Every finding on record at Springfield Rehabilitation & Health Care Center

Based on interview and record review, the facility failed to complete the annual individual performance reviews or evaluations and failed to provide regular in-service education based on these reviews for three certified nurse aides (Certified Nurse Aide (CNA) K, CNA L, and CNA M), out of a sample of six CNAs. The facility census was 117.Review showed the facility did not provide a policy regarding annual individual performance reviews or education for CNAs.1. Review of CNA K's personnel records showed the following:-Hire date of 04/10/24;-Annual performance evaluation due on 04/10/25; -Staff did not document completion of the performance evaluation or education provided to CNA K based on an annual performance evaluation.2. Review of CNA L's personnel records showed the following:-Hire date of 08/22/23;-Annual performance evaluation due on 08/22/25;-Staff did not document completion of the performance evaluation or education provided to CNA L based on an annual performance evaluation.3. Review of CNA M's personnel records showed the following:-Hire date of 09/04/20;-Annual performance evaluation due in September 2021, 2022, 2023, 2024, or 2025;-Staff did not document completion of the performance evaluation or education provided to CNA M based on an annual performance evaluation. 4. During an interview on 04/10/26, at 1:26 P.M., CNA O said the following:-He/she had been working at the facility for over a year;-He/she did not receive an annual performance evaluation. During an interview on 04/10/26, at 1:50 P.M., CNA N said the following:-He/she had worked at the facility for approximately 14 months;-He/she did not receive an annual performance evaluation.During interviews on 04/09/26, at 1:05 P.M., and on 04/10/26, at 9:10 A.M. and 2:30 P.M., the Director of Nursing (DON) said the following:-He/She was responsible for completing the annual performance evaluations for the CNA's;-He/She had not been good at completing annual evaluations, so he/she knew some of them had not been done;-He/She did not know the performance appraisals needed to be tracked;-In January of 2025, the facility started using an electronic system to complete annual evaluations, but he/she had not been consistent in completing the CNA annual evaluations;-Prior to the electronic performance appraisal system being implemented, the facility did not have a performance evaluation system in place, not even in paper format;-He/She had only been addressing concerns in person with the CNA's if an issue is identified rather than completing an annual performance appraisal;-He/She did not have time to complete the annual performance appraisals;-The CNA's annual performance evaluations should be completed annually.During an interview on 04/10/26, at 2:30 P.M., the Administrator said the following:-The facility had a new electronic system to complete the annual performance evaluations;-He expected the CNA annual performance evaluations to be completed annually.

Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff member (Licensed Practical Nurse (LPN) A) spoke in a disrespectful tone and manner when interacting with one resident (Resident #70) resulting in the resident becoming upset. The facility census was 117. Review of the facility policy titled Patient Rights, undated, showed the following:-The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.-A facility must protect and promote the rights of each resident. 1. Review of Resident #70's face sheet (a form used to provide resident information at a quick glance) showed the following:-admission date of 09/26/25;-Diagnoses included muscle weakness, age related cognitive decline (a decline on cognitive function due to age), major depressive disorder (a serious mental health condition characterized by at least two weeks of persistent, severe low mood, loss of interest, and low energy), and anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/02/26, showed the resident was cognitively impaired. Review of the resident's care plan, revised on 04/04/26, showed the following:-Staff should observe for non-verbal symptoms of distress;-Cue to sources of reality orientation as indicated;-Introduce self and role, reorient to room, call light, environment as needed;-Speak clearly and use simple terms, explain procedures prior to beginning. Observation and interview on 04/07/26, at approximately 3:45 P.M., showed the following: -The resident walked with his/her walker near the water/ice cart getting ice in his/her water pitcher;-LPN A approached the ice/water cart and said loudly in a stern voice to the resident you know you are not supposed to get into the ice and water cart;-The resident said, well, there was nobody around to help. The resident said he/she was just getting some ice;-LPN A said you are not allowed to get the ice/water. Staff are to do this. LPN A said he/she was right there at the nurses' station;-The resident became visibly upset and there were other residents sitting near this area;-The resident walked off without his/her walker and water pitcher. The resident had tears in his/her eyes and kept saying he/she didn't do anything wrong and the nurse got onto him/her for no reason;-Registered Nurse (RN) Q followed and walked with the resident to his/her room;-The resident sat in a chair in his/her room and began crying and kept saying he/she didn't deserve that. He/she did not know what he/she did wrong;-LPN A approached the resident's room with the walker and water pitcher and did not say anything to the resident;-The resident then said he/she wanted to use the phone to call his/her family member to come and get him/her;-RN Q gave the resident his/her walker and walked with the resident to the nurses' station to make a call to his/her family member. Observation and interview on 04/07/26, at approximately 4:05 P.M., showed the following: -The resident and RN Q sat in the main dining room where the resident remained visibly upset with tears running down his/her face;-The resident said he/she did not know what he/she did wrong;-RN Q told the resident he/she did not do anything wrong;-The resident said he/she did not want to be in trouble. Tears continued to run down his/her face;-Other residents asked the resident what was wrong. Observation and interview on 04/07/26, at 4:15 P.M., showed the following: -Resident was tearful with red watery eyes and asked if the surveyor was there to arrest him/her;-The resident wiped his/her eyes with tissue papers trying to dry his/her face from the tears;-He/she said he/she did not know what happened just that he/she was accused of something he/she did not do;-Resident said he/she was scared, thought he/she was in trouble, and thought he/she had done something wrong. During an interview on 04/07/26, at 4:20 P.M., LPN A said the following:-Residents are not supposed to get into the ice and water cart;-He/she got up from the nurses' station after the resident had already filled his/her cup with ice and water;-He/she told the resident to ask for help next time;-The resident said he/she could not find anyone to help him/her;-He/she took the resident's water pitcher to close the lid, and the resident became upset, and walked off without the water or his/her walker;-The resident was very upset;-He/she was trying to redirect the resident;-He/she could have just left it alone, snapped the lid on the resident's water pitcher, and took the cart to the kitchen to be cleaned. During an interview on 04/07/26, at 4:18 P.M., RN Q said the following:-The cart that sat on B-hall was the refreshment cart used to pass ice and water to residents;-If a resident approached the refreshment cart, he/she would offer to get ice and/or water for the resident;-Staff wear gloves when handling the ice scoop;-If a resident had already gotten the ice, like what happened with Resident #70, he/she would not say anything and would sanitize the ice bucket if needed. During an interview on 04/09/26, at 11:23 A.M., Certified Nursing Assistant (CNA) C said the following:-He/she believed yelling at or speaking harshly to a resident should be reported to the Nurse or Director of Nursing (DON):-If a resident was doing something that is dangerous or something he/she should not be doing, the aide would intervene by redirecting the resident or asking if the resident needed help, not by yelling or speaking harshly to the resident. During an interview on 04/09/26, at 11:28 A.M., CNA D said the following:-He/she would use redirection if they saw a resident getting into something;-He/she would ask if they needed help to direct their attention elsewhere;-Yelling or speaking down to a resident not appropriate. During an interview on 04/07/26, at 4:13 P.M., RN P said the following:-The ice/water cart that sits at the end of B-Hall is for the staff to pass to residents;-The staff encourage residents not to get into the ice/water cart due to contamination concerns;-If a resident approaches the ice/water cart, staff will tell the resident to let them get that for the resident;-Staff should not scold residents for getting ice/water from the cart;-The resident was alert and oriented with some confusion and required minimal assistance with care.-The resident gets upset if he/she feels like staff are getting onto him/her. During an interview on 04/07/26, at 4:52 P.M., the resident's family member said the facility notified him/her that someone had gotten on to the resident and he/she was upset. During an interview on 04/10/26, at 11:30 A.M., the Director of Nursing (DON) said the following:-He/she expected all staff to be kind with all residents;-Staff should utilize redirection when approaching residents who may be getting into something;-LPN A was concerned with infection control when he/she was stern with the resident and could have approached the situation differently. During an interview on 04/07/26, at 4:31 P.M., the Administrator said the following:-The water/ice cart was for the residents, and they have several independent residents who used it. -Staff usually take the cart down the hall and pass water and ice;-If a resident goes to the cart, staff should offer to help them get ice and water.-Staff should never scold a resident;-Staff should have let the resident get his/her ice and water and then if needed clean the ice/water cart.

Based on interview and record review, the facility failed to ensure all allegation of possible abuse were reported immediately to facility management and to the Department of Health and Senior Services (DHSS) within the required two hour timeframe when staff one resident's (Resident #76) allegation of physical abuse. The facility census was 117.Review of the facility's policy titled Abuse Protection and Response Policy, showed the following:-Abuse, Neglect, and Misappropriation of Patient Property, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center;-Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of abuse if it meets any of the following criteria: any allegation (or) indication of possible willful infliction of injury to include unexplained bruising; unreasonable confinement to include unwanted restriction of access to all patient areas of the building; any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others; any instances of hitting, slapping, pinching, or kicking or other potentially harmful action;-Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, or misappropriation of patient property must report the event immediately;-All alleged violations and all substantiated incidents will be reported immediately to the administrator or her/his designated representative and to other officials in accordance with State and Federal law (including to the State survey and certification agency). All allegations and incidents will be reported to the DHSS within two hours.1. Review of Resident #76's face sheet (a document that gives a patient's information at a quick glance) showed the following:-admission date of 03/21/26;-Diagnoses included diverticulitis (inflammation or infection of small pouches (diverticula) that form in the weak spots of the colon wall), heart disease, and anxiety.Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff,) dated 03/21/26, showed the following:-The resident had severe cognitive impairment;-The resident had no behaviors;-The resident required moderate assistance from staff for upper body dressing and personal hygiene and was dependent on staff to shower, toilet and for lower body dressing;-The resident required moderate to maximum assistance from staff for bed mobility and was dependent on staff to transfer.Review of the resident's care plan, dated 04/03/26, showed the following:-The resident had a cognitive deficit. Allow the resident time to process what was said and give a response. Ask yes or no questions when indicated. Keep all communication simple when the resident was overwhelmed;-The resident had a cognition and communication deficit related to a history of a brain abscess (a life-threatening, pus-filled, and inflamed swelling within the brain tissue, often resulting from bacterial or fungal infections, trauma, or surgery) with residual deficits. The resident was able to make his/her needs known. The resident had a short-term memory problem; -The resident had an activities of daily living (ADL - dressing, eating, bathing, etc.) deficit and required moderate assistance with ADL's related to lower extremity weakness while he/she recovered from diverticulitis. Review of the resident's nurse's progress note dated 03/29/26, at 5:38 P.M., showed Registered Nurse (RN) H documented the following:-The resident received skilled nursing services related to diverticulitis. The resident was cooperative upon approach. The resident had no report of unrelieved pain or discomfort. The resident was alert and oriented to person, place and time. His/her lungs were clear to auscultation (no abnormal breath sounds), respirations were even and unlabored. Staff did not observe a cough and no one reported a cough;-The resident did experience some shortness of breath around 4:00 P.M. The resident said he/she could not breathe and reported being strangled by someone who was in his/her room. Nobody was in the room with the resident at the time;-The resident's SpO2 (oxygen (O2) saturation in the blood) read 75% (normal is over 90%) per the certified nursing assistant (CNA). Staff obtained oxygen and the resident's SpO2 increased to 95% at the time but the resident still demonstrated shortness of breath. Staff applied O2 at one liter using a nasal canula which helped.(The RN did not document reporting the allegation of possible abuse to management or DHSS.)Review of DHSS records showed the facility did not self-report the allegation of possible abuse. During an interview on 04/08/26, at 9:37 A.M., RN H said the following:-On 03/29/26, the resident did allege abuse to him/her;-RN H did not document he/she reported to anyone so he/she cannot say that he/she did for sure;-RN H believed he/she reported the allegation;-The allegation made by the resident should have been reported to DHSS within two hours and law enforcement should have been notified;-He/she should have notified the resident's physician and responsible party;-Types of abuse included physical, emotional, verbal and neglect;-If a resident reported abuse to a CNA or Certified Medication Tech (CMT), they reported it to the charge nurse immediately;-The charge nurse reported to social services immediately and wrote a progress note;-The charge nurse notified the resident's physician and responsible party;-Social services reports it to DHSS; -If a resident reported that someone strangled them, he/she considered that abuse and would report that to social services immediately;-The allegation should be reported to DHSS;-All allegations of abuse were reported. During an interview on 04/08/26, at 9:21 A.M., Licensed Practical Nurse (LPN) G said the following:-The allegation made by the resident should have been passed on to be followed up on;-The way he/she read the nurse's progress note, he/she considered this an allegation of abuse that should have been reported to DHSS;-The resident's mental status should not affect whether the allegation was reported;-Types of abuse included verbal, mental, physical, elder and financial;-If a resident reported abuse to a CNA or a CMT, they immediately reported the allegation to the charge nurse;-The charge nurse immediately reported the allegation to the Director of Nursing (DON);-The DON reported allegations of abuse to DHSS within 24 hours;-The charge nurse assessed the resident and notified the resident's responsible party and physician;-The DON or charge nurse notified law enforcement;-All allegations of abuse were reported to DHSS;-If a resident reported someone strangled them in their room, he/she considered that physical abuse and should be reported to DHSS.During an interview on 04/08/26, at 9:07 A.M., CNA E said the following:-Types of abuse included emotional, physical, verbal, neglect and financial;-If a resident reported abuse to him/her, he/she reported it to the charge nurse immediately;-The charge nurse assessed the resident and reported it to the DON;-The DON reported allegations of abuse to DHSS immediately;-All allegations of abuse were reported;-If a resident reported to him/her that someone strangled them in their room, he/she considered this abuse and would report this immediately and the facility would be required to report the allegation to DHSS.During an interview on 04/08/26, at 9:14 A.M., CNA F said the following:-Types of abuse included misappropriation, neglect, sexual, verbal, mental and physical;-If a resident reported abuse to him/her, he/she reported it to the charge nurse immediately;-The charge nurse filled out an abuse report and sent the report to the DON;-The charge nurse, Assistant Director of Nursing (ADON), DON, or Administrator reported it to DHSS within two hours;-If a resident reported to him/her that someone strangled them in their room, he/she considered this an allegation of physical abuse and reported the allegation;-The facility should report the allegation to DHSS;-The facility should report all allegations of abuse to DHSS.During an interview on 04/09/26, at 4:56 A.M., RN I said the following:-Types of abuse included physical, neglect, mental, psychological, verbal, sexual and financial;-If a resident reported abuse to a CNA or CMT, they reported it to the charge nurse immediately;-The charge nurse reported it to the DON or supervisor in the building immediately;-The charge nurse, supervisor or DON reported it to DHSS immediately after they ensured the resident was safe;-The charge nurse notified the resident's responsible party and physician;-If a resident reported someone strangled them in their room, he/she considered that an allegation of physical abuse and reported that immediately to the Administrator and DHSS.During an interview on 04/10/26, at 9:57 A.M., CMT J said the following:-Types of abuse included verbal, physical, sexual, neglect and financial;-If a resident reported abuse to him/her, he/she immediately reported it to the charge nurse and if the report was about the charge nurse, he/she reported it to the ADON or DON;-The charge nurse reported it to the DON immediately;-The DON or Administrator reported it to DHSS within two hours;-All allegations of abuse were reported to DHSS even if the resident who made the allegation had dementia;-If a resident reported someone strangled them in their room, he/she considered this an allegation of physical abuse and would report it immediately;-If a resident made that allegation, the allegation should have been reported to DHSS.During an interview on 04/10/26, at 2:13 P.M., the DON said the following:-He/she expected staff to immediately report all allegations of abuse after they ensured the resident was safe;-RN H did not report the allegation made by the resident to her;-If a resident reported someone strangled them he/she considered this an allegation of abuse and should be reported to DHSS within two hours;-Staff should notify the resident's physician and responsible party if a resident made an allegation of abuse;-All allegations of abuse have to be reported to DHSS.During interviews on 04/08/26, at 9:55 A.M., and on 04/10/26, at 2:13 P.M., the Administrator said the following:-If someone was in the resident's room when the resident made the allegation of being strangled, he/she would consider it an allegation of abuse;-The resident had severe cognitive impairment;-The allegation was not reported to him;-The leadership team was responsible for ensuring staff knew when to report allegations of abuse;-He expected staff to report allegations of abuse immediately and was responsible for ensuring allegations of abuse were reported to DHSS.

