitted [DATE]; - Diagnosis of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order for oxygen at three liters per minute (lpm) by nasal cannula (a device to deliver oxygen through to the nose) as needed to titrate oxygen saturation greater than 89%, dated 07/01/24; - An order for bipap (a device to assist with breathing) at bedtime for hypoxia (low oxygen), sleep apnea (compromised airway making it difficult to breathe) may place on when the oxygen saturation is low when sleeping during the day, dated 01/13/25; - An order to check the oxygen saturation every shift two times a day related to acute respiratory failure with hypoxia. If oxygen saturation is less than 93%, apply oxygen by nasal cannula, dated 04/08/24; - An order to elevate the head of bed 30-45 degrees at bedtime when sleeping for shortness of breath when lying flat related to COPD, dated 09/29/24; - An order for ipratropium-albuterol (medication used to treat COPD) nebulizer (a medical device that converts liquid medication into a fine mist) solution 3 milligram (mg)/3 milliliters (ml) to inhale orally every six hours as needed for shortness of breath and hypoxia, dated 10/22/24. The resident's care plan, undated, did not address COPD, the resident's respiratory status, or the resident's oxygen needs. Observation on 03/03/25 at 11:30 A.M., showed the resident in his/her room with 5 lpm of oxygen per nasal cannula and a bipap at the bedside. Observations on 03/04/25 at 12:45 P.M., 03/05/25 at 9:10 A.M., and on 03/06/25 at 11:38 A.M., showed the resident in his/her room with 4 lpm of oxygen per nasal cannula and a bipap at the bedside. 2. Review of Resident #30's medical record showed: - An admitted [DATE]; - Diagnoses of hemiplegia (muscle weakness) and hemiparesis (partial paralysis) following an intracranial hemorrhage (trauma to the brain that may cause brain damage), pneumonia (an infection involving the lungs), acute respiratory failure (not breathing normal or impaired gas exchange causing issues) with hypoxia, and acute pulmonary edema (fluid in or around the lung space making it more difficult to breathe; - An order for oxygen at 2 lpm per nasal cannula as needed for shortness of breath, wheezing, congestion to keep oxygen saturation greater than 90%, dated 02/07/25. The resident's care plan, undated, did not address the resident's respiratory status and oxygen use. Observations on 03/03/25 at 10:01 A.M., 03/04/25 at 12:15 P.M., 03/05/25 at 2:55 P.M., and on 03/06/25 at 11:37 A.M., showed the resident in his/her room with oxygen on at 2 lpm per nasal cannula. During an interview on 03/06/25 at 3:45 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) Coordinator and Administrator said they would expect the care plans to reflect the residents' current conditions. 49152

Based on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #59) out of two sampled closed discharge records. The facility's census was 58. Review of the facility's policy titled, Discharge Summary and Plan, revised October 2002, showed: - The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing the release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: current diagnosis; medical history (including any history of mental disorders and intellectual disabilities); course of illness, treatment and/or therapy since entering the facility; current laboratory, radiology, consultation, and diagnostic test results; physical and mental functional status; ability to perform activities of daily living including such as bathing, dressing, grooming, transferring, ambulating, toilet use, eating, using speech, language, and other communication systems; the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; the ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility; sensory and physical impairments (neurological, or muscular deficits; for example, a decrease in vision and hearing, paralysis, and bladder incontinence); nutritional status and requirements including weight and height; nutritional intake; eating habits, preferences and dietary restrictions; special treatments or procedures (treatments and procedures that are not part of basic services provided); mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); discharge potential (the expectation of discharging the resident from the facility within the next three months); dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of dentures or other dental appliances); activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); rehabilitation potential (the ability to improve independence in functional status through restorative care programs); cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident); - As part of the discharge summary, the nurse reconciles all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation is documented; - Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan; - The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his/her family and includes: where the individual plans to reside; arrangements that have been made for follow-up care and services; a description of the resident's stated discharge goals; the degree of caregiver/support person availability, capacity and capability to perform required care; how the interdisciplinary team will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed; - The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge; - The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan; - Residents are asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he/she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences; - If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination; - Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility are assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. 1. Review of Resident #59's medical record showed: - Resident discharged to the community on 01/23/25; - No documentation of the recapitulation/discharge summary of the resident's stay. During an interview on 03/05/25 at 3:40 P.M., the Social Services Director (SSD) said a recapitulation of the resident's stay was not completed. During an interview on 03/06/25 at 3:45 P.M., the Administrator and Director of Nursing (DON) said they would expect a recapitulation of a resident's stay to be completed when a resident was discharged from the facility.

Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident #4) out of two sampled residents with wounds. The facility census was 58. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #4's medical record showed: - admitted on [DATE]; - Diagnoses of post-traumatic stress syndrome (PTSD - psychological distress following a traumatic event), generalized anxiety disorder (persistent worry and fear about everyday situations), major depressive disorder (long-term loss of pleasure or interest in life), chronic obstructive pulmonary disorder (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), right above the knee amputation, and hypertension (high blood pressure). Review of the resident's wound care showed: - An order for the right stump to cleanse with wound cleanser, pat dry, cover with a band aid. Change daily and as needed, dated 10/11/24, and discontinued on 12/04/24; - An order for the right stump to cleanse with wound cleanser, pat dry, apply calcium alginate (a type of wound treatment), and cover with a band aid. Change daily and as needed, every day shift, dated 12/05/24, and discontinued on 12/18/24; - An order for the right stump to cleanse with wound cleanser, pat dry, pack the open area daily with Iodoform (a type of wound treatment), apply a 4x4 bandage, apply ABD (a type of dressing), and wrap with Kerlix (a type of dressing) every day shift, dated 12/19/24, and discontinued on 01/22/25; - An order for the right stump to cleanse the with wound cleanser, pat dry, apply adapact (a type of treatment) and a foam dressing daily and as needed, every day shift, dated 01/22/25, and discontinued on 02/13/25; - An order to cleanse the right stump with wound cleanser/normal saline, pat dry, 1/2 inch Iodoform gauze, 4x4, and ABD daily, one time a day for the wound, dated 02/14/25; - November 2024 Treatment Administration Record (TAR) with no treatments completed on 11/02/24, 11/03/24, 11/04/24, 11/16/24 and 11/24/24, with five missed opportunities out of 30 opportunities; - December 2024 TAR with no treatments completed on 12/02/24, 12/03/24, 12/04/24, 12/18/24, 12/22/24, and 12/25/24, with six missed opportunities out of 31 opportunities; - January 2025 TAR with no treatments completed on 01/04/25, 01/16/25, 01/18/25, 01/28/25 and 01/31/25, with five missed opportunities out of 31 opportunities; - February 2025 TAR with no treatments completed on 02/03/25, 02/04/25, 02/14/25, 02/19/25, 02/21/25, 02/23/25, and 02/26/25, with seven missed opportunities out of 28 opportunities. During an interview on 03/03/25 at 12:15 P.M., Resident #4 said his/her wound care wasn't done at times. During an interview on 03/06/25 at 1:56 P.M., Licensed Practical Nurse (LPN) K said Resident #4's wound dressing was supposed to be changed every day and didn't know it had not been done. During an interview on 03/06/25 at 3:47 P.M., the Administrator and Director of Nursing (DON) said they expected wound care and dressing changes to be completed as ordered.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 64. Review of the facility's policy titled, Food Preparation and Service, revised November 2022, showed: - Appropriate measures are to prevent cross contamination; - Cleaning and sanitizing work surfaces including cutting boards and food-contact equipment between uses, following food code guidelines; - Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) are transferred to food by hands including gloved hands, food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned; - All food service equipment and utensils will be sanitized according to current guidelines and manufacturer's recommendations. 1. Observation on 02/06/24 at 9:32 A.M., and 02/09/24 at 8:19 A.M., of the kitchen showed: - Food debris lay in the garbage disposal sink; - The commercial range with brown grime build-up along the top surface; - Food debris and oily film build-up on the floor beneath the range; - Microwave oven interior with splattered food debris on all surfaces; - Cabinet drawers contained cooking utensils and scattered debris on the bottom surface; - The ice machine had no air gap; - An 1 inch (in.) ice machine polyvinyl chloride (PVC) drainage line lay upon the 4 in. floor drain cover in the dishwashing area with black grime and debris on interior and exterior surfaces; - Ice machine exterior surface near dispensing area with white grime build-up; - Reach-in refrigerator interior with scattered debris and no separate thermometer; - Floor below reach-in freezer with scattered debris; - The commercial dishwasher with white grime build-up and debris on the exterior surfaces; - Black grime build-up on the drain pipes below the dishwashing counter; - Ceiling lights over food preparation areas with five broken fluorescent light fixture covers; - A 12-inch (in.) diameter (dia.) ceiling section above the dishwashing area sink with a black substance; - Four ceiling diffusers (one of the few visible parts of an air conditioning system) with a brown substance on the front exterior surfaces and between the ventilation louvers; - The commercial style can opener with a worn cutting edge, black grime build-up, and base edges with a brown substance; - Mop bucket with gray water, attached mop head and handle sat in the opened janitor closet; - Four non-intact 6 in. by 6 in. ceramic floor tiles in the dishwashing and food prep area; - Two large plastic bins with non-intact lids and dry pasta beside the steam table. 2. Observation on 02/06/24 at 9:37 A.M., and 02/09/24 08:19 A.M., of the dry food storage room showed: - One 6 pound (lb.) 10 ounce (oz.) dented can of green peas and one 7 lb. 3 oz. dented can of ketchup on the canned food rack; - Scattered debris below the food storage shelves; - A 12-in. dia. wall section with a sticky brown substance behind the food shelves. 3. Observation on 02/06/24 at 9:37 A.M., and 02/09/24 08:20 A.M., of the walk-in refrigerator showed: - An 8 in. frost formation surrounded the ventilation unit; - A sticky film, a french fry, spilled liquid and debris on the floor aisle and below the food shelves and with no separate thermometer; - Dust and grime build-up between the ventilation louvers; - Electrical box with exposed electrical wires; - Food shelf with an unlabeled bag of onion and a tomato with a gray substance. 4. Observation on 02/06/24 at 9:42 A.M., and 02/09/24 08:25 A.M., of the walk-in freezer showed: - A damaged door seal on the entire right side; - No separate thermometer; - A sticky film, an ice cream cup and scattered debris on the floor aisle and below the food shelves. During an interview on 02/09/24 at 8:35 A.M., Dietary Aide F said deep cleaning was expected once monthly and all dietary staff members were supposed to do regular cleaning daily. The Dietary Manager also helped, there should not be damaged lighting covers in the dishwashing and food preparation area. All appliances should work properly and be clean. Refrigeration areas should be kept clean. The can opener should not have grime and drawers should be clean. The dietary staff were expected to keep the floors, stove, toaster, dishwasher, walk-in freezer, and refrigerator clean. The staff should also clean under and behind appliances. Cleaning should be done at least three times a week but limitations in staffing had made cleaning a challenge. During an interview on 02/09/24 at 8:43 A.M., the Dietary Manager said the walk-in refrigerator had a problem with ice build-up, but it had been defrosted. The walk-in refrigerator should be clean, but it would need some work. Sweeping under the appliances was expected and be moved out from the wall. The dishwasher should be clean inside and out along with the other appliances. The dishwasher, appliances and floor surfaces should be cleaned. The floors in the walk-in freezer and refrigerator should be cleaned and mopped. Deep cleaning was expected monthly, and all staff should be helping with daily cleaning. All staff were expected to help with basic cleaning. New thermometers should be placed in each refrigerator. The floor tiles should have already been replaced. During an interview on 02/09/24 at 9:20 A.M., the Assistant Administrator said all issues in the kitchen were a concern and should be corrected. Deep cleaning should be done more often. The lighting and fixtures should be clean and intact. During an interview on 02/09/24 at 9:23 A.M., the Administrator said deep cleaning was a concern and should be done more often, lighting and ventilation should be clean and intact, all appliances should be clean, there should not be a filled mop bucket with a dirty mop head in the supply closet, and the door should be closed. Floor tiles, lighting and food containers should be intact, and ceiling should not have mold. There should not be dented cans in the dry storage racks, but should be stored separately and sent back or thrown out. The refrigerators should have separate thermometers and the floors should be clean in the walk ins. There should be an air gap for the ice machine, and it should be clean. All the counter tops, floors and vents should be clean and work properly. All issues were a concern.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility also failed to ensure one resident (Resident #20) outside of the sample of 16 residents had a physician's order to keep medications at the bedside. This had the potential to affect all residents. The facility census was 64. Review of the facility policy titled, Storage of Medications, revised November 2020, showed: - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper handling before storing; - Discontinued, outdated, or deteriorated drugs or biologics are returned to the dispensing pharmacy or destroyed; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1. Review of Resident #20's Physician Order Sheet (POS), dated February 2024, showed: - An order for Symbicort (medication to ease difficulty breathing)160-4.5 microgram (mcg) inhaler inhale two puffs every 12 hours for chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dated 01/18/23; - An order for fluticasone (medication that decreases a stuffy nose) 50 mcg spray two sprays both nostrils every day for rhinitis (inflammation of mucous membrane of the nose, dated 11/21/23; - Visine dry eye relief (eyedrops for itchy dry eyes) 1 percent (%) drops twice a day, dated 12/11/23; - No documentation of an order for the resident to self-administer and keep the Symbicort, fluticasone, and Visine dry eye relief medications at the bedside. Review of the resident's Medication Administration Record Review (MAR), dated February 2024, showed no documentation of an order for the resident to self-administer and keep the Symbicort, fluticasone, and Visine dry eye relief medications at the bedside. Review of the resident's medical record showed no documentation of an assessment, evaluation, or education for the resident to self-administer and keep the Symbicort, fluticasone, and Visine dry eye relief medications at the bedside. Review of the resident's care plan, dated 09/07/23, showed it did not address the resident to self-administer and keep the Symbicort, fluticasone, and Visine dry eye relief medications at the bedside. Observations on 02/08/24 at 8:35 A.M., and 4:25 P.M., showed Registered Nurse (RN) A opened Resident #20's bedside dresser drawer where the Symbicort inhaler, Visine eye drops, and the fluticasone nose spray were kept by the resident. During an interview on 02/08/24 at 4:25 P.M., Resident #20 said he/she used the inhaler in the morning and at night, the nose spray at night only, and the eye drops in the morning and night. Staff did education and an assessment on how to use the medications. If he/she needed help, then staff would help. During an interview on 02/08/24 at 8:35 A.M., RN A said the resident administered the Symbicort, fluticasone, and the Visine eye drop medications on his/her own. During an interview on 02/09/24 at 8:54 A.M., the Assistant Director of Nursing (ADON) said if medications were kept at the resident's bedside, then the resident was assessed and educated on using the medications and the assessment and education documentation should be in the care plan. During an interview on 02/09/24 at 2:25 P.M., the Director of Nursing (DON) and Administrator said they expect for the physician orders to be followed and for the medications to be administered as ordered.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices for wound care for one resident (Resident #5) out of two sampled residents, failed to perform hand hygiene during medication administration for four residents (Resident #7, #12, #20, and #34) out of four sampled residents, and failed to maintain proper infection control practices for glucose monitoring for three residents (Resident #6, #7, and #33) out of six sampled residents. The facility census was 64. Review of the facility's policy titled, Wound Care, revised 2010, showed: - Verify physician's order; - Review the resident's care plan to assess any special needs of the resident such as pain control; - Assemble supplies and equipment and wipe equipment with alcohol wipes if necessary; - Establish a clean field on the resident's overbed table and put supplies down; - Wash and dry hands thoroughly. Put on gloves; - Use no-touch technique. Pour liquid solutions directly onto the gauze; - Wear exam gloves for holding gauze to catch irrigation solutions poured over the wound; - Wear sterile gloves when physically touching the wound or holding moist surface over the wound; - Place gauze to cover the broken skin. Wash tissue around the wound usually covered by the dressing, tape, or gauze with soap and water or antiseptic; - Remove dry gauze and apply the treatment; - Dress the wound and make sure the clean items are on the clean field; - Wash and dry hands thoroughly. 1. Observation of wound care for Resident #5 on 02/07/24 at 12:16 P.M. showed: - Licensed Practical Nurse (LPN) C did perform hand hygiene before putting on gloves; - LPN C contaminated the scissors when the scissors touched the resident's bed. Without disinfecting the scissors, LPN C used the scissors to cut the calcium alginate (a wound dressing), kerlix (a type of gauze), and iodoform (a wound dressing) for the resident's leg and coccyx wounds; - LPN C put the contaminated scissors on the bedside table; - LPN C put the contaminated scissors in his/her pocket and then put them back on the bedside table; - LPN C cut the iodoform with the contaminated scissors; - The iodoform touched the outside of the iodoform bottle and LPN C put the contaminated iodoform back into the bottle and then placed the bottle in the resident's drawer for later dressing changes; - LPN C washed his/her hands and then waved them in the air to dry them next to the resident's coccyx wound; - LPN C contaminated the iodoform dressing when it touched the incontinent pad under the resident; - LPN C packed the contaminated iodoform dressing into the coccyx wound. During an interview on 02/13/24 at 1:28 P.M., LPN C said he/she should gather supplies, get them ready, and then wash his/her hands before performing wound care. He/she would change gloves when going from clean to dirty care. If equipment got dirty, then he/she would use the purple top disinfecting wipes for the recommended amount of time to clean it. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2019, showed: - Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; - Use an alcohol based hand rub containing at least 62 percent (%) alcohol or soap and water before and after coming on duty, direct contact with residents, prepping or handing medications, any non-surgical invasive procedures, handling an invasive device, putting on sterile gloves, handling clean or soiled dressings, moving from a contaminated body site to a clean body site during resident care, contact with a resident's intact skin, contact with bodily fluids or blood, handling used dressing or contaminated equipment, contact with objects in the immediate facility of the resident, after removing gloves, before and after entering isolation precaution settings, eating or handling foods, assisting a resident with meals, and after use of toilet or conducting personal hygiene; - Hand hygiene is the final step after removing and disposing pf personal protective equipment; - To wash hands, wet hands first with water, apply recommended amount of product, rub hands vigorously for at least 15 seconds, rinse hands with water and dry thoroughly with a disposable towel, use a towel to turn off the faucet, and avoid using hot water; - To apply gloves, perform hand hygiene before applying non-sterile gloves, remove one glove from box at a time touching only the top of the cuff; - To remove gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out, hold the removed glove with the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove, and final step is to perform hand hygiene. Observations on 02/08/24 of the medication administration pass showed: - At 8:35 A.M., Registered Nurse (RN) A failed to perform hand hygiene before preparing, before administering, and after administering the medications to Resident #20; - At 8:42 A.M., RN A failed to perform hand hygiene before preparing, before administering, and after administering the medications to Resident #34; - At 8:50 A.M., RN A failed to perform hand hygiene before preparing, before administering, and after administering the medications to Resident #12. The facility did not provide a glucometer (a device for measuring the amount of concentration in the blood) policy. Review of the Wipes Plus Disinfecting Wipes manufacturer's recommendations showed: - Wipe thoroughly and keep wet for 10 minutes to clean and disinfect. Let air dry; - If an extremely dirty surface, clean first with another wipe before disinfecting. Observations on 02/08/25 of the blood glucose monitoring showed: - At 11:25 A.M., RN A performed blood glucose monitoring for Resident #7. RN A failed to perform hand hygiene before applying gloves to use the glucometer. RN A cleaned the glucometer with a Wipes Plus Disinfecting Wipes wipe for five seconds, then discarded the wipe and placed the glucometer on top of the treatment cart; - At 11:35 A.M. RN A performed blood glucose monitoring for Resident #6. RN A failed to perform hand hygiene before applying gloves to use the glucometer. RN A cleaned the glucometer with a Wipes Plus Disinfecting Wipes wipe for five seconds, then discarded the wipe and placed the glucometer on top of the treatment cart; - At 11:40 A.M., RN A performed blood glucose monitoring for Resident #33. RN A failed to perform hand hygiene before applying gloves to use the glucometer. RN A cleaned the glucometer with a Wipes Plus Disinfecting Wipes wipe for five seconds, then discarded the wipe and placed the glucometer on top of the treatment cart. RN A failed to perform hand hygiene after the use of the glucometer. During an interview on 02/09/24 at 2:25 P.M., the Administrator said proper cleaning and disinfecting of equipment was expected. She also expected wound care, blood glucose checks, and medication administration to be performed using proper infection control practices. 47447 49152

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 64. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Staff provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences; - The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment. Observation on 02/06/24 at 9:40 A.M. of room [ROOM NUMBER] showed: - A hole in the bathroom door approximately the size of a tennis ball; - No closet doors on the closet and clothes lay in the closet floor covering the entire closet floor area; - Clothes hanging up in the closet and out of reach of the wheelchair bound resident. During an interview on 02/06/24 at 9:40 A.M., the resident in room [ROOM NUMBER] said he/she had asked the staff to lower the clothes hanging in the closet because he/she could not reach anything. He/She had also asked the staff to help clean up his/her closet area but that had not been done. Observation on 02/06/24 at 10:35 A.M., of room [ROOM NUMBER] showed the sliding door on the closet was off it's track and the door was leaned against the front of the closet. Observations on 02/06/24 at 11:16 A.M., of the 200 Hallway showed: - A non-intact plastic light fixture cover above the seating area in the Activity Room; - A sink base cabinet without a drawer face in the Activity Room. Observation on 02/06/24 at 11:17 A.M. of room [ROOM NUMBER] showed a section of exposed sharp metal sheetrock corner bead 2 ft. along the lower outside corner of the bathroom wall. Observation on 02/06/24 at 11:18 A.M., of room [ROOM NUMBER] showed a packaged terminal air conditioner (PTAC)(a type of self-contained heating and air conditioning system intended to be mounted through a wall) unit without ventilation louvers on the top and front. During an interview on 02/09/24 at 11:06 A.M., the resident in room [ROOM NUMBER] said the air conditioner and wall corner should be fixed. Observation on 02/06/24 at 11:19 A.M., of room [ROOM NUMBER] showed: - A 1 in. crack along the top, left and right side edges of the PTAC unit; - A section of exposed sharp metal sheetrock corner bead 6 in. along the lower outside corner of the bathroom wall. During an interview on 02/07/24 at 8:45 A.M., the resident in room [ROOM NUMBER] said the cracks should be fixed around the air conditioner and the wall corner should be fixed near the bathroom. Observation on 02/06/24 at 11:23 A.M., of room [ROOM NUMBER] showed the PTAC unit rattled during the heating mode. During an interview on 02/06/24 at 11:26 A.M., the resident in room [ROOM NUMBER] said the heater rattled and was noisy. Observation on 02/06/24 at 11:53 A.M., of room [ROOM NUMBER] showed: - A 6 in. section of the cove base missing from the left outside corner of the bathroom door to the wall wrapping around the side; - A sticky fly trap hanging from the ceiling above the sink beside the resident bed with eight dead flies stuck on it; - The top of the dresser surface without the laminate top; -The bathroom vent flow obstructed by gray and black buildup. Observation on 02/06/24 at 11:58 A.M., of room [ROOM NUMBER] showed: - The call light plastic light fixture cover outside the resident room above the door hanging loose with exposed wires; - No closet door for the closet behind the room door. Observation on 02/08/24 at 3:10 P.M., of room [ROOM NUMBER] showed: - The bathroom door with a 2 inch (in.) by 3 in. hole in the outer surface of the door; - The sliding door on the closet was off it's track and the door was leaned against the front of the closet. During an interview on 02/08/24 at 3:15 P.M., the resident in room [ROOM NUMBER] said the hole had been in his/her bathroom door for five years. He/She wasn't sure how long the closet door had been off it's track. Observation on 02/08/24 at 2:55 P.M., of the Women's Employee restroom showed a 3 foot (ft.) section of cove base directly behind the toilet was pulled away from the wall. Observation on 02/09/24 at 11:37 A.M., of room [ROOM NUMBER] showed: - The sink basin surround chipped with a big chunk out of the corner; - An approximate 3 ft. by 3 ft. area of uneven, patched ceiling plaster. Observation on 02/09/24 at 11:45 A.M., of room [ROOM NUMBER] showed: - An approximate 2 ft. by 2 ft. area of ceiling plaster peeling off; - Floor area extremely sticky and a wet floor sign sat on the floor. During an interview on 02/09/24 at 12:14 P.M., the Maintenance Director said he/she did monthly inspections but didn't keep a regular log of them. There was a log book for staff to write needed repairs in. None of the repairs that were needed in Resident rooms 402, 404, or 405 had been addressed in the log book. Residents came to him/her with issues/problems that need to be fixed. During an interview on 02/15/24 at 10:10 A.M., the Administrator said she would expect the resident environment to be in good repair and she would expect needed repairs to be addressed in a timely manner. 49879 50260

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were 12 errors out of 39 opportunities for errors, resulting in an error rate of 30.77%. This practice affected two residents (Resident #12 and #20) out of three sampled residents. The facility census was 64. Review of facility's policy titled, Administering Medications, revised April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training; - If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person prepping or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns; - The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication; - Allergies and vital signs are checked/verified for each resident prior to administering medications; - The individual administering the medication records in the resident's medical record the date and time medication is administered, the dosage, route, injection site, why drug is administered like complaints or symptoms, any results achieved, and signature and title of person administering the drug; - Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. 