Based on interview and record review, the facility failed to ensure all allegations of abuse were investigate when staff failed to complete an investigation of an allegation of physical abuse made by one resident (Resident #76). The facility census was 117.Review of the facility's policy titled Abuse Protection and Response Policy, undated, showed the following:-Abuse, Neglect, and Misappropriation of Patient Property, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center;-All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of patient property did or did not take place. The Administrator or Director of Nurses (DON) will determine the direction of the investigation once notified of alleged incident;-The investigation is conducted immediately under the following circumstances: when it is identified that an alleged incident may have occurred and as soon as any partner has knowledge and reports an alleged event;-When there is question as to whether to conduct an investigation, it is best to do so;-The results of all investigations will be completed within five working days of the incident. Depending on the result of the investigation all necessary corrective actions will be taken;-Allegations of abuse, neglect, or misappropriation of patient property will trigger an internal investigation following the protocol of the Untoward Events Policy and Procedure;-Trends of investigative findings will be analyzed and addressed by the Quality Improvement (QI) committee process.1. Review of Resident #76's face sheet (a document that gives a patient's information at a quick glance), showed the following:-admission date of 03/21/26;-Diagnoses included diverticulitis (inflammation or infection of small pouches (diverticula) that form in the weak spots of the colon wall), heart disease, and anxiety.Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 03/21/26, showed the following:-The resident had severe cognitive impairment;-The resident had no behaviors;-The resident required moderate assistance from staff for upper body dressing and personal hygiene and was dependent on staff to shower, toilet and for lower body dressing;-The resident required moderate to maximum assistance from staff for bed mobility and was dependent on staff to transfer.Review of the resident's care plan, dated 04/03/26, showed the following:-The resident had a cognitive deficit. Allow the resident time to process what was said and give a response. Ask yes or no questions when indicated. Keep all communication simple when the resident is overwhelmed;-The resident had a cognition and communication deficit related to a history of a brain abscess (a life-threatening, pus-filled, and inflamed swelling within the brain tissue, often resulting from bacterial or fungal infections, trauma, or surgery) with residual deficits. The resident was able to make his/her needs known. The resident had a short-term memory problem. Staff should introduce self and role, reorient the resident to his/her room, call light and environment as needed. Speak clearly and use simple terms;-The resident had an activities of daily living (ADL - dressing, eating, bathing, etc.) deficit and required moderate assistance with ADL's related to lower extremity weakness while he/she recovered from diverticulitis. Assist the resident with toileting and incontinence care as needed. The resident required one to two staff assistance. Encourage independence as much as possible.Review of the resident's nurse's progress note dated 03/29/26, at 5:38 P.M., showed Registered Nurse (RN) H documented the following:-The resident received skilled nursing services related to diverticulitis. The resident was cooperative upon approach. The resident had no report of unrelieved pain or discomfort. The resident was alert and oriented to person, place and time. His/her lungs were clear to auscultation (no abnormal breath sounds), respirations were even and unlabored. Staff did not observe a cough and no one reported a cough;-The resident did experience some shortness of breath around 4:00 P.M. The resident said he/she could not breathe and reported being strangled by someone who was in his/her room. Nobody was in the room with the resident at the time. The resident's SpO2 (oxygen (O2) saturation in the blood) read 75% (normal is above 90%) per the certified nursing assistant (CNA). Staff obtained oxygen and the resident's SpO2 increased to 95% at the time but the resident still demonstrated shortness of breath. Staff applied O2 at one liter using a nasal canula which helped.(Staff did not document beginning an investigation into the resident's allegation of abuse. )Review of DHSS records showed the facility did not provide an investigation of the resident's allegation of abuse. During an interview on 04/08/26, at 9:37 A.M., RN H said the following: -Allegation the resident made to him/her on 03/29/26 was considered an allegation of abuse and should have been investigated;-Types of abuse included physical, emotional, verbal and neglect;-Social services investigated allegations of abuse;-All allegations of abuse were investigated in house;-If a resident reported someone strangled them, he/she considered that an allegation of abuse and it should be investigated.During an interview on 04/08/26, at 9:21 A.M., Licensed Practical Nurse (LPN) G said the following: -Allegation the resident made about someone strangled him/her in his/her room should have been investigated;-Types of abuse included verbal, mental, physical, elder and financial;-Abuse investigations started with the charge nurse;-The Assistant Director of Nurses (ADON), DON and social services assisted with the investigation;-All allegations of abuse were investigated;-If a resident reported someone strangled them in their room, he/she considered that physical abuse and it should be investigated.During an interview on 04/08/26, at 9:07 A.M., Certified Nursing Assistant (CNA) E said the following:-Types of abuse included emotional, physical, verbal, neglect and financial;-All allegations of abuse were investigated;-The charge nurse and DON investigated allegations of abuse;-If a resident reported that someone strangled them in their room, he/she considered this abuse, and the DON or Administrator should investigate the allegation.During an interview on 04/08/26, at 9:14 A.M., CNA F said the following:-Types of abuse included misappropriation, neglect, sexual, verbal, mental and physical;-The DON and Administrator investigated all allegations of abuse;-If a resident reported to him/her that someone strangled them in their room, he/she considered this an allegation of physical abuse that should be investigated. During an interview on 04/09/26, at 4:56 A.M., RN I said the following:-Types of abuse included physical, neglect, mental, psychological, verbal, sexual and financial;-The ADON, DON and Administrator investigated all allegations of abuse;-If a resident reported someone strangled them in their room, he/she considered that an allegation of physical abuse that should be investigated.During an interview on 04/10/26, at 9:57 A.M., Certified Medication Technician (CMT) J said the following:-Types of abuse included verbal, physical, sexual, neglect and financial;-The DON and Administrator investigated all allegations of abuse even allegations made by residents who had dementia;-If a resident reported someone strangled them in their room, he/she considered that an allegation of physical abuse that should be investigated.During an interview on 04/10/26, at 2:13 P.M., the DON said the following:-The allegation made by the resident (of being strangled) should have been investigated;-He/she had not completed an investigation related to the allegation;-All allegations of abuse were investigated by the DON, ADON and social services.During interviews on 04/08/26, at 9:55 A.M., and on 04/10/26, at 2:13 P.M., the Administrator said the following:-The allegation made by the resident (of being strangled) should have been investigated;-The leadership team was responsible for ensuring staff knew when to report allegations of abuse so they could be investigated;-He was responsible for ensuring allegations of abuse were investigated.

Based on observation, interview, and record review, the facility failed to ensure all residents received pain management consistent with standards of practice when staff failed to consistently administer pain medications in a timely manner to one resident (Resident #112). The facility census was 117.Review of a facility policy entitled Preparation and General Guidelines: Medication Administration-General Guidelines, revised 02/25/25, showed the following:-The facility has staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions;-Medications are administered in accordance with written orders of the prescriber;-Medications are administered without unnecessary interruptions;-A schedule of routine dose administration times is established by the facility and utilized on the administration records;-Medications are administered within 60 minutes before or after the medication administration record (MAR) scheduled times where possible;-Documented administration should be after the administration.1. Review of Resident #112's face sheet (brief look at resident information) showed the following information:-admission date of 02/16/26;-Diagnoses included fractures of lower end of radius (one of the two long bones in the forearm), dislocation of right hip, long-term opioid (a class of drugs used as pain relievers) use, anxiety (mental health condition characterized by excessive worry and fear), depression, chronic pain syndrome (a condition where pain lasts longer than 3-6 months), post-traumatic stress disorder (PTSD-mental health condition triggered by experiencing or witnessing terrifying, life-threatening events), osteoarthritis (a joint disease where cartilage breaks down over time causing pain, stiffness, and joint damage), fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties), and muscle spasms (a sudden, involuntary, and often painful contraction of one or more muscles). Review of the resident's physician order sheet (POS) showed an order, dated 02/16/26, for oxycodone-acetaminophen (APAP) 5-325 milligram (mg) (Percocet - medication used to treat moderate to severe acute pain), give two tablets every four hours as needed by mouth.Review of the resident's care plan, revised on 02/18/26, showed the following information:-Prescribed oxycodone/APAP as needed to help manage acute pain related to right hip dislocation and right wrist fracture;-Pain will be managed at patient's tolerable level;-Administer medications as ordered;-Required moderate assistance with activities of daily living (ADL) related to pain and limited mobility while recovering from a right hip dislocation/fracture and right wrist fracture. Review of the resident's POS, showed an order, dated 02/23/26, for methocarbamol (used to relieve the discomfort caused by acute (short-term), painful muscle or bone conditions) 750 mg tablet for muscle spasms, give one tablet every twelve hours, at 7:00 A.M. and 7:00 P.M.Review of the resident's March 2026 MAR showed methocarbamol 750 mg tablet scheduled to be administered every twelve hours with the morning dose scheduled for 7:00 A.M. Staff administered the medication as follows:-On 03/02/26, staff documented administration at 9:16 A.M.;-On 03/04/26, staff documented administration at 9:21 A.M.Review of the resident's March 2026 MAR showed staff administered oxycodone-acetaminophen 5-325 mg, two tablets, on 03/06/26, at 8:44 A.M. and 2:59 P.M. Both times the resident reported a pain level of seven on a scale of zero to ten.Review of a progress note dated 03/06/26, at 3:26 P.M., showed the following:-The resident verbalized a complaint of pain and was upset that his/her midday pain medication was not given;-The registered nurse (RN) reviewed pain medication orders with the resident;-The resident said the medication technician was late with his/her pain pill;-The RN reinforced education that Percocet was ordered as needed and the resident had to request it, otherwise it would not be given;-The resident requested that the medication technician be instructed to give his/her medication when first requested;-Information was shared with the medication technician.Review of the resident's March 2026 MAR showed methocarbamol 750 mg tablet scheduled to be administered every twelve hours with the morning dose scheduled for 7:00 A.M. Staff administered the medication as follows:-On 03/13/26, staff documented administration at 10:25 A.M.;-On 03/16/26, staff documented administration at 11:16 A.M.;-On 03/17/26, staff documented administration at 10:07 A.M.;-On 03/18/26, staff documented administration at 10:24 A.M.;-On 03/19/26, staff documented administration at 11:11 A.M.;-On 03/20/26, staff documented administration at 10:21 A.M;-On 03/25/26, staff documented administration at 10:15 A.M.;-On 03/26/26, staff documented administration at 9:49 A.M.;-On 03/27/26, staff documented administration at 10:23 A.M.;-On 03/28/26, staff documented administration at 10:19 A.M.;-On 03/29/26, staff documented administration at 10:16 A.M.;-On 03/30/26, staff documented administration at 9:26 A.M.;-On 03/31/26, staff documented administration at 11:11 A.M.Review of the resident's April 2026 MAR showed methocarbamol 750 mg tablet scheduled to be administered every twelve hours with the morning dose scheduled for 7:00 A.M. Staff administered the medication as follows:-On 04/01/26, staff documented administration at 10:11 A.M.;-On 04/02/26, staff documented administration at 10:32 A.M. Review of the resident's POS, showed an order, dated 04/02/26, for oxycodone-acetaminophen 5-325 mg tablet for post laminectomy syndrome (a surgical procedure the removes the back part of a vertebra to widen the spinal canal, give two tablets by mouth every twelve hours 9:00 A.M. and 9:00 P.M.Review of the resident's April 2026 MAR showed the following: -Methocarbamol 750 mg tablet scheduled to be administered every twelve hours with the morning dose scheduled for 7:00 A.M;-Oxycodone-acetaminophen 5-325 tablet, give two tablets, was scheduled to be administered every twelve hours with the morning dose scheduled for 9:00 A.M.;-On 04/03/26, staff documented administration of both medications at 10:47 A.M.;-On 04/04/26, staff documented administration of both medications at 10:13 A.M.;-On 04/05/26, staff documented administration of both medication at 10:51 A.M.During an observation and interview on 04/07/26, at 9:58 A.M., the resident said he/she called for his/her pain medication about an hour ago, but the nurse had not brought it him/her. He/She had pain in his/her neck and right arm. The resident was observed in bed with a neck pillow placed around his/her neck.Review of the resident's April 2026 MAR showed the following:-Methocarbamol 750 mg tablet scheduled to be administered every twelve hours with the morning dose scheduled for 7:00 A.M.;-Oxycodone-acetaminophen 5-325 tablet, give two tablets, scheduled to be administered every twelve hours with the morning dose scheduled for 9:00 A.M.;-On 04/07/26, staff documented administration of both medications at 10:14 A.M. on 04/07/26.During an interview and observation on 04/08/26, at 9:58 A.M., the resident said he/she should have received his/her pain medication at 9:00 A.M., but he/she had not received it yet. He/She had pain in his/her neck and right shoulder. He/She rested in bed with a neck pillow around his/her neck. Review of the resident's April 2026 MAR showed the following: -Oxycodone-acetaminophen 5-325 tablet, give two tablets, scheduled to be administered every twelve hours with the morning dose scheduled for 9:00 A.M.;-On 04/08/26, staff documented administration at 10:03 A.M. on 04/08/26.During an interview on 04/06/26, at 10:59 A.M., the resident said the following:-He/She had pain related to numerous injuries from a recent fall at home and he/she had issues getting his/her pain medications;-Getting pain medications had been a constant problem since he/she admitted to the facility;-He/She was not receiving his/her pain medications on time;-His/Her pain medications were scheduled for certain times, and he/she gets them one to two hours later than the scheduled time.During an interview on 04/10/26, at 11:43 A.M., Certified Medication Technician (CMT) J said the following:-The resident has let him/her know several times that his/her pain medications were late;-The resident has complained about late medications every day;-He/She would try to administer the resident's pain medications before he/she complained, but the resident's room was located at the end of the hall and the residents at the end of the hall receive their medications last;-The resident did frequently request pain medication from him/her;-Scheduled medication should be administered within one hour before or one hour after the scheduled time;-It would be considered a medication error if staff administered a scheduled medication outside the one hour before or one hour after timeframe the medication was scheduled for;-If a medication is administered late, he/she documented the late administration in the resident's electronic medical record;-The residents at the end of the hall that he/she worked on received their medications last;-Residents that resided on the B and C hall typically received their medications late.During an interview on 04/10/26, at 12:06 P.M., CMT C said the following:-The medications that are scheduled for 8:00 A.M. and 9:00 A.M. on the B hall where the resident resided were typically administered late;-The resident gets upset with him/her because it seems like forever before he/she gets to him/her with his/her medications;-He/She thought there was a communication issue with staff, and the resident did not get his/her pain medications as soon as he/she would like;-Staff did not tell him/her that the resident requested pain medication, so he/she did not know to administer the pain medication when the resident requested it;-The resident complained about pain constantly;-After the resident's pain medication changed from as needed to a scheduled time, he/she tried to get his/her pain medication to him/her on time, but he/she still administered it late because the residents on the hall the resident resides on typically receives their medications late;-Scheduled medication should be administered within one hour before or one hour after the scheduled time;-It would be considered a medication error if staff administered a scheduled medication outside the one hour before or one hour after timeframe of the scheduled medication time;-He/She notified the nursing staff when he/she is late passing medications;-He/She documented late medication administrations in the resident's electronic medical record;-Several residents complained about their medications being administered late.During an interview on 04/10/26, at 12:45 P.M., Registered Nurse (RN) P said the following:-The B Hall where the resident resided had the most residents and the residents at the end of the hall receive their medications last, so the medications may be late;-The resident had complained to him/her about late medications in the past, but has not complained about it as much lately;-The resident had several recent injuries, but he/she was not sure what the specific injuries are.During an interview on 04/10/26, at 12:45 P.M., Registered Nurse (RN) P said the following:-Scheduled medication should be administered within one hour before or one hour after the scheduled time;-Scheduled pain medications should be administered on time;-If pain medications were administered outside of the one hour before or one hour after scheduled time, it would be considered a medication error.During an interview on 04/10/26, at 2:30 P.M., the Director of Nursing (DON) said the following:-The resident complained of pain a lot;-He/She initially had pain medication scheduled as needed, but the facility recently had the pain medications scheduled due to the number of complaints the resident made regarding pain;-Scheduled medications should be administered within one hour of the time it is scheduled to be administered;-Medications scheduled as needed should be administered as soon as possible.During an interview on 04/10/26, at 2:30 P.M., the Administrator said the following:-Scheduled medications should be administered within one hour of the time it is scheduled to be administered;-Medications scheduled as needed should be administered as soon as possible.