1. Review of Resident #20's Physician Order Sheet (POS), dated February 2024, showed: - Diagnoses of heart failure (chronic condition where heart does not pump blood as well it should), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order for Symbicort (medication to ease difficult breathing) 160-4.5 microgram (mcg) inhaler two puffs into the lungs every 12 hours, dated 01/18/23; - An order for fluticasone (medication to decrease stuffy nose) 50 mcg spray two sprays both nostrils every day at 8 A.M., dated 11/21/23; - An order for isosorbide dinitrate (blood pressure medication) 30 milligram (mg) once a day at 8 A.M. Hold for a blood pressure (bp) of less than 110/70 and notify the physician, dated 09/19/23; - An order for ranolazine (blood pressure medication) 500 mg twice a day for bp. Hold if bp is less than 110/70 and call the physician, dated 09/19/23; - An order for Visine dry eye relief (eyedrops for itchy dry eyes) 1% drops twice a day at 8 A.M. and 6 P.M. daily, dated 12/11/23; - An order for furosemide (fluid retention medication) 20 mg tablet by mouth once a day at 8 A.M., dated 11/16/23. Review of the resident's Medication Administration Record (MAR), dated February 2024, showed: - RN A documented Symbicort 160-4.5 mcg two puffs administered on 02/08/24 at 8:00 A.M., and RN A did not administer the medication to the resident; - RN A documented Visine dry eye relief 1% one drop to both eyes administered on 02/08/24 at 8:00 A.M., and RN A did not administer the medication to the resident; - RN A documented fluticasone 50 mcg spray two sprays both nostrils administered on 02/08/24 at 8:00 A.M., and RN A did not administer the medication to the resident; - RN A documented isosorbide dinitrate 30 mg not administered on 02/08/24 at 8:00 A.M., and RN A did administer the medication to the resident; - RN A documented ranolazine 500 mg not administered on 02/08/24 at 8:00 A.M., and RN A did administer the medication to the resident; - RN A documented furosemide 20 mg not administered on 02/08/24 at 8:00 A.M., and RN A did administer the medication to the resident. Observation of the medication pass for Resident #20 on 02/08/24 at 8:35 A.M., showed: - Registered Nurse (RN) A did not administer the Symbicort 160-4.5 mcg and charted he/she administered the medication; - RN A did not administer fluticasone 50 mcg dosage spray two sprays both nostrils and charted he/she administered the medication; - RN A took the resident's bp which was 113/44. He/She charted the resident's bp as 114/44; - RN A administered the isosorbide dinitrate 30 mg daily and the ranolazine 500 mg. RN A charted he/she did not administer the isosorbie dinitrate and ranolazine medications due to the resident's bp was 114/44; - RN A did not administer Visine dry eye relief 1% both eyes and charted he/she administered the medication; - RN A administered furosemide 20 mg and charted he/she did not administer the medication. During an interview on 02/08/24 at 11:43 A.M., RN A said there were parameters in the orders for medications like for Resident #20's blood pressure. He/She held the medications and followed the order if needed. If the order showed to call the physician, then the physician was called to see what to do for the resident. 2. Review of Resident #12's POS, dated February 2024, showed: - Diagnoses of Alzheimer's Disease (progressive mental deterioration), epilepsy (a disease that causes recurrent seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), hypothyroidism (a decreased level of thyroid hormone), dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety, major depressive disorder (a constant feeling of sadness and loss of interest), and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions); - An order for ferosul 325 mg tablet by mouth everyday at 8:00 A.M., dated 05/15/23. Review of the resident's MAR, dated February 2024, showed RN A documented ferosul 325 mg administered on 02/08/24 at 8:00 A.M., and RN A did not administer the medication to the resident. Observation of the medication pass for Resident #12 on 02/08/24 at 8:50 showed RN A did not administer ferosul 325 mg and charted he/she administered the medication. During an interview on 02/09/24 at 2:25 P.M., the Director of Nursing (DON) and the Administrator said they expect for the orders to be followed and for the medications to be administered as ordered.

Based on interview and record review, the facility failed to ensure a resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure services to promote the resident's highest level of functioning and psychosocial needs for four residents (Residents #5, #12, #23 and #47) out of 16 sampled residents. The facility census was 64. Review of the facility's policy titled, Comprehensive Person - Centered Care Plans, revised March 2022, showed: - The care plan is person-centered and includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs; - Describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. Review of the facility's policy titled, Dementia - Clinical Protocol, revised November 2018, showed: - The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician; - The interdisciplinary team will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of the dementia, development of new acute medical conditions or complications, and changes in the resident's or family's wishes, etc. 1. Review of Resident #5's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia and mild intellectual disabilities. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 01/11/24, showed: - Diagnosis of dementia; - No cognitive impairment. Review of the resident's care plan, dated 10/10/23, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. 2. Review of Resident #12's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia and major depressive disorder (a constant feeling of sadness and loss of interest). Review of the resident's quarterly MDS, dated [DATE], showed: - Diagnosis of dementia; - No cognitive impairment. Review of the resident's care plan, dated 11/03/23, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. 3. Review of Resident #23's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's annual MDS, dated [DATE], showed: - Diagnosis of dementia; - No cognitive impairment. Review of the resident's care plan, dated 07/22/23, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. 4. Review of Resident #47's medical record showed: - An admitted [DATE]; - Diagnoses of post traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), dementia, neurocongnitive disorder with Lewy bodies (a type of dementia associated with abnormal deposits of protein in the brain), and major depressive disorder. Review of the resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Diagnosis of dementia. Review of the resident's care plan, dated 09/07/23, showed: - Did not address dementia; - Did not address specific problems, interventions, or goals for dementia care; - Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. During an interview on 02/09/24 at 10:27 A.M., the MDS coordinator said the care plan should address dementia and with personalized interventions. During an interview on 02/09/24 at 2:25 P.M. ,the Administrator said she would expect the care plan to be person centered and reflect a resident's current diagnoses. 46521 47447

Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for two residents (Residents #8 and #47) with a diagnosis of post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 64. Review of the facility's policy titled, Trauma-Informed and Culturally Competent Care, revised August 2022, showed: - Perform universal screening of the resident, which includes a brief, non-specialized identification of possible exposure to traumatic events; - Utilize initial screening to identify the need for further assessment and care; - Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers; - Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate; - Identify and decrease exposure to triggers that may re-traumatize the resident. 1. Review of Resident #8's medical record showed: - admitted [DATE]; - Diagnoses of PTSD, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizophrenia (a serious mental condition affecting the way a person thinks and communicates with the outside world, can include hallucinations and delusions), bipolar disorder (a mental health disorder that causes extreme mood swings), generalized anxiety disorder (persistent feeling of worry) and borderline personality disorder (a mental disorder in which you have a rigid and unhealthy pattern of thinking, behaving and functioning); - Brief Trauma Questionnaire, dated 07/09/21, did not address the resident's PTSD triggers. Review of the resident's Physician Order Sheet (POS), dated February 2024, showed: - An order for buprenorphine (a pain medication) 2 mg sublingual (under the tongue) tab once a day with no diagnosis documented, dated 01/22/24; - An order for duloxetine (an antidepressant medication) 30 mg capsule 1 capsule by mouth everyday for bipolar disorder, dated 02/20/23; - An order for lamotrigine (a seizure medication) 100 mg tablet 1 tab by mouth every day at bedtime for schizophrenia, dated 02/20/23; - An order for lurasidone (an antipsychotic medication) 120 mg tablet 1 tablet by mouth at bedtime for major depressive disorder, dated 02/20/23; - An order for trazadone (an antidepressant medication) 100 mg tablet 2 tablets daily as needed with no diagnosis documented, dated 02/05/24. Review of the resident's Preadmission Screening and Resident Review (PASARR) (a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 02/15/22, showed: - Resident with anxiety disorder and PTSD; - No behaviors documented. Review of resident's care plan, revised 11/15/23, showed: - Did not identify PTSD as a problem; - Did not address personalized triggers or interventions associated to the resident or triggers. During an interview on 02/13/24 at 1:38 P.M., the Administrator said the PTSD diagnosis must have been missed when Resident #47's PASARR was completed. Resident #47 was admitted to the facility with the diagnosis of PTSD. The diagnoses listed in the resident's medical record were reviewed and signed off by the resident's physician on a monthly basis. During an interview on 02/09/24 at 8:57 A.M., Licensed Practical Nurse (LPN) D said he/she didn't know of any residents in the facility with a diagnosis of PTSD or any triggers. During an interview on 02/09/24 at 10:05 A.M., LPN B said he/she was not aware of any residents in the facility with a diagnosis of PTSD. 2. Review of Resident #47's medical record showed: - admitted [DATE]; - Diagnoses of PTSD, unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), neurocongnitive disorder with Lewy bodies (a type of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) associated with abnormal deposits of protein in the brain), and major depressive disorder; - Brief Trauma Questionnaire, dated 05/26/22, did not address resident's the PTSD triggers. Review of the resident's POS, dated February 2024, showed: - An order for quetiapine (an antipsychotic medication) 50 mg by mouth every morning with no diagnosis documented, dated 10/10/23; - An order for quetiapine 300 mg by mouth every evening with no diagnosis documented, dated 10/10/23; - An order for Depakote (a seizure medication) delayed release 500 mg by mouth every morning for dementia with behavioral disturbance, dated 10/14/23; - An order for Depakote delayed release 250 mg by mouth every evening for mood disorder, dated 12/06/23; - An order for buspirone (an antianxiety medication) 15 mg tablet by mouth three times a day with no diagnosis documented, dated 12/13/23; An order for fluoxetine (an antidepressant medication) 20 mg by mouth once a day with no diagnosis documented, dated 11/16/22. Review of the resident's PASARR, dated 02/15/22, showed: - Resident with anxiety disorder; - No behaviors documented. Review of the resident's care plan, revised 09/07/23, showed: - Did not identify PTSD as a problem; - Did not address personalized triggers or interventions associated to the resident or triggers. During an interview on 02/13/24 at 1:38 P.M., the Administrator said the PTSD diagnosis must have been missed when Resident #47's PASARR was completed. Resident #47 was admitted to the facility with the diagnosis of PTSD. The diagnoses listed in the medical record were reviewed and signed off by the resident's physician on a monthly basis. During an interview on 02/09/24 at 10:30 A.M., Certified Nursing Assistant (CNA) E said that he/she did know Resident #47 had a diagnosis of PTSD, but did not know what the resident's triggers were. During an interview on 02/09/24 at 9:56 A.M., the Director of Nursing (DON) said she would expect a resident with a diagnosis of PTSD to be assessed for triggers. During an interview on 02/09/24 at 1:00 P.M., the Social Services Designee said he/she would expect a resident with a diagnosis of PTSD to be assessed for triggers. During an interview on 02/09/24 at 2:25 P.M., the Administrator said she would expect a resident with a diagnosis of PTSD to be assessed for triggers. 47447