Based on observation, interview, and record review, the facility failed to implement a pain management program that managed resident pain effectively when staff failed to address one resident's (Resident #1) on-going pain and when staff failed to address one resident's (Resident #2) behavioral indications of pain. The facility census was 121.Review of the facility policy Pain-Clinical Protocol, dated 2001, showed the following:-The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain such as degenerative joint disease, rheumatoid arthritis, osteoporosis, post-stroke syndromes;-The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain;-The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity;-Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level;-The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated such as wound care, ambulation, or repositioning;-The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life;-Staff will reassess the individual's pain at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living, sleep patter, mood, behavior, and participation in activities;-The staff will evaluate and report the resident's use of standing and PRN analgesics: depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding nonpharmacological measures.1. Review of Resident #1's face sheet (admission information at a glance) showed the following:-admission date of 11/18/24;-Diagnoses included rheumatoid arthritis (a chronic inflammatory disorder which causes joint pain, swelling, and stiffness and inflammation in other parts of the body) with rheumatoid factor of multiple sites without organ or systems involvement, neuralgia (pain caused by damaged or irritated nerves and causes sensitivity of the skin, numbness, tingling, or other unpleasant sensations), and neuritis (inflammation of one or more peripheral nerves that can cause pain, numbness, tingling, or weakness in the area). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 5/28/25, showed the following:-Cognitive skills were intact and made decisions;-On scheduled pain medication and received as needed (PRN) pain medication;-Had frequent pain that affected sleep and interfered with day to day activities;-A numeric pain level of 6 (indicating moderate pain);(Staff did not assess for indicators of pain such as non-verbal sounds such as crying, gasping, moaning, or groaning, whining, vocal complaints such as that hurts, ouch, stop, facial expressions such as grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw, protective body movements or postures such as bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement. Staff did not assess for indicator of pain or possible pain in the last 5 days such as indicators of pain observed 1 to 2 days, 3 to 4 days, or observed daily.)Review of the resident's pain assessment, dated 05/28/25, showed the following:-Received scheduled pain medications and had received medications in the past five days;-The resident received PRN pain medications or was offered and/or declined pain medications in the past 5 days;-Had not received any non-medication intervention for pain in the last 5 days;-Had frequent pain in the past 5 days;-Had not limited participation in rehabilitation therapy sessions in past 5 days because it did not apply;-Had pain which frequently limited day-to-day activities;-Pain intensity 6 (0-10 pain scale) over the past 5 days;(Staff did not assess the intensity (mild, moderate, severe, very severe, horrible, unable to answer, not assessed) of the resident's worst pain over the last 5 days. The staff assessment for pain was not conducted.)Review of the resident's care plan, revised 05/29/25, showed the following:-Resident had chronic pain related to rheumatoid arthritis (RA);-Pain will be managed at resident's tolerable level;-Administer medications as ordered and assess effectiveness, assess for pain, and intervene as indicated including non-pharmacological interventions to manage pain and assisting with positioning for comfort.Review of the resident's current Physician Orders showed the following:-An order, dated 01/14/25, for gabapentin (for seizures and a pain reliever for certain conditions in the nervous system);-An order, dated 01/16/25, for cyclobenzaprine (muscle relaxant to treat muscle spasms associated with painful musculoskeletal conditions and typically used short-term). Review of the resident's pain screen every shift (day and evening shift) showed the following:-On 06/01/25, day shift pain was assessed as a 4 and night shift pain was assessed at a 6;-On 06/02/25, day shift pain was assessed at a 4 and night shift pain was assessed at a 5;-On 06/03/35, day shift pain was assessed at a 4 and night shift pain was assessed at a 5;-On 06/04/25, day shift pain was assessed at a 4 and night shift pain was assessed at a 4;-On 06/05/25, day shift pain was assessed at a 3 and night shift pain was assessed at a 2.Review of the resident's current Physician Orders showed the following:-An order, dated 06/06/25, for hydrocodone-acetaminophen (narcotic for moderate pain) 5-325 mg one tablet every eight hours and scheduled at 6:00 A.M., 2:00 P.M., and 10:00 P.M.;-An order, dated 06/06/25, for hydrocodone-acetaminophen 5-325 mg one tablet every four hours prn for pain. Review of the resident's pain screen every shift (day and evening shift) showed the following:-On 06/06/25, day shift pain was assessed at a 5 and night shift pain was assessed at a 5;-On 06/07/25, day shift pain was assessed at a 4 and night shift pain was assessed at a 5;-On 06/08/25, day shift pain was assessed at a 4 and night shift pain was assessed at a 5;-On 06/09/25, day shift pain was assessed at a 4 and night shift pain was assessed at a 10;-On 06/10/25, day shift pain was assessed at a 2 and night shift pain was assessed at a 5. Review of the resident's June 2026 PRN Medication Administration Record (MAR), showed the following:-On 06/10/25, at 2:13 P.M., staff administered hydrocodone-acetaminophen 5-325 mg tablet for pain assessed at a 6 for generalized pain which was noted a somewhat effective for pain relief;-On 06/10/25, at 7:12 P.M., staff administered hydrocodone-acetaminophen 5-325 mg one tablet for pain assessed at a 5 for pain all over which was noted as effective. Review of the resident's progress notes dated 06/10/25, at 8:15 P.M., showed staff documented the resident continued to complain of pain and was medicated with scheduled pain medications and PRN pain medications. Resident's appetite was very poor. Staff encouraged resident to eat and eat unassisted when he/she will accept food. Review of the facility's wound report, dated 06/11/25, showed the resident had a pressure ulcer Stage III (a full thickness tissue loss) on the coccyx (tail bone) that measured 0.4 centimeters (cm) length by 0.4 cm width by 0.3 cm depth. Review of the resident's pain screen every shift (day and evening shift) showed on 06/11/25, day shift pain was assessed at a 4 and night shift pain was assessed at a 6. Review of the resident's PRN MAR showed on 06/11/25, at 4:10 P.M., staff administered hydrocodone-acetaminophen 5-325 mg tablet for pain assessed at a 5 for generalized pain which was noted as somewhat effective for pain relief. Review of the resident's pain screen every shift (day and evening shift) showed the following:-On 06/12/25, day shift pain was assessed at a 4 and night shift pain was assessed at a 4;-On 06/13/25, day shift pain was assessed at a 3 and night shift pain was assessed at a 10 Observation and interview on 06/13/25, at 11:45 A.M., showed the resident was in bed and wore a hospital gown. He/she had a pillow behind his/her right side. The resident said he/she had a sore on his/her bottom. Staff did come in and check him/her every two hours and change his/her position. Observation and interview on 06/13/25, at 11:50 A.M., showed the following:-Certified Nurse Aide (CNA) A said the resident had rheumatoid arthritis and his/her whole body hurt;-The resident said he/she was in pain and that his/her right hand was stiff. Both the resident's hands were drawn up to his/her chest in bed while lying on his/her side and fingers were curled and clenched. CNA A checked the resident who was incontinent with urine. When CNA A touched the resident, the resident winced and said it hurts as CNA A moved the resident slowly to check the incontinence brief;-When surveyor asked level of pain from 0-10 with 10 being highest level of pain, the resident said 10;-At 11:55 A.M., Certified Medication Technician (CMT) B came into the room and offered a hydrocodone 5/325 mg one tablet for pain. He/she said this was the first pain medication administered to the resident today because he/she did not ask for a pain medication earlier when he/she administered the resident's morning medications;-At 11:56 A.M., the residents said his/her knees hurt and as CNA A helped move his/her legs to remove the wet incontinence brief and provide perineal care to the resident, the resident kept grimacing with open mouth and lightly huffing. The resident said, He/she hurts all over especially his/her knees but also arms and legs and I wish I could get something stronger for pain as CNA A provided cleansing to the perineal area. CNA A asked resident about moving the pillows under his/her knees so he/she could turn the resident. The resident said when staff turned him/her, he/she felt dizzy. With each move, the resident grimaced and lightly huffed as CNA performed the perineal care slowly;-During the perineal care, the resident kept groaning, eyes were shut, brow furrowed, and made verbal noises huh .huh with each time CNA A moved him/her. CNA A moved slowly and spoke quietly to the resident during the care.Review of the resident' June 2025 PRN MAR showed on 06/13/25, at 11:57 A.M., staff administered hydrocodone-acetaminophen 5-325 mg tablet for pain assessed at a 10 for the resident's knees and documented as effective for pain relief. During an interview on 06/13/25, at 12:19 P.M., the resident said he/she did not think about asking for pain medication all the time. Sometimes he/she just deals with it. He/she said the pain level was now down to level 7 (moderate to severe pain level). The physician comes but only will give hydrocodone to him/her, and it doesn't help at all. They do give him/her a medication for muscle spasms, but he/she gets cramps in his/her feet routinely. Observation and interview on 06/13/25, at 1:52 P.M., showed the following:-Registered Nurse (RN) C entered the resident's room to do the resident's wound care. RN C did not ask the resident about pain;-The resident lay on his/her right side;-RN C asked the resident to turn more on the right side to do the dressing change;-The resident raised his/her head and said, the room is spinning and said when he/she raised his/her head, things spin;-RN C began to pull the dressing off the resident's coccyx and the resident began to blow and said who, who and hurts;-RN C cleansed the area with wound cleanser with gauze and when he/she wiped the area, the resident made ooh, ooh sounds and breathing increased. When RN C packed the wound, the resident said, Oh, oh, it hurts.;-CNA A entered the room to assist RN C. He/she held the resident over more on the right side for the nurse to put on the dressing on and tape it;-CNA A asked to turn the resident to the left side and the resident said he/she wanted to remain on the right side.Review of the resident's pain screen every shift (day and evening shift) showed on 06/14/25, day shift pain was assessed as a 4 and night shift pain was assessed at a 4. Review of the resident's PRN MAR showed on 06/14/25, at 4:00 A.M., staff administered hydrocodone-acetaminophen 5-325 mg tablet for pain assessed at a 6 for pain all over and noted a documented as somewhat effective for all over pain relief.Review of the resident's pain screen every shift (day and evening shift) showed on 06/15/25, day shift pain was assessed as a 4 and night shift pain was assessed as no pain. Review of the resident's PRN MAR showed on 06/15/25, at 7:25 P.M., staff administered hydrocodone-acetaminophen 5-325 mg tablet pain assessed at an 8 for generalized pain which and noted as somewhat effective pain relief.Review of the resident's pain screen every shift (day and evening shift) showed on 06/16/25, day shift pain was assessed as a 5 and night shift pain was assessed as a 5 or 6. Review of the resident's PRN MAR, dated 06/16/25, showed the following:-At 10:53 A.M., staff administered hydrocodone-acetaminophen 5-325 mg one tablet for pain assessed at a 5 and noted as effective;-At 7:31 P.M., staff administered hydrocodone-acetaminophen 5-325 mg one tablet for assessed at a 6 for general pain and noted as effective. Review of the resident's pain screen every shift (day and evening shift) showed on 06/17/25, day shift pain was assessed as a 4.Observation and interview on 06/17/25, at 8:45 A.M. showed the following:-The resident was lying in bed on his/her side. He/she said he/she didn't go to sleep until 3:30 A.M;-He/she said his/her pain level was currently an 8 and he/she did take a pain medication earlier but it still hurt all over;-To alleviate some pain, he/she will rock a little bit and exhibited moving his/her head and shoulders slightly back and forth. He/she said it hurt all the time and did not go away. -The hydrocodone does not work for him/her and they keep giving it to him/her;-He/she had told the physician that the hydrocodone was not helping his/her pain and would like something different than hydrocodone, but they still give it to him/her.During an interview on 06/17/25, at 8:50 A.M., Certified Medication Tech (CMT) B said the following:-He/she administered a hydrocodone-acetaminophen 5 mg/325 mg at 6:00 A.M to the resident;-The resident will request pain medication when he/she wants it;-On 6/16/25, he/she gave the hydrocodone-acetaminophen 5/325mg one tablet at 10:50 A.M. and another scheduled hydrocodone-acetaminophen at 1:00 P.M. to the resident;-The hydrocodone-acetaminophen does not work for the resident. They had increased the hydrocodone-acetaminophen and then lowered it;-He/she assessed for pain with the pain scale and if they can verbalize the pain level, he/she will document this.During an interview on 06/17/25, at 9:23 A.M., Licensed Practical Nurse (LPN) F said the following:-The resident had arthritic pain and had both scheduled and PRN pain medication;-The resident did not want staff to move him/her because it hurt;-It hurts to turn and reposition him/her even with taking different strengths of medications;-The resident asked for pain medications and both scheduled and PRN would benefit him/her;-The resident did have hydrocodone-acetaminophen 10mg and then physician changed it back to hydrocodone-acetaminophen 5mg.During an interview on 06/17/25, at 9:44 A.M., RN G said the following:-The resident had rheumatoid arthritis and chronic pain;-The resident's functional level decreased, was contracted in extremities, causing severe pain to turn and does not want to get up, and had weight loss;-The resident was on scheduled hydrocodone-acetaminophen.During an interview on 06/17/25, at 10:10 A.M., RN H said the following:-The resident had rheumatoid arthritis and knew the resident had pain and it was never completely gone;-They had asked the physician for something different for pain, but the pain was not controlled;-The resident had hydrocodone-acetaminophen 5/325 mg every 8 hours and every 4 hours PRN;-The resident can tell the CMT when he/she needed something for pain;-He/she was unaware the hydrocodone-acetaminophen didn't seem to help control the pain for the resident.During an interview on 06/17/25, at 1:25 P.M., the Director of Nursing (DON) said the following:-The resident had pain and interventions included positioning him/her, reduction of light and noise, heel boots for feet and ankles;-They had contacted the physician multiple times regarding dose and frequency and any changes in medications;-The resident had PRN hydrocodone-acetaminophen 5/325 mg and was increased to 10/325 mg and then lowered with Tylenol to keep pain control;-When the resident was first admitted to the facility, he/she had therapy and when the pain increased, the resident stopped moving and they did try to educate him/her;-The physician hesitated to give the resident too much pain medication and wanted to treat the underlying condition with prednisone (which reduces inflammation in the joints with the rheumatoid arthritis);-The resident wanted the hydrocodone at first and when they increased it to 10mg, the resident's appetite decreased;-Some days, the resident sat up and had no pain and then other days, he/she complained a lot about the pain.2. Review of Resident ##2's face sheet showed the following:-admission date of 12/10/21;-Diagnoses included peripheral vascular disease (reduced circulation of blood to a body part due to narrowed or clocked blood vessel) and vascular dementia (brain damage caused by multiple strokes). Review of the resident's Care Plan, revised 03/17/25, showed the following:-Resident may experience intermittent generalized pain;-Pain will be managed at resident's tolerable level;-Administer medications as ordered and assess effectiveness, assess for pain and intervene as indicated and use non-pharmacological interventions to manage pain such as assist with positioning for comfort.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderately impaired cognition;-Had altered level of consciousness which fluctuated;-No behaviors or rejection of cares;-On scheduled pain medication and received PRN pain medication;-Pain presence of rarely or not at all and rarely interferes with daily activities.Review of the resident's pain assessment, dated 3/23/25, showed the following:-Received scheduled pain medications and had received medications in the past 5 days;-The resident received PRN pain medications or was offered and/or declined pain medications in the past 5 days;-Had not received any non-medication intervention for pain in the last 5 days;-Had rarely or not at all pain in the past 5 days;-Had not limited participation in rehabilitation therapy sessions in past 5 days because it did not apply;-Had pain which rarely or not at all limited day-to-day activities;-Pain intensity 2 over the past 5 days;(Staff did not assess the intensity of the resident's worst pain (mild, moderate, severe, very severe, horrible, unable to answer, not assessed) over the last 5 days.)Review of the resident's Physician's Orders showed an order, dated 03/27/25, for acetaminophen 325 mg two tablets (650mg) three times a day at 8:00 A.M., 1:00 P.M., and 8:00 P.M.Review of the resident's progress notes showed the following:-On 05/28/25, at 6:56 P.M, staff documented resident slapped two different CNAs this shift. One was trying to get the resident up for lunch and the other was attempting to change the resident;-On 05/31/25, at 7:07 P.M., staff documented CNA reported the resident had bitten him/her when he/she attempted to change him/her this shift. Review of the resident's June 2025 MAR showed the following: -On 06/01/25, day shift pain was assessed as a 2 and the night shift pain was assessed at a 0;-On 06/02/25, day shift pain was assessed at a 2 and the night shift pain was assessed at a 0;-On 06/03/25, day shift pain was assessed at a 2 and the night shift pain was assessed at a 0; -On 06/04/25, day shift pain was assessed at a 2 and the night shift pain was assessed at a 0;-On 06/05/25, day shift pain was assessed at a 2 and the night shift pain was assessed at a 0;-On 06/06/25, day shift and night shift pain was assessed as a 0;-On 06/07/25, day shift and night shift pain was assessed as a 0:-On 06/08/25, day shift and night shift pain was assessed as a 0. Review of the resident's progress notes showed on 06/09/25, at 5:52 P.M., staff documented resident was reported as hitting and biting shower aide today and told him/her to go to hell. Staff notified the physician. Review of the resident's June 2025 MAR showed the following:-On 06/09/25, day shift pain was assessed at a 2 and night shift pain was assessed at a 0;-On 06/20/25, day shift pain was assessed at a 2 and night shift pain was assessed at a 0;-On 06/11/25, day shift pain was assessed at a 1 and night shift pain was assessed at a 0;-On 06/12/25, day shift pain was assessed as a 2 and night shift pain was assessed at a 0.Observation and interview on 06/13/25, beginning at 12:25 P.M., showed the following:-CNA A came out of the resident's room and said he/she had to get someone to help him/her with the resident's personal cares because the resident was cussing and he/she cannot deal with this;-At 12:30 P.M., CNA A and Nurse Aide (NA) D entered the resident's room to perform perineal care. The resident was scratching his/her thighs with loose feces on the thighs. NA D assisted CNA A to turn the resident on his/her back as the resident was digging the feces with his/her fingers;-CNA A and NA D used cleansing wipes to wipe the resident's fingers and the resident began to curse. The resident yelled God damn! It hurts. I hate your guts. It hurts like hell! It hurts like hell! as they cleansed the resident's hands and fingers. The resident was resisting their care and pushing them away;-The resident raised his/her head and said, I told you to leave me alone. I will bust your hand, you son of a bitch! and hit CNA A with a closed fist as she was holding the resident's hand to cleanse the hand;-The resident kept saying It hurts like hell, you son of bitch! Stop hurting my hand!;-CNA A explained quietly what they needed to do to clean the resident as the resident kept yelling, I hate your guts. It hurts like hell, you son of a bitch! CNA A and NA D quickly provided perineal care;-The resident started to hit CNA A on his/her shoulder and kept trying to scratch him/her. NA D told the resident not to hit him/her and to stop scratching him/her, as they provided perineal care;-CNA A put a clean bed pad beneath the resident as NA D held the resident's arms, and then CNA A put barrier cream on the resident with a raised voice, over and over, It hurts like hell! The staff would tell the resident what they were doing each time. They tried to work fast. When they stopped touching the resident, the resident was quiet;-When CNA A told the resident they were going to move the resident up in bed, the resident said, It hurts like hell son of a bitch! I hope you go to hell in a [NAME] basket! ;-When they turned the resident to lay on his/her left side, the resident said, Help me, it hurts. When NA D talked about lunch, the resident quieted and then said, water, please in a normal voice. NA D gave a drink to the resident. NA D raised the head of the bed slowly for lunch. The resident said, Leave me be, please as CNA A removed the trash and they left the room. During interview on 06/13/25, at 12:45 P.M., CNA A said staff sometimes have to help the resident eat because he/she falls asleep. The resident does not want to be touched. When they ask if he/she hurts, sometimes he/she can point to an area or sometimes says, All over. CNA tell staff when he/she has pain and had behaviors. Review of the resident's June 2025 MAR showed on 06/13/25, day shift pain was assessed as a 2 and night shift pain was assessed at a 3.Review of a physician's order, dated 06/13/25, showed the following:-An order for acetaminophen 325 mg one tablet to give twice a day at 8:00 A.M. and 8:00 P.M;-An order for hydrocodone-acetaminophen 5-325mg one tablet with acetaminophen twice a day at 8:00 A.M. and 8:00 P.M.Review of the resident's June 2025 MAR showed the following:-On 06/14/25, day shift pain was assessed as a 3 and night shift pain was assessed at a 4;-On 06/15/25, day shift pain was assessed as a 3 and night shift pain was assessed at a 0;-On 06/16/25, day shift pain was assessed as a 2 and night shift pain was assessed at a 2.During interview on 06/17/25, at 8:50 A.M., Certified Medication Tech (CMT) B said the following:-The resident now had scheduled hydrocodone 5/325 mg with Tylenol;-The other day the resident was screaming and said he/she was in pain. He/she thinks this is why they gave the hydrocodone to the resident;-The resident will let him/her know on the pain scale of 1 to 10 and say very bad;-He/she had observed the resident's pain had increased lately, but was no aware of what the nurses and the physicians know or do about this. During interview on 06/17/25, at 9:00 A.M., CNA I said the following:-If a resident became combative during patient care and they can't tell why, they were usually in pain;-Some residents have facial expressions and some residents do not when they are in pain;-This resident was like this. He/she has not asked a pain level for the resident, but if he/she was combative, or gets belligerent and verbal, like says, Get away from me! and gets physical, he/she is hurting pretty bad;-The resident will tell you when you roll him/her, Ow, that hurts!;-The resident was contracted in extremities;-He/she will ask when rolling the resident over, what kind of pain or say, do you still hurt? after positioning him/her;-The resident did not usually hit him/her, but will grab on to him/her. This was common for the resident to do when changing him/her;-Usually in the morning, it was easier to change him/her but not sure if he/she slept all night or had a pain medications;-The last round on night shift was 4:00 A.M. and staff have to do a fast change on the resident;-If the resident was in pain, he/she will report this to the nurse.During interview on 06/17/25, at 9:30 A.M., Licensed Practical Nurse (LPN )F said the following:-The resident yells out all the time, was combative, cursed, and it was hard to tell if he/she had pain;-The resident will say That hurts and curses. He/she had looked at the tubi grips (protective sleeves) on the resident's arms and the resident yells, It hurts. Get away!;-The resident had PRN and now scheduled pain medications;-There were times, he/she offered medication for pain and the resident won't take it.During interview on 06/17/25, at 9:59 A.M., RN G said the following:-The resident had been at the facility a long time and rarely gets out of bed;-The resident always screams like someone was hurting him/her and always complains of pain and itching;-They had tried multiple things for him/her;-The resident doesn't like to get up to shower and doesn't like to get out of bed;-If he/she was up for one hour, he/she says he/she was hurting and they put him/her back to bed.During interview on 06/17/25, at 1:25 P.M., the Director of Nursing (DON) said the following:-The resident can tell staff if he/she was hurting;-The resident did not like to sit up and pain was positional such as to turn and move him/her, the pain increases;-Staff were to reposition the resident with slow movements;-When the resident did get up like for meals, he/she did not sit up long;-The resident can't tell you what hurts;-When the resident had behaviors and he/she did not want to get up;-If he/she was saying, he/she hurts, staff should go see what to give him/her.3. During an interview on 06/17/25, at 9:15 A.M., CMT E said the following:-Verbally assess residents for pain but sometimes there were facial cues for pain or the nurse aides will let him/her know such as moaning and groaning while turning a resident;-The CMTs were to chart pain level for every shift. There was a prompt on the electronic MAR for each shift;-They don't fully chart until the end of the shift;-If they ask for a pain medication, he/she will reassess later for their pain level and does check the physician orders for pain medications to administer.During an interview on 06/17/25, at 9:23 A.M., LPN F said the following:-He/she would assess pain by asking the resident to rate pain level from 1 to 10;-If staff told him/her that the resident had shoulder pain, he/she would assess the resident and if the resident could not verbalize pain, he/she would move the shoulder, then see what medication they can have such as a muscle rub;-It would depend on what kind of pain which medication would be given;-If the resident needed a pain medication, he/she would go to the medication technician to get a pain medication to administer to the resident. If the med tech was busy, he/she would get it and administer to the resident and chart it;-He/she will assess for facial grimacing but most of the time, they will whine or have cross eyes, and he/she will chart in the progress notes.During an interview on 06/17/25, at 9:44 A.M., RN G said the following:-They look at a resident's diagnoses and for verbal and nonverbal cues for pain;-The CMTs assess the resident for pain every 12 hours and administered the pain medications;-The nurses do pain assessments unless a targeted individual which was usually brought to their attention by family or the resident;-Pain was usually not an issue, but resident's shouldn't be in pain.During an interview on 06/17/25, at 10:10 A.M., RN H said the following:-For pain management, if pain was an issue with a resident, and the resident said they were in a lot of pain, usually they were on hospice services;-Acute pain was someone with a new condition like had surgery or had a fall and hurt their self;-If a resident's pain was not controlled and they had a PRN pain medication which was not alleviating the pain, staff would contact the physician to see if they could have scheduled pain medication.During an interview on 06/17/25, at 1:25 P.M., the DON said the following:-Staff did pain assessments on residents three times per day in the electronic medical record and it was documented on the MAR;-Staff ask the resident what their pain level was and if unable to give a number between 0 to 10 with 10 being the highest level of pain;-They were to administer pain medication as scheduled and as needed to the residents. During an interview on 06/17/25, at 3:18 P.M., the Administrator said the following:-Staff were to do pain assessments especially when there was obvious signs of pain which can include behaviors, or the resident said they were in pain;-Staff were to administer pain medications and reassess if the pain medications were effective or not effective for pain relief.MO00253450

Based on interview and record review, the facility failed to provide respiratory care per standards of practice when the facility failed to provide a physician ordered bipap (noninvasive machine that helps people breathe by delivering pressurized air into their airways) or CPAP (a machine that treats breathing disorders by delivering pressurized air to the airways to keep them open while one sleeps) or document timely steps to acquire needed bipap supplies for one resident (Resident #1). Facility census is 120. Review of the facility policy titled, CPAP/Bipap (continuous positive airway pressure/bilevel positive airway pressure) Support, revised March 2015, showed the following: -Purpose of the machine was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen; -Improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease; -Promote resident comfort and safety; -Bipap delivers CPAP, but allows separate pressure settings for expiration and inspiration; -CPAP is used when residents have not responded to attempts to increase PaO2 (partical pressure of oxygen) with other types of oxygen delivery systems; -Document the following in the resident's medical record: general assessment, time CPAP started and duration of therapy; oxygen concentration and flow; and how resident tolerated; -Notify the physician if the resident refuses or if the resident experiences any adverse consequences. 1. Review of Resident #'1's face sheet (resident's information at a quick glance) showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included chronic respiratory failure with hypercapnia and hypoxia (blood has too much carbon dioxide or not enough oxygen), chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe), dependence upon supplemental oxygen - 2 liter (L), cardiomyopathy (disease of the heart), and chronic pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/01/24, showed the following: -Cognitively intact; -Resident received Oxygen therapy and non-invasive mechanical ventilator (bipap or CPAP). Review of the resident's care plan, updated on 09/13/24, showed the following information: -Resident was prescribed oxygen to help manage his/her COPD; -Resident will have needs related to deficits in respiratory function addressed and risk of complications minimized; -CPAP at night; -Oxygen as ordered. -Resident is at increased risk for falls related to debility. Review of the resident's July 2024 Physician Order Sheet (POS) showed the following: -An order, dated 06/04/24, to apply CPAP anytime resident is in the bed sleeping (day or night). Self regulating machine; -An order, dated 02/29/24, remove CPAP every morning. Review of the resident's Progress Note, dated 07/18/24, showed the following: -Resident had oxygen off when nurse practitioner arrived to room and resident seemed more confused than baseline and had had an incontinent episode. Resident's oxygen was applied and resident seemed more alert, was joking around, and smiling; -Primary diagnosis of chronic respiratory failure, unspecified whether with hypoxia or hypercapnia; -Bipap; -Dependence upon oxygen 1 liter to keep blood oxygen level above 90% on bipap; -Obstructive sleep apnea and new bipap since being at the facility -Chronic obstructive pulmonary disease, needs consistency with oxygen and bipap. The resident is dependent upon oxygen/ Review of the resident's July 2024 Physician Order Sheet (POS) showed an order, dated 07/19/24, for oxygen at 2 L per minute via nasal cannula. Review of the resident's July 2024 Medication Administration Record (MAR) showed the following: -On 07/23/24, staff documented the resident did not use the CPAP because tubing was broken; -Resident did not wear the CPAP from 07/23/24 through 07/31/24 due to the machine not having the needed supplies. Review of the resident's July 2024 Nurses' Notes showed the following: -On 07/23/24, at 12:34 P.M., staff left a message for the Durable Power of Attorney (DPOA) asking for a return phone call. It was reported by night shift that resident's bipap tubing was broken and needed to be replaced; -On 07/23/24, at 1:26 P.M., the DPOA called back and this nurse and the DPOA were able to obtain the faxed orders from a supplier get the resident's supplies ordered for bipap machine; -On 07/24/24, at 3:29 A.M., the resident has been doing well this shift without his/her bipap and using just oxygen. Review of the resident's July 2024 Nurses' Notes showed staff did not document regarding the resident's bipap/CPAP or any steps to obtain the needed to supplies to allow the machine to be functional. Review of the resident's August 2024 POS showed the following: -An order, dated 06/04/24, to apply CPAP anytime resident is in the bed sleeping (day or night). Self regulating machine; -An order, dated 02/29/24, remove CPAP every morning; -An order, dated 07/19/24, for oxygen at 2 L per minute via nasal cannula. Review of the resident's August 2024 MAR showed staff documented the resident did not wear the CPAP the month of August 2024 due to the machine being inoperable. Review of facility records showed on 08/14/24 (22 days after the resident's machine became inoperable) a fax was sent to a home health agency for supplies. Review of the resident's Progress Note, dated 08/20/24, showed the following: -Resident seen by nurse practitioner; -Refused to wear his/her bipap overnight. He/she got the tubing to the bipap, but now states he/she does not have the face piece and thinks it got thrown away when his/her room was cleaned; -Dependence upon oxygen 1 liter to keep blood oxygen level above 90%, on bipap; -Obstructive sleep apnea, bipap, needs encouragement to wear. Resident states something is broke and -nursing to follow up; -COPD, needs consistency with oxygen and bipap. Resident is dependent upon oxygen 1 to 2 L. Review of the Resident's August 2024 nurse's notes showed on 08/26/24, at 1:59 A.M., staff noted CPAP not in use due to face mask missing. He/she was wearing 2 L of oxygen per nasal cannula. His/her vitals were stable and he/she was able to make needs known. Review of the resident's August 2024 Nurses' Notes showed staff did not document regarding the resident's bipap/CPAP or any steps to obtain the needed to supplies to allow the machine to be functional. Review of the resident's September 2024 POS showed the following: -An order, dated 06/04/24, to apply CPAP anytime resident is in the bed sleeping (day or night). Self-regulating machine; -An order, dated 02/29/24, to remove CPAP every morning; -An order, dated 07/19/24, for oxygen 2 L per minute via nasal cannula. Review of the resident's September 2024 Nurses' Notes dated 09/11/24, at 2:28 A.M., showed a family member called to asked about the resident and voiced concerns with resident having confusion over the weekend during a visit. Family member asked about the resident's CPAP and stated that he/she sent his/her son to home health supplier for the part of the CPAP and the supplier told him/her that the part that was needed and they did not have it. Staff told the family member that Registered Nurse (RN) C was the one working on it and that he/she would be the best person to talk to about it. Review of facility records shows on 10/22/24 showed RN C faxed [NAME] care information on the resident showing a physician's order for the bipap on 09/12/24. Review of the resident's Progress Note, dated 09/20/24, showed the following: -Resident had not been wearing bipap and was waiting on parts to come in. Resident also had follow up appointment with pulmonology; -Bipap needing new supplies, mentioned in last note, which has been a barrier to compliance; -Needs consistency with oxygen and bipap; -Dependent on 2 L of oxygen. Review of the resident's September 2024 POS showed the following: -The 07/19/24 order for oxygen 2 L per minute via nasal cannula was discontinued on 09/25/24; -The 06/04/24 order apply CPAP anytime resident is in the bed sleeping, (day or night), self-regulating machine, discontinued of 09/25/24; -An order, dated 09/25/24, for no CPAP/bipap for two weeks due to recent fall; -An order, dated 09/25/24, for oxygen at 3 L per nasal cannula with exertion and at night. Maintain oxygen saturation level at 88-92 %; -An order, dated 02/29/24, remove CPAP every morning. Review of the resident's September 2024 MAR showed the following: -From 09/01/24 through 09/17/24, staff noted the resident did not wear the CPAP/bipap and noted drug/item unavailable, waiting on part or missing supplies; -From 9/18/24 through 09/23/24, staff signed off the resident wore no bipap/CPAP; -On 09/24/24, staff noted CPAP/bipap unavailable; -On 09/25/24, order changed to no CPAP/bipap for two weeks and oxygen increased from 2 L to 3 L. Review of the resident's September 2024 Nurses' Notes showed staff did not document anything additional regarding the resident's bipap/CPAP or any steps to obtain the needed to supplies to allow the machine to be functional. Review of the resident's POS, dated October 2024, showed the following: -An order, dated 09/25/24, for oxygen at 3 L with exertion and at night. Maintain oxygen saturation levels at 88-92%; -An order, dated 02/29/24, to remove CPAP every morning; -An order, dated 09/25/24 to 10/14/24, to hold CPAP/bipap for two weeks due to fall. During an interview on 10/24/24, at 1:40 P.M., the resident said he/she does better when sleeping with a bipap, but it doesn't always have the parts needed to work. During an interview on 10/24/24, at 12:30 P.M., Certified Nurse's Assistance (CNA) A said the following: -The resident used oxygen, but doesn't always keep it on; -If the resident didn't have oxygen on, he/she tended to get tired; -He/she didn't know if the resident wore a sleep machine like CPAP or bipap. During an interview on 10/24/24, at 4:27 P.M., the Certified Medication Technician (CMT) F said the following: -If he/she noticed a CPAP or bipap not working he/she would notify the nurse; -He/she would see if the facility had any supplies to repair the machine or contact the outside provider. During an interview on 10/24/24, at 12:53 P.M., Licensed Practical Nurse (LPN) B, said the following: -The resident has an order for a bipap; -The family member was supposed to get some parts. RN C had been working with the family member to get the parts; -He/she said it was hard to say if or how not wearing the bipap affected the resident. During an interview on 10/24/24, at 4:16 P.M., LPN D said the following: -He/she worked on the rehab unit only and they do not have any CPAP/bipaps; -If the resident's CPAP broke and they did not have the supplies needed at the facility he/she would contact the Assistant Director of Nursing (ADON) or the DON and the family; -If it didn't get fixed timely, he/she would notify the doctor to see if the doctor had further orders; -He/she would also add a progress note in the medical record; -If the problem didn't get resolved before the next shift, he/she would pass it along to the nurse on the following shift and follow until the problem is resolved. During an interview on 10/24/24, at 4:21 P.M., the RN E said the following: -If a resident's CPAP broke, he/she would see if they have supplies and if not go to the supply company; -He/she would also fill out an FYI or call the doctor; -He/she would also notify RN C as He/she takes care of these things; -He/she would notify the next shift if the machine isn't working. During an interview on 10/24/24, at 1:06 P.M., RN C said the following: -The resident had bedbugs prior to coming to the facility, so the machine was not brought to the facility and the facility was unaware the resident was using a bipap or CPAP at home; -The resident had been in the hospital for hypercapnia and they found after that the resident was using the bipap; -The facility purchased a new machine and all was fine until they couldn't get any supplies or replacement parts; -He/she attempted to get supplies from two suppliers and they needed a new order from the pulmonologist; -He/she made several calls to two suppliers and had not been successful with getting the replacement parts; -Resident sleeps with oxygen at night; -Resident has not been compliant in the past with the bipap. During interviews on 10/24/24, at 1:54 P.M. and 3:33 P.M., the Director of Nursing (DON) said the following: -When the resident first came he/she was in rehab and when he/she came from the hospital they said the resident had bedbugs and the family was told not to bring things to the facility, however, the family did not mention the resident being on a CPAP; -In December 2023, the resident had an increase in sleepiness, they adjusted meds as that was thought to be the issue; -On 01/27/24, the resident was less alert, had an altered mental status, and oxygen levels were down so the resident was sent out to the hospital; -On 02/07/24, the resident returned from the hospital. The resident was on a bipap at the hospital and oxygen and wasn't tolerating it well; -On 02/21/24, the resident was hospitalized again and on the discharge paperwork, dated 02/29/24, it stated the resident wears a bipap at the nursing home; -They called home support and instead of renting a machine, which would cost more in the long run, they purchased the machine, with all of the supplies; -In July 2024, the hose broke and they called the supplier and because they did not have orders, they would not provide the parts; -They called another supplier and they wouldn't provide anything because they needed a new order from the pulmonologist; -Another supplier would not provide the supplies because the machine didn't come from them and since the resident was in the nursing home a contract would be needed; -The resident has refused to wear oxygen and gets more lethargic; -The facility was not aware the resident was ordered a bipap/CPAP; -Then the resident threw his/her mask away; -The resident's family had a friend that provided some supplies, but they still don't have things worked out; -The resident takes his/her oxygen off and has been in hospital due to hypercapnia; -When he./she sleeps without bipap the resident gets confused and lethargic; -The resident would usually keep the mask on half of the night; -The facility got the new mask about two weeks after the resident fell . During an interview on 10/24/24, at 3:14 P.M., the Administrator said the following: -He/she didn't all that was going on with the bipap; -He/she knew the facility was not aware the resident wore a bipap at home and he/she didn't always wear it there; -He/she didn't know about the tubing breaking. During an interview on 10/24/24, at 4:30 P.M., DON and Administrator said the following: -When staff find a resident's CPAP or bipap isn't working, they should first check the facility supplies. If they don't have what's needed, they should go to RN C; -RN C takes care of it from there; -Each case is situational. If the CPAP or bipap isn't available, the resident could be put on oxygen; -The facility would notify the doctor to get new orders; -He/she expected the staff to document in the medical record the timeline of what's being done and the contacts; -He/she would expect staff to continue pursuing the issues until it's resolved. MO00242206