Based on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for three residents (Residents #8, #47, and #65) out of 16 sampled residents. The facility's census was 64. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan includes: measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and reflects currently recognized standards of practice for problems areas and conditions. 1. Review of Resident #8's medical record showed: - An admitted [DATE]; - Diagnoses of post traumatic stress disorder (PTSD) (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and triggers may bring back memories, intense emotions and physical reactions) and major depressive disorder (long-term loss of pleasure or interest in life). Review of the resident's care plan, revised 11/15/23, showed: - PTSD not addressed; - Did not address personalized triggers or interventions associated to the resident or the triggers. 2. Review of Resident #47's medical record showed: - An admitted [DATE]; - Diagnoses of PTSD, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), neurocognitive disorder with Lewy bodies (a type of dementia associated with abnormal deposits of protein in the brain), and major depressive disorder. Review of the resident's care plan, dated 09/07/23, showed: - PTSD not addressed; - Did not address personalized triggers or interventions associated to the resident or the triggers. 3. Review of Resident #65's medical record showed: - An admitted [DATE]; - Diagnoses of gastrointestinal hemorrhage (bleeding of the digestive tract), hypertension (high blood pressure), atrial fibrillation (abnormal heart rhythm), stroke (damage to the brain from interrupted blood supply), pneumonia (infection in the lungs), and septicemia (bloodstream infection). - An order for Eliquis (medication used to treat and/or prevent blood clots) 5 milligram (mg) every 12 hours, dated 01/11/24. Review of the resident's care plan, dated 02/06/24, showed: - Did not address the use of Eliquis; - Did not address specific interventions or side affects for the Eliquis use. During an interview on 02/09/24 at 12:40 P.M., the Director of Nursing (DON) said she would expect the care plan to be person-centered and to reflect a resident's diagnosis of PTSD. During an interview on 02/09/24 at 2:25 P.M., the Administrator said she would expect the care plan to be person-centered and to reflect a resident's current diagnoses. 47447

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff for four residents (Residents #11, #12, #21 and #23) out of 16 sampled residents. The facility census was 64. The facility did not provide a policy related to the accuracy of MDS assessments. 1. Review of Resident #11's medical record showed: - An admitted [DATE]; - Diagnoses of schizophrenia (a serious mental condition affecting the way a person thinks and communicates with the outside world, can include hallucinations and delusions), anxiety (an emotion characterized by feelings of tension and worried thoughts), bipolar disorder (a mood disorder with depressive lows to manic highs), and borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships); - A Level II Preadmission Screening and Record Review (PASARR) (a comprehensive evaluation required as a result of a positive Level I screening and to determine whether placement or continued stay in a nursing facility to be appropriate), dated 04/19/23. Review of the resident's significant change MDS, dated [DATE], showed: - Documented the Level II PASARR not completed; - Schizophrenia not documented as a diagnosis for the resident. 2. Review of Resident #12's medical record showed: - An admitted [DATE]; - Diagnoses of Alzheimer's Disease (progressive mental deterioration), epilepsy (a disease that causes recurrent seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness)), hypothyroidism (a decreased level of thyroid hormone), dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety, major depressive disorder (a constant feeling of sadness and loss of interest), and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions). Review of the resident's quarterly MDS, dated [DATE], showed Alzheimer's disease, seizures, and hypothyroidism not documented as diagnoses for the resident. 3. Review of Resident #21's medical record showed: - An admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypothyroidism, major depressive disorder, dementia, diabetes mellitus (DM)(a condition that affects the way the body processes blood sugar), schizophrenia, and seizures; -Hypothyroidism dated 08/02/22; -Seizures dated 08/02/22; -Schizophrenia dated 09/01/22. Review of the resident's quarterly MDS, dated [DATE], showed schizophrenia, seizures, and hypothyroidism not documented as diagnoses for the resident. 4. Review of Resident #23's medical record showed: - An admitted [DATE]; - Diagnoses of schizophrenia, psychosis (a mental disorder characterized by disconnection from reality), and depression (a mood disorder causing persistent feelings of sadness and loss of interest); - A Level II PASARR, dated 7/22/15. Review of the resident's annual MDS, dated [DATE], showed: - Documented the Level II PASARR not completed; - Schizophrenia not documented as a diagnosis for the resident. During an interview on 02/09/24 at 11:26 A.M., the MDS Coordinator said the Level II PASARR should be documented as completed if it was done. He/She was not aware of this and would need to start looking for that. The correct diagnoses should be documented. They were missed. During an interview on 02/09/24 at 2:25 P.M., the Director of Nursing and the Administrator said expectations were for the MDS to accurately reflect the condition of the resident and the Resident Assessment Instrument (RAI) manual should be followed in regards to MDS assessments. 46521 49152

Based on observation, interview and record review, the facility failed to ensure two residents (Resident's #20 and #65) were free of significant medication errors when staff did not administer medications as ordered by the physician. The facility census was 64. Review of facility policy titled, Administering Medications, revised April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training; - If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person prepping or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns; - The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication; - Allergies and vital signs are checked/verified for each resident prior to administering medications; - The individual administering the medication records in the resident's medical record the date and time medication is administered, the dosage, route, injection site, why drug is administered like complaints or symptoms, any results achieved, and signature and title of person administering the drug. 1. Review of Resident #20's Physician Order Sheet (POS), dated February 2024, showed: - Diagnoses of heart failure (chronic condition where heart does not pump blood as well it should), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order for Symbicort (medication to ease difficult breathing) 160-4.5 microgram (mcg) inhaler two puffs into the lungs every 12 hours, dated 01/18/23; - An order for fluticasone (medication to decrease stuffy nose) 50 mcg spray two sprays both nostrils every day at 8 A.M., dated 11/21/23; - An order for isosorbide dinitrate (blood pressure medication) 30 milligram (mg) once a day at 8 A.M. Hold for a blood pressure (bp) of less than 110/70 and notify the physician, dated 09/19/23; - An order for ranolazine (blood pressure medication) 500 mg twice a day for bp. Hold if bp is less than 110/70 and call the physician, dated 09/19/23; - An order for furosemide (fluid retention medication) 20 mg tablet by mouth once a day at 8 A.M., dated 11/16/23. Review of the resident's Medication Administration Record (MAR), dated February 2024, showed: - RN A documented Symbicort 160-4.5 mcg two puffs administered on 02/08/24 at 8:00 A.M., and RN A did not administer the medication to the resident; - RN A documented fluticasone 50 mcg spray two sprays both nostrils administered on 02/08/24 at 8:00 A.M., and RN A did not administer the medication to the resident; - RN A documented isosorbide dinitrate 30 mg not administered on 02/08/24 at 8:00 A.M., and RN A did administer the medication to the resident; - RN A documented ranolazine 500 mg not administered on 02/08/24 at 8:00 A.M., and RN A did administer the medication to the resident; - RN A documented furosemide 20 mg not administered on 02/08/24 at 8:00 A.M., and RN A did administer the medication to the resident; - The Symbicort 160-4.5 mcg inhaler two puffs into the lungs every 12 hours administered three times a day at 8:00 A.M., 2:00 P.M., and 8:00 P.M., on 02/01/24, 02/02/24, 02/04/24, 02/05/24, and 02/06/24. Observation of the medication pass for Resident #20 on 02/08/24 at 8:35 A.M., showed: - Registered Nurse (RN) A did not administer the Symbicort 160-4.5 mcg and charted he/she administered the medication; - RN A did not administer fluticasone 50 mcg dosage spray two sprays both nostrils and charted he/she administered the medication; - RN A took the resident's bp which was 113/44. He/She charted the resident's bp as 114/44; - RN A administered the isosorbide dinitrate 30 mg daily and the ranolazine 500 mg. RN A charted he/she did not administer the isosorbie dinitrate and ranolazine medications due to the resident's bp was 114/44; - RN A did not administer Visine dry eye relief 1% both eyes and charted he/she administered the medication; - RN A administered furosemide 20 mg and charted he/she did not administer the medication. 2. Review of Resident #65's POS, dated February 2024, showed: - Diagnoses of gastrointestinal hemorrhage (bleeding of the digestive tract), hypertension (high blood pressure), atrial fibrillation (abnormal heart rhythm), stroke (damage to the brain from interrupted blood supply), pneumonia (infection in the lungs), and septicemia (bloodstream infection); - An order for metoprolol tartrate (blood pressure medication) 25 mg every 12 hours. Hold for blood pressure (bp) less than 110/70 or heart rate (hr) less than 60 and call the physician, dated 01/11/24; - An order for amiodarone (irregular hr medication) 200 mg once daily. Hold for bp less than 110/70 or hr less than 60 and call the physician, dated 01/11/24. Review of the resident's MAR, dated February 2024, showed: - On 02/01/24 at 8:00 P.M., metoprolol tartrate 25 mg administered with a bp of 104/65; - On 02/02/24 at 8:00 A.M., metoprolol tartrate 25 mg and amiodarone 200 mg administered with a bp of 93/63; - On 02/02/24 at 8:00 P.M., metoprolol tartrate 25 mg administered with a bp of 108/69; - On 02/03/24 at 8:00 A.M., metoprolol tartrate 25 mg and amiodarone 200 mg administered with a bp of 92/59; - On 02/04/24 at 8:00 A.M., metoprolol tartrate 25 mg and amiodarone 200 mg administered with a bp of 102/64; - On 02/06/24 at 8:00 P.M., metoprolol tartrate 25 mg administered with a bp of 105/69. During an interview on 02/08/24 at 11:43 A.M., RN A said there were parameters in the orders for medications like for the residents' blood pressures. He/She held the medications and followed the orders if needed. If the order showed to call the physician, then the physician was called to see what to do for the resident. During an interview on 02/09/24 at 2:25 P.M., the Director of Nursing (DON) and the Administrator said they expect for the orders to be followed and for the medications to be administered as ordered.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) of three sampled residents received treatment for chest pain per accepted standards of practice when Registered Nurse (RN) A administered a dose of Nitroglycerin when the resident's systolic blood pressure was 75 (below 100). RN A continued to administer two more doses of Nitroglycerin without obtaining a physician's order and without getting a blood pressure reading prior to the dose. The resident's blood pressure was 45/26 upon leaving the facility via ambulance and he/she spent two days in the hospital receiving treatment for low blood pressure. The facility census was 67. The Administration was notified on 09/18/23 of the Past Non-Compliance Immediate Jeopardy which occurred on 09/11/23. On 09/11/23, the facility inserviced nursing staff on the standards of practice for administering Nitroglycerin. The noncompliance was corrected on 09/11/23. The facility did not provide a specific policy for the administration of Nitroglycerin (a medication used to treat chest pain). 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 08/23/2023, showed: - Cognition intact; - Diagnoses of coronary artery disease (plaque buildup in the wall of the arteries that supply blood to the heart), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), hypertension (high blood pressure), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and depression. Review of progress notes showed: - On 09/11/2023 at 2:00 P.M., Resident #1 complained of chest pain, vital signs: blood pressure 75/44 (normal blood pressure 120/80), heart rate 76 (normal heart rate between 60-100). Staff notified the Physician Assistant (PA) who gave the order to call 911 and administer one dose of Nitroglycerin 0.4 mg/tab sublingual (under the tongue) (SL). Staff administered Nitroglycerin at 2:08 P.M., called ambulance at 2:10 P.M., Ambulance arrived at 2:45 P.M.; - On 09/13/2023, late entry noted blood pressure prior to second dose of Nitroglycerin 76/48, prior to third dose, 77/52; - No mention of additional contact with the PA for more than one dose of nitroglycerin. Review of the emergency room (ER) notes, dated 09/11/2023, showed: - Resident #1 brought to ER with complaints of chest pain while at the facility; - Facility staff administered three doses of Nitroglycerin for chest pain; - Resident #1 presented in the ER with hypotension (low blood pressure); - Resident #1 received intravenous (IV) fluids (fluids administered through a vein) to increase blood pressure; - Resident #1 returned to the facility on [DATE]. During an interview on 09/18/2023 at 10:20 A.M., Registered Nurse (RN) A said on 09/11/2023 around 2:00 P.M., a Certified Nurse Aide (CNA) reported Resident #1 complained of chest pain. RN A went to the resident's room to complete an assessment. He/she applied the resident's oxygen cannula (a plastic tubing used to administer oxygen through the nose), checked the life vest (an appliance used as an external defibrillator (a device used to shock the heart into normal rhythm) battery to make sure the battery was not run down and took vital signs. At that time, the resident's blood pressure was 75/44. RN A called the PA and reported the resident's complaints of chest pain and vital signs and received an order to administer Nitroglycerin and call 911. After administering the first dose, the resident continued to complain of chest pain. RN A completed another set of vitals. The resident's systolic reading was still below 100, but he/she was alert and oriented so he/she administered another dose. RN A said, once again, after the second dose the resident continued to complain of chest pain, and the ambulance was not at the facility yet, so he/she administered the third dose knowing the systolic blood pressure was still below 100. RN A said he/she was following the PA's telephone orders, although the PA did not specify whether to give one dose or three. RN A admitted the general rule is not to administer Nitroglycerin if the blood pressure is below 90/60. RN A said he/she should have called the PA back and verified the orders or notified the Director of Nursing (DON) for direction. During an interview on 09/18/2023 at 10:15 A.M., the PA said on 09/11/2023 Registered Nurse (RN) A called to report Resident #1 complaining of chest pain. The PA could not recall if RN A informed him/her of the resident's blood pressure or not. The PA gave an order for the nurse to call 911 and administer one dose of Nitroglycerin, this was not an order for three doses, only one. The PA said he/she expected RN A to check the resident's blood pressure and to administer Nitroglycerin using his/her nursing training. The PA said it is a standard practice to never administer Nitroglycerin if the systolic (top number) blood pressure is below one hundred. The PA said if RN A was unsure if he/she should or should not administer more than one Nitroglycerin, he/she should have called back to clarify the order. During an interview on 09/18/2023 at 10:35 A.M., the facility Pharmacist said it is a standard of practice, and taught in nursing school, to hold Nitroglycerin if the systolic blood pressure is below 100. The Pharmacist said he/she would have expected the RN to contact the physician for clarification prior to any dose of Nitroglycerin if a resident's systolic blood pressure was less than 100. During an interview on 09/18/2023 at 10:50 A.M., the DON said the standard dose of Nitroglycerin is to administer up to three doses if chest pain continues, although the nurse must check the blood pressure. If the systolic blood pressure is below 100, it is the standard to hold the dose and notify the physician. The DON said she expected RN A to call the PA back and verify the orders due to Resident #1's systolic blood pressure was below 100 before the first does of Nitroglycerin was administered. The DON stated she was in the facility when the ambulance arrived and advised of medication given and current reading of blood pressure. When EMS assessed Resident #1 upon their arrival, the resident's blood pressure was very low. The resident was unresponsive while being loaded into the ambulance. During an interview on 09/25/2023, a Paramedic with Emergency Medical Services said on 09/11/2023, upon arrival to the facility, RN A gave the report Resident #1 had complained of chest pains and he/she had administered Nitroglycerin with no results. RN A said he/she administered two additional doses without checking the resident blood pressure in between each dose. RN A further reported the resident's systolic blood pressure was initially 75. The Paramedic said he/she was trained to never administered Nitroglycerin to anyone with systolic blood pressure below 100. The DON said RN A was following physician's orders and facility protocol. When EMS assessed Resident #1 his/her blood pressure was 45/26, the resident went unresponsive upon loading into the ambulance. During an interview on 09/18/2023 at 1:00 P.M., the resident's Primary Care Physician (PCP) said the standard of practice for administering Nitroglycerin is part of a nurse's training. Nitroglycerin should not be administered to any resident with a systolic blood pressure below 100. The PCP said he/she would expect the nurse to return a call to the PA and question whether or not the PA understood the resident's current blood pressure reading. If a nurse is not comfortable administering any medication the expectation is for that nurse to call the PCP, the DON or Medical Director for advisement. He/she stated Resident #1 should not have been administered the Nitroglycerin. Complaint #MO224286