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination when staff stacked clean dishware inside one another instead of air drying, which could potentially contaminate food served from those items, and failed to keep dented cans separate from other canned goods. The facility census was 115. 1. Review of the 2022 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility's policy titled Warewashing Machines Operation, by Safety and Sanitation Best Practice Guidelines, revised November 2017, showed the following information: -Air-dry all items; -Make sure all items are completely dry before stacking to prevent wet-nesting. Observation on 05/06/24, beginning at 9:05 A.M., showed the following items left wet and stacked on top of one another trapping water between the items: -Three metal pans for the steam table; -Seventy-eight plastic soup/cereal bowls. Observation on 05/10/24, at 11:44 P.M., showed the following items left wet and stacked on top of one another trapping water between the items: -Thirty-eight plastic bowls stacked together and sitting in a large plastic tub; -Nine plastic coffee cups; -Five plastic divided plates. During an interview on 05/10/24, at 11:58 A.M., Dietary Aide AA said the following: -The few that have worked in the kitchen for some time, know to let dishes air dry before putting them away; -There are a few new employees, that are not doing a good job of air drying dishes. During an interview on 05/10/24, at 12:15 P.M., Dietary Aide DD said dishes should always be air dried and never stacked while still wet. During an interview on 05/10/24, at 12:20 P.M., Regional Dietary Manager, said the following: -He/she is aware that some dishes have not been air dried; -He/she has tried to redirect this current dishwasher. 2. Review of the 2022 Food Code showed the following information: -Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard; -Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food; -If the integrity of the packaging has been compromised, contaminants may find their way into the food. Review of the facility's policy titled Review Cans Using Following Guidelines, by Safety and Sanitation Best Practice Guidelines, revised November 2017, showed the following information: -A can is unacceptable if a dent is on side seam, top, or bottom rim or if severely dented or buckled, resulting in bulged lids; -Before discarding unacceptable cans, review with manager for appropriate credit. Observation on 05/06/24, beginning at 9:05 A.M., showed the following cans were dented and not separated from the cans that were appropriate to use: -One 6.93 pound (lb) can of tomato paste; -One 6.12 lb can of mixed sweet peas; -One 6.14 lb can of navy beans; -On 6.9 lb can of grapefruit sections. During an interview on 05/10/24, at 11:58 A.M., Dietary Aide AA, said the following: -He/she was not aware of any dented cans on the shelf; -Dented cans should be put to the side; -The manager will send pictures to the food provider to get credit. During an interview on 05/10/24, at 12:20 P.M., the Regional Dietary Manager said staff had already noticed that there were dented cans and have put them in the correct place. 3. During an interview on 05/10/24, at approximately 1:00 P.M., the Administrator said he/she was already aware of the issues in the kitchen from the Regional Dietary Manager.

Based on observation, interview, and record review, the facility failed to ensure the dignity of all residents was maintained when staff failed to provide a dignity bag for urine collection bags for three residents (Residents #29, #2, and #61) with an indwelling urinary catheters (tubing placed internally to drain the bladder). A sample of 29 residents was selected for review in a facility with a census of 115. Review of the facility's policy titled Resident Rights, dated 06/2006, showed residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote the rights for each resident. 1. Review of the facility's policy titled, Urinary Catheter Care, undated, showed a catheter with a closed drainage system is preferred to be covered with a dignity bag. 2. Review of Resident #29's face sheet (brief information sheet about the resident) showed the following information: -admitted [DATE]; -Diagnoses included chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should),. Review of the resident's care plan, dated 04/10/24, showed the following: -The resident had an indwelling catheter; -Staff should position and anchor catheter tubing and bag below the level of the bladder. (Staff did not care plan related to the use of a dignity bag.) Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility), dated 04/17/24, showed the resident had an indwelling catheter. Observations of the resident showed the following: -On 05/06/24, at 10:07 A.M., the resident was in bed facing the wall. The resident's catheter bag was hanging on the lower bed rail facing the doorway. The bag was not covered by or inside of a dignity bag. The urine in the bag was clear yellow and up to the 200 milliliter (ml - unit of volume for liquids) line on the collection bag. The bag could be seen from the doorway/hall; -On 05/07/24, at 2:00 P.M., the resident was in bed with eyes closed. The catheter bag was hanging on the lower bed rail facing the doorway. The bag was not covered by or inside of a dignity bag. The urine in the bag was clear yellow and above the 100 ml line on the collection bag. The bed was in the lowest position and the catheter bag was touching the floor. The bag could be seen from the doorway/hall; -On 05/08/24, at 9:31 A.M., the resident was in bed with eyes closed. The catheter bag was on the lower bed rail and was facing the doorway. Clear yellow urine was visible in the collection bag and tubing. The bag was not covered by or inside of a dignity bag. The bag could be seen from the doorway/hall; -On 05/10/24, at 10:30 A.M., the resident was in bed facing away from the door. The catheter bag was on the lower bed rail inside of a catheter bag and was touching the floor. The bag could be seen from the doorway/hall. 37358 3. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included personal history of frequent urinary tract infections (UTI's), neuromuscular dysfunction of bladder (when the brain does not communicate with the bladder), and retention of urine (when one is unable to completely empty the bladder). Review of the resident's care plan, dated 06/11/22, showed the following: -Resident had an indwelling urinary catheter; -Staff are expected to maintain, clean, and position catheter tubing and bag below level of bladder and provide daily care. (Staff did not care plan the use of a dignity bag.) Review of the resident's annual MDS, dated [DATE], showed the following: -Resident required an indwelling urinary catheter; -Total dependence on staff for toileting needs. Observation on 05/09/24, at 4:05 P.M., showed the following: -The resident lay in his/her bed with the resident's urinary catheter hooked to the side of the bed; -The catheter drainage bag was visible from the hallway; -The catheter drainage bag did not have a dignity bag covering it. 50185 4. Review of Resident #61's face sheet (resident information at quick glance) showed the following information: -admitted [DATE]; -Diagnoses included chronic kidney disease and benign prostatic hyperplasia (age associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms. Review of the resident's care plan, last revised on 01/14/24, showed the following information: -Indwelling catheter; -Change catheter as needed, by orders; -Maintain catheter for diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow); -Position and anchor catheter tubing and bag below the level of the bladder; -Provide catheter care daily and as needed; -Report changes in output, color, and odor. (Staff did not care plan the use of a dignity bag.) Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Dependent on staff for toileting, dressing, and mobility; -Indwelling urinary catheter. Observation of the resident on 05/06/24 showed the following: -At 9:40 A.M., the door to the resident's room open and the resident lay in the bed with his/her eyes closed. The resident's urinary catheter drainage bag was hooked to the side of the bed, visible from the hall. The catheter bag did not have a dignity bag covering it; -At 4:06 P.M., the resident's room door was open with the resident in the bed on his/her back. The resident's catheter bag was hooked to the side of the bed, visible from the hall. The resident's urinary catheter drainage bag did not have a dignity bag to cover the urine. Observation on 05/07/24, at 8:36 A.M., showed the resident's room door was open with the resident in the bed on his/her back. The resident's catheter bag was hooked to the side of the bed, visible from the hall. The resident's urinary catheter drainage bag did not have a dignity bag to cover the urine. Observations on 05/08/24, at 9:14 A.M. and 11:22 A.M., showed the resident's room door was open with the resident in the bed on his/her back. The resident's catheter bag was hooked to the side of the bed, visible from the hall. The resident's urinary catheter drainage bag did not have a dignity bag to cover the urine. 5. During an interview on 05/09/24, at 10:34 A.M., Certified Nurse Aide (CNA) J said the catheter drainage bag should always have a dignity bag on it regardless of the resident's location. People should not be able to walk past the resident's room and see it. During an interview on 05/09/24, at 1:02 P.M., CNA K said the dignity bags are found under the resident's wheelchairs. He/she believes the catheter drainage bag should be always covered with a dignity bag. If a dignity bag is unavailable, he/she covers the bag with the resident's blanket. During an interview on 05/09/24, at 1:52 P.M., Licensed Practical Nurse (LPN) C said catheter drainage bags should be inside a dignity bag. That is the expectation for all residents. During an interview on 05/10/24, at 11:00 A.M., the Director of Nursing (DON) said the catheter drainage bag should be always covered with a dignity bag. During an interview on 05/10/24, at 12:00 P.M., the Administrator said catheter drainage bags should be placed inside a dignity bag. 31464

Based on observation, interview, and record review, the facility failed to promote all residents' right for self-determination of schedule and cares when staff failed to provide showers as preferred and care planned for nine residents (Resident #9, #21, #23, #55, #108, #33, #8, #15, and #11) of 29 residents sampled. The facility census was 115. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of residents' skin. The policy did not address the scheduling of showers/baths. 1. Review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -Readmitted [DATE]; -Diagnoses include stroke, hemiplegia (paralyzed on one side of the body), anxiety disorder (feelings of worry, anger or fear), and depression (feelings of sadness). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/03/24, showed the following: -Cognitively intact; -Requires partial/moderate assistance with shower/bath. Review of the resident's care plan, revised 05/08/24, showed the following: -Provide and set up for him/her to do own hygiene and oral care; -Provide and encourage two baths per week. Review of the weekly shower sheet showed the resident scheduled for showers on Tuesdays and Fridays. Review of the the resident's April 2024 shower sheets showed the staff document shower/baths provided on the following dates: -On 04/04/24; -On 04/09/24; -On 04/16/24 (seven days after the previous shower); -On 04/22/24 (six days after the previous shower); -On 04/30/24 (eight days after the previous shower). Review of the resident shower sheets, dated 05/01/24 through 05/07/24, showed staff had not provided the resident a shower. During interviews on 05/06/24, at 8:59 A.M., and on 05/07/24, at 8:35 A.M., the resident said the following: -He/she is only receiving one shower per week and would like to have two; -He/she feels dirty, especially his/her hair and armpits. 2. Review of Resident #21's face sheet showed the following: -admitted [DATE]; -Diagnoses included Type 2 diabetes (body has problem with regulating and using sugar as fuel), chronic kidney disease stage 3 (kidneys have mild damage and are less able to filter waste), and heart disease. Review of the the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Requires partial/moderate assistance with shower/bath. Review of the resident's care plan, revised 03/06/24, showed the following: -The resident requires minimum to moderate assistance with activities of daily living (ADLs) related to generalized weakness/advanced age. Staff to support daily routines/preferences. Review of the weekly shower sheet showed the resident scheduled for showers on Tuesdays and Fridays. Review of the the resident's April 2024 shower sheets showed staff provided showers on the following dates: -On 04/01/24; -On 04/06/24; -On 04/18/24 (12 days after the previous shower); -On 04/26/24 (eight days after the previous shower); -On 04/30/24. Review of the resident shower sheets, dated 05/01/24 through 05/07/24, showed staff had not provided the resident a shower. During interviews on 05/06/24, at 1:40 P.M., and on 05/08/24, at 9:20 A.M., the resident said the following: -He/she is only receiving one shower per week and used to get two per week. He/she would like to received two showers per week; -Staff was supposed to come in on his/her day off to give him/her a shower last week and did not show up; -He/she doesn't remember when he/she had a shower last, the staff was supposed to give the resident a shower 05/07/24, but the shower staff didn't come to work. 3. Review of Resident #23's face sheet showed the following: -Readmitted [DATE]; -Diagnoses include Type 2 diabetes with chronic kidney disease stage, major depression disorder, and generalized anxiety. Review the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial assistance with shower/bath. Review of the resident's care plan, revised 04/17/24, showed the following: -The resident required minimum to moderate assistance with ADLs related to generalized weakness/advanced age. Staff to support daily routines/preferences. Review of the weekly shower sheet showed the resident scheduled for showers on Tuesdays and Fridays. Review of the the resident's April 2024 shower sheets showed staff provided on one shower on 04/18/24. Review of the resident's shower sheets, dated 05/01/24 through 05/07/24, showed staff provided on shower on 05/02/24. During an interview on 05/07/24, at 2:20 P.M., the resident said he/she usually gets a shower one time per week and would like a bath. He/she wasn't sure when the last shower was. 4. Review of Resident #55's face sheet showed the following: -Readmitted [DATE]; -Diagnoses included muscle weakness, major depression, and insomnia (sleep problems). Review the resident's significant change MDS, dated [DATE], showed the following: -Cognitive impairment; -Requires maximum assistance with shower/bath. Review of the resident's care plan, revised date 04/17/24, showed the following: -The resident needs assistance with ADLs during times of weakness and depression; -Offer and encourage two showers a week. Review of the weekly shower sheet showed the resident scheduled for showers on Tuesdays and Fridays. Review of the the resident's April 2024 shower sheets showed staff provided a shower on the following dates: -On 04/04/24; -On 04/10/24 (six days after the previous shower); -On 04/18/24 (eight days after the previous shower). Review of the resident's shower sheets, dated 05/01/24 through 05/07/24, showed staff;provided a shower to the resident on 05/02/24 (14 days after the previous shower). During an interview on 05/06/24, at 1:40 0 P.M., the resident said the following: -He/she would like a shower at least one time per week, but really would like two per week; -He/she said it had been two weeks since he/she had a shower. 5. Review of Resident #108's face sheet showed the following: -Admission on 03/22/24; -Diagnoses includes wedge compression fracture of fourth lumbar vertebra (back). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Requires partial/moderate assistance with showers. Review of the resident's care plan, revised 04/17/24, showed the following: -Resident required minimal assistance with ADLs; -ADLs will be met with staff assistance. Review of the resident April 2024 shower sheets showed staff provided a shower on the following dates: -On 04/04/24; -On 04/06/24; -On 04/16/24 (ten days after the previous shower); -On 04/22/24 (six days after the previous shower); -On 04/30/24 (eight days after the previous shower). Review of the resident shower sheets, dated 05/01/24 through 05/07/24, showed staff had not provided the resident a shower. During an interview on 05/07/24, at 10:10 A.M., the resident said the following: -He/she has gone three weeks without a shower before and it has been almost two weeks since he/she had a shower; -He/she takes a washcloth and washes him/herself by the sink and goes to the beauty shop to get his/her hair washed weekly. Observation and interview on 05/08/24, at 9:08 A.M., with the resident showed the following: -He/she had his/her clothes beside of him/her; -Resident said he/she needed a shower; -He/she had been waiting a while to get a shower. 31464 6. Review of Resident #33's face sheet showed the following information: -admitted [DATE]; -Diagnoses included difficulty in walking, muscle weakness, chronic gout (arthritis that causes swelling, redness and tenderness in joints) to left ankle and foot, and spinal degeneration and stenosis (bones of spine too close together, can cause pain, tingling, or weakness, and/or bowel/bladder dysfunction). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition intact; -Limited range of motion; upper and lower extremities, one sided; -Required moderate assist of one person for personal hygiene; -Regarding making his/her own choice between tub bath, shower, bed bath, or sponge bath, resident responded very important. Review of the resident's care plan, dated 04/23/24, showed the following: -Required moderate/maximum assist with ADLs related to weakness while recovering. Staff to assist with toileting/incontinence care as needed and support daily routines/preferences. Review on 05/09/24, at 8:33 A.M., of the resident's shower sheets for April 2024 and May 2024, showed staff documented the following: -Shower given on 04/22/24 (six days following admission); -Shower given on 04/30/24 (eight days since previous shower). During an interview on 05/07/24, at 10:48 A.M., the resident said he/she had not had a shower or bed bath for the last two weeks and felt like he/she needed one badly. During an interview on 05/08/24, at 9:39 A.M., the resident said he/she did not know his/her shower schedule, but again said he/she had not had a bath or shower for two weeks and wanted one. 41787 7. Review of Resident #8's face sheet showed the following information: -admitted [DATE]; -Diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required staff supervision or touching assistance for showers. Review of the resident's care plan, reviewed 05/04/24, showed the following: -Resident required minimal to moderate assistance with ADLs; -Staff should support daily routines and preferences; -Resident had limited ability to perform self-care; -Resident will have clean, neat appearance daily and/or will be able to participate in self-care as able. Review of the facility shower list showed resident scheduled for showers on Tuesday and Fridays. Review of the resident's April 2024 shower sheets showed staff documented showers provided on the following dates: -On 04/05/24; -On 04/09/24; -On 04/22/24 (13 days after the previous shower). Review of the resident shower sheets, dated 05/01/24 through 05/07/24, showed staff had not provided the resident a shower. During an interview on 05/07/24, at 9:38 A.M., the resident said he/she would like to receive showers more often. He/she was not sure when the last shower was provided. 8. Review of Resident #15's face sheet showed the following: -admitted [DATE]; -Diagnoses included epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), chronic kidney disease, chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), and chronic pain. Review of the resident's care plan, last updated 04/15/24, showed the following: -Resident requires minimal assistance with activities related to general aging; -Staff should honor resident preferences; -Staff should assist with ADLs per patient's needs and preferences; -Staff should support daily routines and preference. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required staff supervision or touching for showers. Review of the facility shower list showed resident scheduled for showers on Tuesday and Fridays. Review of the resident's April 2024 shower sheets showed staff provided showers on the following dates: -On 04/02/24; -On 04/05/24; -On 04/09/24; -On 04/12/24; -On 04/16/24; -On 04/23/24 (seven days after the previous shower); -On 04/30/24 (seven days after the previous shower). During an interview on 05/07/24, at 2:31 P.M., the resident said his/her shower days were schedule on Tuesday and Fridays. He/she said that he/she had only been receiving showers on Tuesdays as the Friday shower aide was often not available. He/she had missed three Friday showers in a row. He/she felt dirty and would prefer at least the two showers per week. 9. Review of Resident #11's face sheet showed the following: -admitted [DATE]; -Diagnoses included heart failure and major depressive disorder. Review of the resident's April 2024 and May 2024 shower records showed staff provided showers on the following dates: -On 04/04/24; -On 04/09/24; -On 04/18/24 (nine days after the previous shower); -On 04/23/24; -On 04/30/24 (seven after the previous shower). During an interview on 05/07/24, at approximately 4:25 P.M., the resident said the following: -He/she was supposed to have had a shower today (05/07/24), but did not receive one; -He/she should get showers twice a week, -His/her shower days are every Tuesday and Thursday; -The resident said he/she feels dirty and is embarrassed to come out of his/her room because of how he/she may smell to others; -He/she could not say when he/she had a shower last, but said it has been quite a while and staff makes him/her wait sometimes for days or even longer than a week, without getting one. 9. During an interview on 05/08/24, at 10:21 A.M., Certified Nurse Aide (CNA) A said the following: -There used to be two staff doing showers, but one is no longer employed; -Some staff are pulled from the floor to help with showers; -When there were two shower aides one would do halls A and B and the other aide would do halls B and C; -Residents usually get one or two showers per week; -Registered Nurse (RN) D makes up the shower schedule. 10. During an interview on 05/08/24, at 10:27 A.M., CNA B said the following: -When there were two shower aides, one would do halls A and B and the other would do halls B and C; -There are also aides that fill in to help; -There are a couple of residents who don't think they get enough showers. 11. During an interview on 05/09/24, at 9:43 A.M., CNA X said the previous bath aide recently rewrote the current shower schedule. All residents should get two showers per week; either on Mondays/Thursdays or Tuesdays/Fridays. Staff should document the showers or refusals on the shower sheets. Wednesdays and Saturdays are shower make-up days for any missed/refused showers. The nurses do not tell the bath aides when there is a new resident on their hall or when someone transfers over from rehab; they just notice the new person and add them to the schedule. 12. During an interview on 05/08/24, at 10:35 A.M., Licensed Practical Nurse (LPN) C said the following: -He/she doesn't know which staff are giving showers as it has changed; -The residents receive showers at least one time per week; -If they have staff, one aide will do A and B hall and the other C and D hall; -If the residents have wounds they would get them more often. 13. During an interview on 05/08/24, at 10:40 A.M., and on 05/10/24, at 12:32 P.M., the Director of Nursing (DON) said the following: -The facility tries to provide showers twice per week to each resident, but a minimum of one per week; -There are three staff designated to do showers, one for rehabilitation hall, one for Halls A and B, and one for Halls C and D; -The shower aides have there own method of tracking which resident receives showers on which day; -He/she just fired one shower aide as the aide was not giving showers when he/she said he/she was giving showers; -The facility tries to honor resident's preferences on showers; -Staff should document showers and refusals on the shower sheet and give the sheets to the charge nurse for review. 14. During an interview on 05/08/24, at 10:50 A.M., and 05/10/24, at 1:05 P.M., the Administrator said the following: -Staff try to give residents showers twice per week, if they want more and staff have time, they get more; -They have a bath aide for rehab, and two for long term care unit; -They did have residents complain about not getting showers and they found the one bath aide was not giving showers and they fired the staff; -Staff should document showers and refusals on the shower sheets.

Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital that included the reason for the transfer, date of transfer, and destination of transfer for three residents (Resident #100, Resident #5 and Resident #8) out of 29 sampled residents. The facility census was 115. Review of the facility provided copy of Hospital Transfer Checklist, showed the following: -Fill out Interact Nursing Home to Hospital Transfer under observation, print and send with the resident. 1. Review of Resident #100's progress note, dated 01/23/24, showed the following: -The resident was reported to be combative, agitated, yelling, and cursing at staff and refusing cares; -Order received to send resident to hospital for evaluation and treatment; -Staff called daughter and informed of nurse practitioner's (NP) order; -Resident was transferred to the hospital. (Staff did not document staff provided the resident or representative with a hospital transfer notice.) Review of the resident's medical record showed staff did not have a copy of a letter provided to the resident or representative stating the date of transfer, destination of transfer, or the reason for transfer on 01/23/24. Review of the resident's progress note, dated 05/08/24, showed the following: -On 05/08/24 staff went into resident's room to give resident a stat breathing treatment due to oxygen saturation dropping to 82% on routine vital check. Oxygen kept dropping so order was given to send resident to the emergency room if resident became unstable; -Called emergency medical services at 4:05 A.M., to send resident to the hospital; -Emergency Medical Service (EMS) arrived and resident sent to the hospital at 4:20 A.M. (Staff did not document staff provided the resident or representative with a hospital transfer notice.) Review of the resident's medical record showed staff did not have a copy of a letter provided to the resident or representative stating the date of transfer, destination of transfer, or the reason for transfer on 05/08/24. 2. Review of Resident #5's February 2024 progress notes showed the following: -On 02/14/24, at 6:30 A.M., resident transferred to emergency room due to increased temperature, pale color and poor intake; -Resident returned to facility on 02/14/24, at 5:55 P.M.; -Family contacted regarding resident transfer to the hospital; (Staff did not document staff provided the resident or representative with a hospital transfer notice.) Review of the resident's medical record did not show the facility provided the resident or representative with a letter stating the date of transport, destination of transport or the reason for transport. 3. Review of Resident #8's face sheet showed an admitted [DATE]. Review of the resident's electronic medical record progress notes showed the following: -On 02/29/24, at 11:11 A.M., staff documented that the resident was getting ready for the day, with two CNAs present. The resident was standing and leaned to the right. The resident hit his/her head on the roommate's bed and landed hard on right shoulder. The resident did not remember the fall. Staff notified the physician and received an order to send to the emergency room for evaluation and treatment. The resident left via ambulance at 11:03 A.M. The nurse notified the resident's family; -On 02/29/24, at 5:06 P.M., staff documented the resident returned from the emergency room at 5:03 P.M., two-person transfer from stretcher to wheelchair. (Staff did not document staff provided the resident or representative with a hospital transfer notice.) Review of the resident's medical record did not show the facility provided the resident or representative with a letter stating the date of transport, destination of transport or the reason for transport. 4. During an interview on 05/10/24, at 8:56 A.M., the Social Service Director, Long Term Care Social Worker, and Rehabilitation Social Worker said the following: -Nursing does the hospital transfer notices; -The hospital transfer notices are done when the resident is being prepared to transfer to the hospital; -The hospital transfers are sent with the resident at that time. Two copies are give one for emergency medical services and other for the emergency room staff; -The hospital staff should be giving the resident their part of the paperwork; -The staff doesn't give the residents a hospital transfer notice; -The facility provides a letter to the resident or representative if they're admitted . 5. During an interview on 05/10/24, at 9:55 A.M., Licensed Practical Nurse (LPN) E said the following: -The nurses complete the observation that includes hospital transfer information; -He/she sends the observation form with the resident. It is sometimes sent later. 6. During an interview on 05/10/24, at 10:35 A.M., LPN C said the following: -He/she sends the information on the checklist; -He/she sends the observation sheet with the resident unless the ambulance arrives before he/she gets it's completed and then it's send later. 7. During an interview on 05/10/24, at 10:40 A.M., the Director of Nursing (DON) said the following: -When a resident is transferred to the hospital, emergency medical services receives the hospital transfer along with other identifying paperwork; -He/she is not sure who else receives a hospital transfer. Social services takes care of it. 8. During an interview on 05/10/24, at 10: 50 A.M., the Administrator he/she believes nursing sends the hospital transfer with the resident at time of transport 41787