Based on interview and record review, the facility failed to protect the well-being and safety of one resident (Resident #1), out of twelve sampled residents, from verbal and mental abuse, humiliation and an increased risk of infection when a staff member responded to the resident's behaviors by spitting in the resident's face during the COVID 19 (an acute respiratory illness in humans) pandemic. The facility census was 58. On 03/25/21 at 2:51 P.M., the administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 8/21/2020. On 8/21/2020, the facility administrator became aware that a Dietary Aide (DA) had become confrontational with a resident and spit on the resident. The facility took corrective action by immediately initiating an investigation. The Administrator completed a facility wide mandatory inservice on abuse and zero tolerance of abuse of any kind, including spitting on any resident. The resident contacted the local law enforcement. The DA was suspended on 8/21/20 and officially terminated from employment on 9/1/2020. The IJ was removed and corrected on 8/21/20. 1. Record review of the facility's Abuse Prevention Program, dated 1999, showed: - An objective of zero tolerance of verbal, sexual, physical and mental abuse, corporate punishment, involuntary seclusion, neglect or misappropriation of resident property, by employees, family members, visitors or other residents; - The definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; - Mental abuse includes but is not limited to humiliation, harassment and threat of punishment or deprivation; - New employees will be instructed in the care of confused, agitated residents and how to avoid a potentially abusive causing situation. 2. Review of the regional office's Facility Wide Testing records (records kept by the regional office as facility's reported positive staff and residents, as well as testing plans) showed the facility in outbreak status (the potential for extensive transmission of COVID) starting 7/23/20 which continued through 1/05/21. 3. Record review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 9/25/2020 showed: - An admitted [DATE]; - The resident is cognitively intact; - The resident requires extensive assistance with hygiene, toileting, transfers, dressing and bathing. Record review of the Resident's COVID testing showed the resident was positive on 4/30/2020. Testing then ceased until 8/13/2020, in which the resident tested negative. Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan, with no date of problem on-set, showed Resident #1 was verbally aggressive towards staff. The care plan directed staff not to argue with the resident, and to talk to him/her in a calm voice. Staff updated the care plan on 8/21/2020 to note the incident with DA B. No new interventions were implemented. Record review of the facility's abuse investigation, dated 8/21/2020, showed at around 7:00 P.M. on 8/21/2020, the resident pushed his/her call light. Certified Nurse Aide (CNA) A entered the room and the resident began cursing and yelling wanting a snack. DA B then entered the room with snacks. The resident began to curse DA B. DA B removed his/her mask and cursed back. CNA A attempted to intervene and DA B began walking away. Resident #1 yelled and cursed again at DA B. DA B turned, walked up to the resident's bed and spit in the resident's face. DA B left the room and exited the building. The charge nurse, Licensed Practical Nurse (LPN) C entered the hallway and instructed DA B to enter the building. LPN C then called the Director of Nurses (DON) to report the event. The resident contacted the police, but no charges were filed. Record review of Resident #1's statement taken by the DON and witnessed by LPN C showed Resident #1 said: - He/she had pushed the call light for snacks (to have later in the evening) sometime between 3:30 P.M. and 5:00 P.M.; - An hour went by and an aide informed the resident he/she would check on the snacks; - The resident then called the facility from his/her cell phone and spoke with a young male in dietary about getting snacks and was told something would be delivered; - Between 6:00-6:30 P.M., the resident informed LPN C he/she was still waiting on snacks and was informed staff had let DA B know of his/her request; - A few minutes after 7:00 P.M., DA B walked into the resident's room and loudly said Man look here, we are going as fast as we can. We have stuff to do.; - The resident said DA B came in the room and he/she could tell DA B wanted to ramble and fuss. The resident told DA B it had been since 3:30 P.M. when he/she first asked for snacks and told DA B to lower his/her voice as it is not scary. I am not scared of you.; - DA B started toward the resident who was laying in bed and said I'll beat your mother[OBSCENITY] ing ass.; - CNA A and CNA B tried to block and stop DA B from advancing toward the bed, but DA B pushed through and ran into the bedside table causing the resident's IPad and everything else on the table to go flying; - DA B must have tripped and landed on the resident's right knee. DA B then tried to throw a punch at the resident, but the CNAs intervened; - As DA B was standing and being pulled back by the CNAs, he/she reared his/her head back, hocked and spit in my face and neck. - DA B was still cussing I ain't the one mother[OBSCENITY] as the CNAs pulled him/her out of the room. Record review of DA B's COVID test on 8/17/2020 showed negative. During an interview on 3/24/21 at 1:06 P.M., Resident #1 said he/she had problems getting the snacks from the kitchen. Resident #1 said he/she remembered first asking for the snack early afternoon and hours later still had not received them. DA B came from the kitchen and began cursing him/her and then spit in his/her face. Resident #1 said he/she felt degraded and like he/she wanted to kill someone. Resident #1 said being spit on is disgusting and even more so with a pandemic going on. DA B kept saying he/she would beat his/her ass and Resident #1 said he/she was not scared at all, that he/she would stand up for himself/herself. Resident #1 said he/she had not been injured, just degraded. He/she said no charges were filed with the police because he/she (the resident) wanted DA B to have a second chance. The resident confirmed the statement he/she had written on the day of the incident. Resident #1 said he/she could not recall when the second staff member, CNA B came in to the room to help with DA B, but he/she remembered DA B was drug out by his/her arms by two of them. Record review of CNA A's Witness Statement showed: - On 8/21/20 around 7:00 P.M., CNA A answered Resident #1's call light. Resident #1 was upset and started yelling and cussing Where is my goddamn snacks?; - CNA A said he/she attempted to calmly explain to Resident #1 that the dietary department was trying to finish everything and would be by shortly with his/her extra snacks; - Resident #1 said it has been three mother [OBSCENITY] ing hours since he/she asked for those snacks. DA B's fat ass is probably in there eating all the damn cakes and cookies.; - At that time, DA B walked into the room. CNA A said as he/she tried to intervene and pull DA B out of Resident #1's room, then DA B tripped while yelling at the resident You calling me fat, but look at you, [OBSCENITY] you fat too!; - DA B and Resident #1 went back and forth cussing and yelling at each other. Finally DA B started to leave and told Resident #1 [OBSCENITY] you. The resident responded by saying [OBSCENITY] you! [OBSCENITY] you and your mama [OBSCENITY] !; - DA B turned and spit on the resident, then exited the building. During an interview on 3/25/21 at 10:50 A.M., CNA A said he/she was doing rounds and observed DA B enter the resident's room. There was yelling and cursing, so he/she entered the room. The resident was cursing at DA B and DA B was cursing back. CNA A said Resident #1 and DA B exchanged several [OBSCENITY] you or [OBSCENITY] you [OBSCENITY] . CNA A said DA B drew his/her open hand back in a motion that indicated he/she was going to hit the resident. CNA A grabbed DA B's arm. DA B then turned and spit on the resident. CNA A said DA B then walked out of the room. During an interview on 3/25/21 at 10:49 A.M., LPN C said on 8/21/20 he/she was walking down the hall and heard a commotion. LPN C followed the noise and went in Resident #1's room. Resident #1 was yelling [OBSCENITY] you several times. LPN C said the privacy curtain was closed and he/she did not see anything, but did hear what he/she thought was someone spitting. Directly after DA B and CNA A walked out. During an interview on 3/24/21 at 9:40 A.M., the DON said the resident had cursed DA B and made a derogatory comment regarding the DA's mother, who is very ill. DA B responded by threatening to kick Resident #1's mother[OBSCENITY] ing ass and spitting on the resident. The DON said she felt it was poor customer service not abuse. She said DA B had never had any other problems with any other residents. After the incident, DA B left the building. The DON said LPN C caught up with him/her and DA B was escorted back in to the building straight to the DON's office where he/she was instructed to write out a statement. The DON said he/she arrived at the building in less than 10 minutes and informed DA B he/she was at the very least suspended and could not come back to the facility until further notice. During an interview on 3/25/21 at 11:40 A.M., DA B said he/she had received training on abuse at hire and there had always been monthly in-servicing. DA B said there had been no other confrontations with the resident. The resident had been asking for snacks, but DA B had been cleaning the kitchen. DA B then heard the resident yelling to another staff member about the snacks. DA B said he/she then entered the room and the resident began to curse him/her. Resident #1 called DA B a fat [OBSCENITY] and said you probably eating all the snacks for yourself. Resident #1 also said [OBSCENITY] you and your mother. DA B said he/she replied by saying [OBSCENITY] you too and then spit in the resident's face. After that, DA B said he/she walked straight out of the building. DA B said he/she would have hit the resident if CNA A had not stopped him/her. MO 1

Based on observation, interview and record review, the facility staff failed to conduct elopement risk assessments, implement interventions, and provide adequate supervision and monitoring to ensure one (Resident #1) resident with a history of elopements from the facility of three reviewed residents did not leave without supervision. The resident eloped on 9/9/14 without staff knowledge and attempted to cross a busy street in front of the facility. The facility census was 65. 1. Review of the facility's elopement prevention policy, dated 2009, showed the policy identified that residents with [DIAGNOSES REDACTED]. The policy directed staff to: - Complete accurate and timely assessments and care plans to maintain safety. - Assess each resident for elopement/wandering on admission, at each care plan review and with a change in status. - Develop a plan of care, apply a name band and Wanderguard (a bracelet applied to the resident to alert staff of attempts to leave the facility) or other electronic device to the resident, increase frequency of monitoring and add the resident's name to note book at nurses' and reception desks for residents identified at moderate to high risk for elopement. - Monitor the use of Wanderguards daily. - Complete incident reports any time an elopement occurred. Review of the facility's elopement, risk prevention and management of missing resident's policy, dated 2009, showed the policy directed staff to: - Place the resident on increased supervision and document safety checks each shift following an elopement. - Document all elopement attempts and events, including objective and factual statements regarding circumstances and precipitating factors; reassessment of condition upon return, notification of appropriate parties and implementation of additional prevention strategies. - Complete incident reports and forward them to the Administrator/Risk Management Coordinator. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/11/14, showed staff identified the resident as moderately cognitively impaired and independent with ambulation. Staff did not identify that the resident wandered. Review of the Activity Director's (AD) notes, dated 6/11/13, 9/6/13, 6/4/14 and 9/3/14, showed the AD identified the resident liked to be outdoors. Review of the resident's nurses' notes showed: - On 6/6/13, the resident and his/her roommate had an argument and the resident said he/she was leaving the facility and going home. Resident #1 took his/her belongings and headed for the front door. Staff did not document if the resident left the facility or if any interventions were implemented to reduce the risk of elopement. - On 6/14/13, the resident said he/she needed to leave the facility. - On 4/8/14, the resident said he/she wanted to leave and walked to the front door. - On 4/20/14, an unidentified Certified Nurse Assistant (CNA) reported the resident walked across the road and down the highway. The nurse told the resident he/she was unsafe to leave the parking lot and to let someone know before he/she left the building. Staff notified the Director of Nursing (DON) who said a Wanderguard would be applied when available. Staff did not document if the resident sustained [REDACTED]. - On 4/22/14, staff applied the Wanderguard. - On 4/23/14, the resident did not have a Wanderguard in place. - On 6/7/14 at 3:45 P.M., the resident eloped from the facility and was found walking on Truman Boulevard, (a high traffic area in front of the facility). The resident walked for three blocks before agreeing to return to the facility. At 8:00 P.M., the resident was upset and said he/she wanted to go home. Staff contacted the physician and an order was received to send the resident to a psychiatric hospital. At 10:10 P.M., the resident was transferred to the hospital. - On 6/8/14, the resident returned to the facility. At 5:00 A.M., staff found the resident at the front door and told the resident not to go outside without staff. The resident attempted several times to go outside the facility. The alarm sounded and the resident was redirected into the facility. The resident became very agitated that he/she could not go outside and said multiple times that he/she was going home for a couple of days. Staff documented they observed the resident return to his/her room after each incident. Staff documented a Wanderguard was applied. - On 6/18/14, staff documented the resident's sister passed away a few days prior and Resident #1 continued to attempt to elope from the facility. Staff documented an ankle alarm was intact. - On 6/21/14, the resident sat outside with staff present. The nurse instructed staff to bring the resident in when they came inside. - On 7/6/14, staff documented the resident ambulated without assistance and was alert, but unaware at times. The resident continued to go outside by him/herself but stayed under the awning. When asked to come in, the resident became agitated and aggressive. Staff did not identify the time or frequency of the incidents. - On 7/21/14, an unidentified CNA and the Unit Secretary brought the resident in from outside. The resident said he/she was going home. Staff did not document where the resident was found, if the resident sustained [REDACTED]. - On 9/9/14, the resident was found at the edge of the street in front of the facility. The resident did not sustain injury. The facility discussed the elopement with family, whom provided one-on-one supervision overnight. - On 9/11/14, the facility discharged the resident to another facility. - The nurses' notes did not include additional information related to the elopements nor interventions to reduce the risk of future elopement attempts. Record review of the resident's physician's orders [REDACTED]. The POS did not include physician's orders [REDACTED]. Review of Resident #1's medical record showed staff did not complete an elopement risk assessment, wandering assessment, or daily Wanderguard checks for the resident as directed by the facility's elopement prevention policy. Review of the resident's care plan, updated 9/3/14, showed staff did not plan care to address the resident's elopements or develop interventions to reduce the risk of future elopement attempts. Review of a social service progress note, dated 9/10/14, showed the resident was found out near the street on 9/9/14. The Social Service Designee (SSD) identified the resident as confused and wanted to go home. The resident's family member agreed to stay and provide one-on-one monitoring until the resident was transferred to another facility. The SSD had no other notes pertaining to any previous elopements or what interventions staff used to reduce the risk of elopement. Review of a physician's note, dated 9/10/14, showed the physician identified the resident as confused, was found on the highway and refused treatment at a psychiatric hospital. The resident was transferred to another facility. Review of a nurse's note, dated 9/11/14, showed the facility discharged the resident to another facility. Observation on 9/15/14 showed the front entry door of the facility had a keypad lock system in order to exit the facility. The key pad was to the left of the door with the key pad code posted directly on the key pad. During an interview on 9/15/14 at 11:45 A.M., Housekeeper A said on 9/9/14 Resident #1 was standing at the road with two other people. Resident #1 said he/she wanted to go home. During an interview on 9/15/14 at 11:50 A.M., the Business Office Manager (BOM) said on 9/9/14 CNA B notified her that Resident #1 was by the road with two members of the community. Resident #1 was crying and saying that he/she wanted to go home to be with his/her kids. During an interview on 9/15/14 at 12:00 P.M., CNA C said on 9/9/14 he/she was outside with Resident #1 and another resident. CNA C and the residents went back into the facility. CNA C heard an overhead page a couple of minutes later and he/she reported to the front of the facility and saw the resident outside by a red car with two other people. CNA C recognized one of the people from the community but did not know the other. CNA C said staff had to be with the resident when outside. During an interview on 9/15/14 at 12:15 P.M., the DON said the resident was at risk for elopement as he/she had attempted to leave once before. On 6/8/14, staffed placed a Verichip (electronic alarm) on the resident, however, he/she did not have a Verichip in place at the time of elopement. Staff did not complete an elopement risk assessment or develop a care plan to address the resident's risk of elopement. During an interview on 9/15/14 at 1:10 P.M., Licensed Practical Nurse (LPN) D said the facility identified residents at risk for elopement if they talked about leaving or going home and care plans should reflect elopement risks. The facility doors had alarms on them and the front door had a Wanderguard system which required a code to be entered before anyone could leave the front door. The code was posted on a piece of paper by the front door so that visitors could leave. During an interview on 9/15/14 at 1:15 P.M., the MDS Coordinator said she was not aware of an assessment for elopement risk, but said staff identified residents' risk by charting and reading nurses' notes. Staff applied Wanderguards to residents identified at risk for elopement. The MDS Coordinator said some residents went outside without staff supervision by utilizing the code posted by the front door. During an interview on 9/15/14 at 1:30 P.M., the SSD said Resident #1 was confused at times and wanted to go home. The SSD said the resident had previously attempted to elope in June. The facility's policy was to place a Wanderguard on the resident and watch him/her closely. During an interview on 9/15/04 at 1:45 P.M., LPN E said the interventions for residents at risk for elopement included constantly monitoring and going outside with the residents if needed. During an interview on 9/15/14 at 2:00 P.M., LPN F said if a resident had been identified as at risk for elopement, staff would have reflected the risk on the care plan. Nurses usually informed CNAs of elopement risks. During an interview on 9/15/14 at 2:45 P.M., the DON said staff did not complete documentation that they checked the resident's Wanderguard and/or the facility doors to ensure they worked properly. Staff should have checked the alarms daily and the door weekly. During an interview on 9/15/14 at 2:45 P.M., CNA G said he/she pulled in to the parking lot on 9/9/14 for the 3:00 P.M. shift and saw Resident #1 standing by the street in the ditch. CNA G called the facility and reported the incident. During an interview on 9/16/14 at 8:35 A.M., Resident #1's family member said the resident walked to the street on two other occasions. The family member said the resident had not worn a Wanderguard for a long time. During an interview on 9/16/17 at 10:20 A.M., the resident's Physician said the resident was confused, not safe to be left alone, and required monitoring at all times. The Physician said the resident eloped from the facility three to four months previously and got on the highway. The Physician said the resident would get run over if he/she was in the middle of the street. The Physician said the resident needed to go to a psychiatric hospital for a medication adjustment or go to a facility with a locked unit. During an interview on 9/16/14 at 10:35 A.M., CNA H said staff allowed the resident to go outside without supervision. On one occasion, CNA H found the resident across the street. CNA H reported the incident to the nurse who told him/her to watch the resident. During an interview on 9/16/14 at 10:40 A.M., CNA I said on one occasion he/she found the resident outside on the edge of the parking lot by the street. CNA I said staff applied a Wanderguard but the resident always removed it. During an interview on 9/16/14 at 10:45 A.M., the Unit Secretary said in July she found the resident outside, about halfway across the parking lot. The resident did not have an alarm in place as staff could not keep one on the resident. Complaint #MO 168 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. During the onsite visit, the facility staff completed an elopement risk assessment on all residents. Nursing staff will complete wander/elopement risk assessments at the time of admission, quarterly, and as needed. Results of the assessments will be documented in the resident's chart and care planned as needed. Interventions will be implemented as needed. Immediately a staff member was assigned to monitor the front door exit until a new monitoring system could arrive. The front door code was removed from public view. A policy on elopement prevention was immediately implemented and all staff members were educated on elopement risk prevention and missing residents. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.