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent possible urinary tract infection (UTI - infection in any part of the urinary system, the kidneys, bladder) when staff failed to ensure the catheter drainage bag (bag that collects urine from the tube that attaches to a catheter (tube) that is inside the bladder) of three residents (Resident #29, #2, and #61) did not sit or drag on the floor. The facility had a census of 115. Review of the facility's policy titled, Urinary Catheter Care, undated, showed the following information: -Use standard precautions when handling or manipulating the drainage system; -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; -If breaks in aseptic technique, discontinuation, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Review of the Centers for Disease Control and Prevention (CDC), Infection Control, Catheter-Associated Urinary Tract Infections (CAUTI), updated in 2017, showed do not rest the collection bag on the floor. 1. Review of Resident #29's face sheet showed the following information: -admitted [DATE]; -Diagnoses included dementia chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should). Review of the resident's care plan, dated 04/10/24, showed the following: -The resident had an indwelling catheter (A sterile tube inserted into the bladder to drain urine); -Staff should position and anchor catheter tubing and bag below the level of the bladder. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility), dated 04/17/24, showed the following: -Severe cognitive deficit; -Resident had an indwelling catheter. Observation showed the following: -On 05/07/24, at 2:00 P.M., the resident was in bed with eyes closed. The catheter bag was hanging on the lower bed rail facing the doorway. The bag was not covered by or inside of a dignity bag. The bed was in the lowest position and the catheter bag was touching the floor; -On 05/10/24, at 10:30 A.M., the resident was in bed facing away from the door, the catheter bag was on the lower bed rail inside of a catheter bag and touching the floor. 37358 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included personal history of frequent urinary tract infections (UTI's), neuromuscular dysfunction of bladder (when the brain does not communicate with the bladder), and retention of urine (when one is unable to completely empty the bladder). Review of the resident's care plan, dated 06/11/22, showed the following: -Resident does use an indwelling catheter; -Staff are expected to maintain, clean, and position catheter tubing and bag below level of bladder and provide daily care. Review of the resident's annual MDS, dated [DATE], showed the following: -Resident required an indwelling catheter; -Toileting hygiene showed resident as totally dependent on staff for toileting needs. Observation on 05/09/24, at approximately 4:05 P.M., showed the following: -The resident lay in his/her bed and the catheter was hooked to the side of the bed; -The catheter touched the floor. 50185 3. Review of Resident #61's face sheet showed the following information: -admitted [DATE]; -Diagnoses included chronic kidney disease (disease of the kidneys leading to failure) and benign prostatic hyperplasia (age associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms. Review of the resident's care plan, revised 01/14/24, showed the following information: -Needs related to catheter use will be addressed and risks of complications will be minimized; -Change urinary catheter as needed; -Maintain urinary catheter for diagnosis of obstructive uropathy (a urinary tract disorder that occurs when urine cannot drain through the urinary tract); -Position and anchor tubing and bag below level of the bladder; -Provide urinary catheter care daily and as needed; -Provide changes in output, color, and odor. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Dependent on staff for toileting, dressing, mobility, and transfers; -Indwelling urinary catheter. Observations on 05/07/24, at 8:36 A.M. and 1:32 P.M., showed the resident's room door open. The resident lay on his/ her back in bed with eyes closed and bed in lowest position. The urinary catheter collection bag hanging from the side of the bed and touched the floor. 4. During an interview on 05/09/24, at 1:02 P.M., Certified Nurse Aide (CNA) K said no part of the catheter system should touch the floor and the bag should be placed below the level of the bladder. 5. During an interview on 05/10/24, at 11:00 A.M., the Director of Nursing (DON) said the catheter collection bag should be below the level of the bladder and should never touch the floor. 6. During interview on 05/10/24, at 12:00 P.M. and 1:00 P.M., the Administrator said he expects staff to follow the policy and procedure for catheter care. Catheter drainage bags should never touch the floor.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services with accurate documentation and storage for the emergency kit (E-Kit - kits containing commonly prescribed medications for emergency use) when medication lock tags failed to match the form titled All E-Kit Lock Registration for three of five E-Kit boxes. The facility census was 115. Review of the facility policy titled Medication Storage in the Facility, dated 01/01/19, showed the following: -Medications and biologics are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -The provider pharmacy dispenses medications in containers that meet regulatory requirements, including requirements of good manufacturing practices. Medications are kept in these containers; -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications; -Medication storage conditions are monitored on a quarterly basis by the consultant pharmacy or pharmacy designee and corrective action taken if problems are identified; Review showed the facility did not provide a policy related to emergency kit boxes and logs. 1. Observation on 05/10/24, at 9:53 A.M., showed the following: -The A/B medication room had four locked plastic boxes. Each labeled with A, B, C, or narcotic kit on the outside of the box. There was a three-ring binder with forms labeled All E-Kit lock register that had an area for the date, two nurse signatures, the box letter and lock 1 and lock 2 information; -The A kit box tag locks showed numbers 909 and 908, with a white pharmacy tag dated 05/01/24 and signed by the pharmacy; -The C kit box tag locks showed number 953 and 954, with a white pharmacy tag dated 05/01/24 and signed by the pharmacy. Review on 05/10/24, at 9:55 A.M., of the All E-Kit lock register showed the following: -On 03/28/24, staff documented the C kit box tag numbers 431 and 432 on the box received from the pharmacy; -On 04/29/24, staff documented for the A box the tag number 522 removed and 098 put on; -On 05/01/24, there was no documentation on the register form related to A kit box or the C kit box; -On 05/04/24, staff documented tag number 035 removed and 036 put on the A kit box; -There was no documentation matching the numbers currently on the A and C kit box. 2. Observation on 05/10/24, at 10:49 A.M., of the rehab hall medication room, showed the following: -Two emergency medication kits observed in the rehab hall medication room, labeled A box and B box; -The A kit box showed lock tag numbers 247 and 248, with a pharmacy tag dated 04/22/24 and signed by the pharmacy. Review of the E-kit Lock Register on 05/10/24, at 10:50 A.M., showed the following: -On 04/23/24, staff documented that lock 579 and 580 were removed and lock 565 and 566 were put on for the A kit box; -On 04/26/24, staff signed the lock register form that lock 512 and 511 were removed and lock 451 and 452 were put on for the A kit box; -No information on the log matched the lock tags currently on the A kit box. 3. During an interview on 05/10/24, at 10:00 A.M., Licensed Practical Nurse (LPN) F said that the nurses and certified medication technicians (CMT) were able to access the non-narcotic E-Kit boxes, but only the nurses can access the narcotic E-Kit. Each box had two numbered lock tags. The E-Kits are kept in the A/B hall medication room and the rehab therapy hall medication room. He/she did not know who was responsible for monitoring accuracy of the tag numbers and register documentation. 4. During an interview on 05/10/24, at 10:35 A.M., Registered Nurse (RN) D said on Wednesday the pharmacy drops off boxes. they do not put the numbers into the book. The night nurses should be putting the tags on the register form. He/she did not know why the forms did not currently match the boxes. There was not any facility staff that were responsible for reconciliation of the register books. The contents of the emergency kits included commonly prescribed antibiotics, respiratory medications, cardiac medications, intravenous (IV) fluids, and medications. The pharmacy prints the inventory list on the top of each box. 5. During an interview on 05/10/24, at 12:00 P.M., LPN G said when the night nurse received medications, he/she was to check in the medications. The staff should ensure the emergency kit registers and lock tags are correctly documented when accessed. The boxes included common medications such as blood pressure medication, cholesterol medication, muscle relaxants, antibiotics, and non-narcotics medications that would be needed before the pharmacy could deliver a new mediation order. 6. During an interview on 05/10/24, at 12:32 P.M., the Director of Nursing (DON) said that the pharmacy delivers the emergency box kits every four weeks. The boxes are locked with tags from the pharmacy and then the first staff that access the box should ensure they change the tag and enter the information accurately on the register book. The kits should be accessed by two staff and the narcotic box should be accessed by two nurses. No staff at the facility audits the emergency kit locks and register. The pharmacy likely audits when they are here. There is no policy for the facility for emergency medication kits. 7. During an interview on 05/10/24, at 1:32 P.M., the Administrator said the facility received emergency medication kits from the pharmacy, so that commonly ordered medications can be obtained in a timely manner. The pharmacy delivers to the facility six days per week, and they deliver the emergency kits when needed. The emergency medication kit tag locks should match the information on paper register. If the nursing staff enter the emergency kit, they should switch the tag and document on the book accurately. The pharmacist should ensure the information matches.

Based on observation, record review and interview the facility failed to ensure that the medication error rate was not 5 percent or greater, when staff failed to prime insulin pens (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; failure to do so may result in administering too much or too little insulin) for three residents (Residents #220, #215, and #10) of 29 opportunities observed during medication pass (10% error rate). The facility census was 115. Review of the Instructions for Using Insulin Lispro (rapid acting insulin) KwikPen, revised 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. Insulin should be visible at the tip of the needle; -Repeat, no more than four times, until insulin is visible. If insulin is still not visible, change the needle and repeat priming process. Review of the Instructions for Using NovoLog (rapid acting insulin) FlexPen, revised 01/2019, showed to perform an air shot prior to injection. For each injection: -Select a dose of two units; -Take off the outer needle cap (save it) and inner needle cap (throw away); -With the pen pointing up, tap the insulin to move the air bubbles to the top; -Press the button all the way in and make sure insulin comes out of the needle; -Repeat up to two more times with the same needle if needed; -If insulin does not come out after three times, change needle and try again. If insulin still does not come out after changing the needle, the pen may be broken. Review of a facility policy entitled Specific Medication Administration Procedures, (revision date 1/01/2019), showed the following information: -Policy was to administer medications in a safe and effective manner; -Review medication for accuracy; -If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. Review of facility guidelines entitled Insulin Administration, undated, showed the following: -Types of insulin/brand names include rapid-acting insulin lispro (Humalog) and insulin aspart (NovoLog), and long-acting insulin glargine (Lantus); -Priming the pen: Dial up two units and hold the pen with the needle pointing upwards. Tap the pen gently to remove air bubbles, and then push the injection button until a drop of insulin appears at the tip of the needle. 1. Review of Resident #220's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy (nerve pain) and diabetic chronic kidney disease and long term (current) use of insulin. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/07/24, showed the following information: -Cognition intact; -Insulin given seven of seven days during look back period. Review of the resident's care plan, updated 05/03/24, showed the resident was prescribed insulin to help manage his/her diabetes. Staff to administer insulin as ordered. Review of the resident's Physician Order Sheet (POS), dated 05/10/24, showed the following: -An order, dated 04/30/24, to administer insulin lispro, insulin pen 100 units (u)/milliliter (ml) per sliding scale; -If blood sugar is less than 40 milligrams (mg)/deciliter (dL), call physician; -If blood sugar is 120 mg/dL - 160 mg/dL, give 2 units; -If blood sugar is 161 mg/dL - 200 mg/dL, give 4 units; -If blood sugar is 201 mg/dL - 240 mg/dL, give 6 units; -If blood sugar is 241 mg/dL - 280 mg/dL, give 8 units; -If blood sugar is 281 mg/dL - 320 mg/dL, give 11 units; -If blood sugar is greater than 320 mg/dL, give 15 units; -If blood sugar is greater than 320 mg/dL, call physician; -Administer insulin subcutaneously (under the skin) before meals. Observation on 05/09/24, at 11:54 A.M., showed Registered Nurse (RN) M performed an accucheck (finger stick blood test to determine level of sugar) with a result of 183 mg/dL. The RN said the resident required four units of insulin lispro per the sliding scale order. He/she wiped the insulin pen tip with alcohol and attached the needle. Without first priming the insulin pen, RN M set the dial to 4 and administered the insulin to the resident. 2. Review of Resident #215's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus and long term (current) use of insulin. Review of the resident's admission MDS, dated [DATE], showed the following information: -Cognition intact; -Insulin given seven of seven days during look back period. Review of the resident's care plan, updated 05/08/24, showed the resident prescribed insulin to help manage his/her diabetes. Staff to administer insulin as ordered. Review of the resident's POS, dated 05/10/24, showed the following: -An order, dated 05/01/24, for insulin lispro insulin pen, 100 unit/ml, 20 units subcutaneous with meals; -An order, dated 05/01/24, for insulin lispro insulin pen, 100 units/ml, per sliding scale: -If blood sugar is less than 40 mg/dL, call physician; -If blood sugar is 120 mg/dL - 160 mg/dL, give 2 units; -If blood sugar is 161 mg/dL - 200 mg/dL, give 4 units; -If blood sugar is 201 mg/dL - 240 mg/dL, give 6 units; -If blood sugar is 241 mg/dL - 280 mg/dL, give 8 units; -If blood sugar is 281 mg/dL - 320 mg/dL, give 11 units; -If blood sugar is greater than 320 mg/dL, give 15 units; -If blood sugar is greater than 320 mg/dL, call physician; -Insulin administered subcutaneously before meals. Observation on 05/09/24, at 11:33 A.M., showed RN M performed an accucheck for the resident with a result of 94 mg/dL. RN M asked the resident to calculate the required amount of insulin to be given based on the sliding scale (copy provided to the resident). The resident said he/she would not require additional insulin. RN M agreed, stating he/she would wait until the resident ate lunch before administering the ordered base amount of insulin of 20 units. Observation on 05/09/24, at 12:27 P.M., showed RN M retrieved the insulin lispro pen for the resident from the nurses' treatment/medication cart drawer. Without priming the pen, the RN turned the dial to 20, went to the resident's room, showed the pen setting to the resident, and administered the insulin to the resident. 3. Review of Resident #10's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus and long term (current) use of insulin. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognition moderately impaired; -Insulin given seven of seven days during look back period. Review of the resident's care plan, updated 03/15/24, showed the resident prescribed insulin and oral medication to help manage his/her diabetes. Review of the resident's POS, dated 05/10/24, showed the following: -An order, dated 11/24/23, for NovoLog U-100 insulin aspart solution, 100 unit/ml, per sliding scale; -If blood sugar is less than 40 mg/dL, call physician; -If blood sugar is 120 mg/dL to 160 mg/dL, give 3 units; -If blood sugar is 161 mg/dL to 200 mg/dL, give 5 units; -If blood sugar is 201 mg/dL to 240 mg/dL, give 8 units; -If blood sugar is 241 mg/dL to 280 mg/dL, give 12 units; -If blood sugar is 281 mg/dL to 320 mg/dL, give 16 units; -If blood sugar is greater than 320 mg/dL, give 20 units; -If blood sugar is greater than 320 mg/dL, call physician; -Insulin administered subcutaneously before meals. Observation on 05/09/24, at 11:39 A.M., showed RN M performed an Accucheck for the resident, with a result of 242 mg/dL. The RN said he/she would need to retrieve a new insulin pen from the e-kit (emergency use medications to be used when resident specific medication hasn't yet been delivered) however, the resident went to the dining room and began eating before administration of the insulin. Observation on 05/09/24, at 12:02 P.M., showed RN M retrieved a NovoLog insulin pen from the medication room e-kit for the resident. The resident was still eating lunch in the dining room. Observation on 09/05/24, at 12:45 P.M., showed RN M checked the resident's sliding scale to confirm a required dose of 12 units of NovoLog insulin. Without priming the pen, RN M set the dial to 12 and administered the insulin to the resident. 4. During an interview on 05/09/24, at 12:48 P.M., RN M said he/she would usually prime an insulin pen, but forgot to do so prior to the pen injections that day. 5. During an interview on 05/10/24, at 11:00 A.M., Licensed Practical Nurse (LPN) G said the facility was in the process of switching from insulin vials to injectable pens and there had not been a facility in-service yet. LPN G said to use an insulin pen staff should remove the cap, clean the tip with an alcohol wipe, attach the needle, set the dial to the number of units required to give, and administer the insulin. LPN G was not aware of the need to prime an insulin pen. 6. During an interview on 05/10/24, at 12:32 P.M., the Director of Nursing (DON) said the facility was in the process of switching from insulin vials to injectable pens. An in-service training was planned for 05/13/24 and would probably be done by the Assistant Director of Nursing (ADON), who was currently on vacation. Staff should check the pharmacy tag to verify the resident's name, type of insulin, and that dates were marked showing when the pen was opened and the last day to use after opening. Staff should use an alcohol wipe to clean the tip of the pen, apply the needle, dial in two units to prime the pen, then dial in the required number of units of insulin to give. 7. During an interview on 05/10/24, at 1:05 P.M., the Administrator said the facility is switching from vials to the use of insulin pens. There was an in-service training scheduled for 05/13/24. The Administrator was not aware of the need to prime the pens. Staff should follow the manufacturer's guidelines for the use of the pens.

Based on observation, interview, and record review, the facility staff failed ensure all residents were free from significant medication errors when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; failure to do so may result in administering too much or too little insulin) the insulin pens before administering insulin to three residents (Residents #220 #215, and #10) of four residents observed during insulin administration. The facility census was 115. Review of the Instructions for Using Insulin Lispro (rapid acting insulin) KwikPen, revised 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. Insulin should be visible at the tip of the needle; -Repeat, no more than four times, until insulin is visible. If insulin is still not visible, change the needle and repeat priming process. Review of the Instructions for Using NovoLog (rapid acting insulin) FlexPen, revised 01/2019, showed to perform an air shot prior to injection. For each injection: -Select a dose of two units; -Take off the outer needle cap (save it) and inner needle cap (throw away); -With the pen pointing up, tap the insulin to move the air bubbles to the top; -Press the button all the way in and make sure insulin comes out of the needle; -Repeat up to two more times with the same needle if needed; -If insulin does not come out after three times, change needle and try again. If insulin still does not come out after changing the needle, the pen may be broken. Review of a facility policy entitled Specific Medication Administration Procedures, (revision date 1/01/2019), showed the following information: -Policy was to administer medications in a safe and effective manner; -Review medication for accuracy; -If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. Review of facility guidelines entitled Insulin Administration, undated, showed the following: -Types of insulin/brand names include rapid-acting insulin lispro (Humalog) and insulin aspart (NovoLog), and long-acting insulin glargine (Lantus); -Priming the pen: Dial up two units and hold the pen with the needle pointing upwards. Tap the pen gently to remove air bubbles, and then push the injection button until a drop of insulin appears at the tip of the needle. 1. Review of Resident #220's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy (nerve pain) and diabetic chronic kidney disease and long term (current) use of insulin. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/07/24, showed the following information: -Cognition intact; -Insulin given seven of seven days during look back period. Review of the resident's care plan, updated 05/03/24, showed the resident was prescribed insulin to help manage his/her diabetes. Staff to administer insulin as ordered. Review of the resident's Physician Order Sheet (POS), dated 05/10/24, showed the following: -An order, dated 04/30/24, to administer insulin lispro, insulin pen 100 units (u)/milliliter (ml) per sliding scale; -If blood sugar is less than 40 milligrams (mg)/deciliter (dL), call physician; -If blood sugar is 120 mg/dL - 160 mg/dL, give 2 units; -If blood sugar is 161 mg/dL - 200 mg/dL, give 4 units; -If blood sugar is 201 mg/dL - 240 mg/dL, give 6 units; -If blood sugar is 241 mg/dL - 280 mg/dL, give 8 units; -If blood sugar is 281 mg/dL - 320 mg/dL, give 11 units; -If blood sugar is greater than 320 mg/dL, give 15 units; -If blood sugar is greater than 320 mg/dL, call physician; -Administer insulin subcutaneously (under the skin) before meals. Observation on 05/09/24, at 11:54 A.M., showed Registered Nurse (RN) M performed an accucheck (finger stick blood test to determine level of sugar) with a result of 183 mg/dL. The RN said the resident required four units of insulin lispro per the sliding scale order. He/she wiped the insulin pen tip with alcohol and attached the needle. Without first priming the insulin pen, RN M set the dial to 4 and administered the insulin to the resident. 2. Review of Resident #215's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus and long term (current) use of insulin. Review of the resident's admission MDS, dated [DATE], showed the following information: -Cognition intact; -Insulin given seven of seven days during look back period. Review of the resident's care plan, updated 05/08/24, showed the resident prescribed insulin to help manage his/her diabetes. Staff to administer insulin as ordered. Review of the resident's POS, dated 05/10/24, showed the following: -An order, dated 05/01/24, for insulin lispro insulin pen, 100 unit/ml, 20 units subcutaneous with meals; -An order, dated 05/01/24, for insulin lispro insulin pen, 100 units/ml, per sliding scale: -If blood sugar is less than 40 mg/dL, call physician; -If blood sugar is 120 mg/dL - 160 mg/dL, give 2 units; -If blood sugar is 161 mg/dL - 200 mg/dL, give 4 units; -If blood sugar is 201 mg/dL - 240 mg/dL, give 6 units; -If blood sugar is 241 mg/dL - 280 mg/dL, give 8 units; -If blood sugar is 281 mg/dL - 320 mg/dL, give 11 units; -If blood sugar is greater than 320 mg/dL, give 15 units; -If blood sugar is greater than 320 mg/dL, call physician; -Insulin administered subcutaneously before meals. Observation on 05/09/24, at 11:33 A.M., showed RN M performed an accucheck for the resident with a result of 94 mg/dL. RN M asked the resident to calculate the required amount of insulin to be given based on the sliding scale (copy provided to the resident). The resident said he/she would not require additional insulin. RN M agreed, stating he/she would wait until the resident ate lunch before administering the ordered base amount of insulin of 20 units. Observation on 05/09/24, at 12:27 P.M., showed RN M retrieved the insulin lispro pen for the resident from the nurses' treatment/medication cart drawer. Without priming the pen, the RN turned the dial to 20, went to the resident's room, showed the pen setting to the resident, and administered the insulin to the resident. 3. Review of Resident #10's face sheet showed the following: -admitted [DATE]; -Diagnoses included type 2 diabetes mellitus and long term (current) use of insulin. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognition moderately impaired; -Insulin given seven of seven days during look back period. Review of the resident's care plan, updated 03/15/24, showed the resident prescribed insulin and oral medication to help manage his/her diabetes. Review of the resident's POS, dated 05/10/24, showed the following: -An order, dated 11/24/23, for NovoLog U-100 insulin aspart solution, 100 unit/ml, per sliding scale; -If blood sugar is less than 40 mg/dL, call physician; -If blood sugar is 120 mg/dL to 160 mg/dL, give 3 units; -If blood sugar is 161 mg/dL to 200 mg/dL, give 5 units; -If blood sugar is 201 mg/dL to 240 mg/dL, give 8 units; -If blood sugar is 241 mg/dL to 280 mg/dL, give 12 units; -If blood sugar is 281 mg/dL to 320 mg/dL, give 16 units; -If blood sugar is greater than 320 mg/dL, give 20 units; -If blood sugar is greater than 320 mg/dL, call physician; -Insulin administered subcutaneously before meals. Observation on 05/09/24, at 11:39 A.M., showed RN M performed an Accucheck for the resident, with a result of 242 mg/dL. The RN said he/she would need to retrieve a new insulin pen from the e-kit (emergency use medications to be used when resident specific medication hasn't yet been delivered) however, the resident went to the dining room and began eating before administration of the insulin. Observation on 05/09/24, at 12:02 P.M., showed RN M retrieved a NovoLog insulin pen from the medication room e-kit for the resident. The resident was still eating lunch in the dining room. Observation on 09/05/24, at 12:45 P.M., showed RN M checked the resident's sliding scale to confirm a required dose of 12 units of NovoLog insulin. Without priming the pen, RN M set the dial to 12 and administered the insulin to the resident. 4. During an interview on 05/09/24, at 12:48 P.M., RN M said he/she would usually prime an insulin pen, but forgot to do so prior to the pen injections that day. 5. During an interview on 05/10/24, at 11:00 A.M., Licensed Practical Nurse (LPN) G said the facility was in the process of switching from insulin vials to injectable pens and there had not been a facility in-service yet. LPN G said to use an insulin pen staff should remove the cap, clean the tip with an alcohol wipe, attach the needle, set the dial to the number of units required to give, and administer the insulin. LPN G was not aware of the need to prime an insulin pen. 6. During an interview on 05/10/24, at 12:32 P.M., the Director of Nursing (DON) said the facility was in the process of switching from insulin vials to injectable pens. An in-service training was planned for 05/13/24 and would probably be done by the Assistant Director of Nursing (ADON), who was currently on vacation. Staff should check the pharmacy tag to verify the resident's name, type of insulin, and that dates were marked showing when the pen was opened and the last day to use after opening. Staff should use an alcohol wipe to clean the tip of the pen, apply the needle, dial in two units to prime the pen, then dial in the required number of units of insulin to give. 7. During an interview on 05/10/24, at 1:05 P.M., the Administrator said the facility is switching from vials to the use of insulin pens. There was an in-service training scheduled for 05/13/24. The Administrator was not aware of the need to prime the pens. Staff should follow the manufacturer's guidelines for the use of the pens.

Based on observation, interview, and record review, the facility failed to ensure medications were stored safely and securely when staff failed to lock medication and treatment carts when unattended by authorized personnel. The facility had a census of 115. Review of the facility policy titled Medication Storage in the Facility, revised 01/01/19, showed the following information: -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications; -Medication rooms, carts, and medication supplies are to be locked when not attended by persons with authorized access. Review of the facility policy titled Specific Medication Administration Procedures, revised 01/01/19, showed the following information: -All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/tech. 1. Observation on 05/08/24, at 10:48 A.M., showed C hall medication cart, unlocked and accessible with no certified medication technician (CMT) or nurse present with the cart or in sight of the cart. CMT returned to the cart at 10:51 A.M. 2. Observations on 05/09/24 showed the following: -At 9:58 A.M., the rehab hall nurses' treatment cart was backed up against the nurses' desk. The cart was unlocked. The cart contained insulin, glucometers individually bagged/named, prescription creams and ointments, and two sets of keys. No staff were present at the desk or in the area of the cart; -At 10:11 A.M., Registered Nurse (RN) M walked to the unlocked cart and leaned on the cart while speaking on a cell phone regarding a resident's supplies. RN M ended the phone conversation and walked away. The cart remained unlocked; -At 10:24 A.M., the treatment cart remained unlocked. RN M approached the cart and moved it down the hallway, backing the cart up to the doorway of a resident's room. -At 12:02 P.M., RN M stood in front of the rehab hall nurses' treatment cart, which was backed up against the nurses' desk area, facing the open resident dining area. Leaving the cart unlocked, RN M walked away from the cart for several minutes while retrieving a medication from the unit medication room. Six residents, one visitor, and several staff were present in the dining area; -At 12:09 P.M., RN M stood in front of the rehab hall nurses' treatment cart, which was backed up against the nurses' desk area, facing the open resident dining area. The RN drew up insulin from a vial and placed the vial on top of the cart. Leaving the cart unlocked with the insulin vial on top, RN M walked away from the cart for several minutes to a resident's room to administer the insulin. Six residents, one visitor, and several staff were present in the dining area. 50185 3. During an interview on 05/10/24, at 12:00 P.M., Licensed Practical Nurse (LP:N) G said staff should lock the medication and treatment carts when they walk away. 4. During an interview on 05/10/24, at 12:32 P.M., the Director of Nursing (DON) said all medication carts and treatment carts should be locked when unattended by staff, securing the medications and treatments. 5. During an interview on 05/10/24, at 3:05 P.M., the Administrator said all medication and treatment carts should be locked when the staff walks away from the cart. 41787

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program to prevent the risk of contamination and spread of infection when staff failed to complete proper hand hygiene during incontinent care for one resident (Resident #81) and during urinary catheter (bag that collects urine from the tube that attaches to a catheter (tube) that is inside the bladder) care for one resident (Resident #61). The facility also failed to protect clean laundry from possible contamination. The facility census was 115. Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2015, showed the following information: -Hand hygiene is the primary means to prevent the spread of infections; -All personnel should be trained and inserviced on the importance of hand hygiene and shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections; -Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Perform hand hygiene before and after coming on duty, before and after direct care with residents, before and after handling an invasive device, before donning (putting on) sterile gloves, before handling clean or soiled dressings, before moving from contaminated body sites to clean body sites, after contact with residents' skin or any bodily fluids, after handling used dressings or equipment, and after removing gloves. 1. Review of Resident #81's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included Alzheimer's disease, dementia, history of falling, high blood pressure, urine retention, and insomnia. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff), dated 02/14/24, showed the following information: -Severely cognitively impaired; -Dependent on staff for toileting, bathing, dressing, and mobility; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised 02/12/24, showed the following information; -Incontinence care per needs; -Incontinence pads or briefs as needed; -Protective barrier cream as needed; -Requires moderate to maximum assist with all cares; -Assist with toileting and incontinence care as needed. Observation on 05/07/24, at 8:52 A.M., showed the following: -Certified Nursing Assistant (CNA) H and Nursing Assistant (NA) I entered the resident's room. CNA H and NA I donned gloves without performing hand hygiene and shut the resident's room door; -CNA H and NA I transferred the resident from the wheelchair to the bed with a mechanical lift; -CNA H entered the resident's bathroom, removed his/her gloves, and donned new gloves without performing hand hygiene; -CNA H explained to the resident he/she would be changing the resident and providing incontinent care to the resident; -CNA H and NA I undressed the resident. NA I handed CNA H wipes. CNA H wiped the resident's bottom several times. Bowel movement observed on the wipe being used; -CNA H placed the dirty brief and wipes into the trash. CNA H removed his/her gloves and donned new gloves without performing hand hygiene. NA I continued with the same gloves; -A new brief was placed under the resident and CNA H cleansed the resident's front genital area; -NA I removed gloves and donned new gloves without performing hand hygiene; -The resident rolled toward NA I for clothing adjustments and brief latch; -NA I removed the gloves and threw the gloves in the trash; -CNA H continued adjusting the resident's clothing with the contaminated gloves, covered the resident with a blanket, laid the fall mat down on the right side of the bed, and placed the resident's call light on his/her chest. NA I lowered the resident's bed; -CNA H removed his/her gloves. CNA H and NA I removed the trash bags and left the room; -CNA H and NA I applied hand sanitizer in the hallway outside of the resident's room. 2. Review of Resident # 61's face sheet (brief resident profile sheet), showed the following information: -admitted [DATE]; -Diagnoses included senile degeneration of the brain (loss of intellectual ability), type two diabetes, chronic kidney disease (disease of the kidneys leading to failure), benign prostatic hyperplasia (age associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms, and irregular heartbeat. Review of the resident's care plan, revised 01/14/24, showed the following information: -Change catheter as needed; -Provide catheter care daily and as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Dependent on staff for toileting, dressing, mobility, and transfers; -Indwelling catheter. Observations on 05/08/24, at 11:41 A.M., showed the following: -CNA K entered the resident's room and donned gloves without performing hand hygiene; -The CNA closed the door, turned on the lights, raised the bed to his/her waist level, uncovered the resident, and prepared the brief and wipes; -The CNA removed the resident's brief and pants. Without performing hand hygiene or changing gloves, the CNA performed pericare the resident's genitals and catheter. The CNA completed multiple wipes of the catheter with the same wipe; -The CNA threw the dirty wipe into the trash. Without completing any hand hygiene or glove change, he/she placed a clean brief under the resident; -The CNA wiped the resident's buttocks with a new wipe. Without completing any hand hygiene or glove change, the CNA pulled up the resident's brief in the front and fastened it; -The CNA pulled up the resident's pants, removed his/her gloves, and collected the trash. During an interview on 05/09/24, at 10:23 A.M., CNA J said the aides or the nurses can complete catheter care. Hand hygiene should be performed before starting care and staff should don gloves. Staff should wipe the catheter tubing in a downward motion. Staff should change the position of the cloth with each cleansing stroke. During an interview on 05/09/24, at 1:02 P.M., CNA K said staff should wash their hands prior to donning gloves. Staff should change the position of the cloth with each cleansing stroke of the catheter tubing or use a new wipe with each stroke. During an interview on 05/09/24, at 1:52 P.M., Licensed Practical Nurse (LPN) C said the nurses are the ones generally responsible for catheter care. When providing catheter care, staff should change the position of the cloth with each cleansing stroke or use a new wipe with each stroke. During an interview on 05/10/24, at 11:00 A.M., the Director of Nursing (DON) said staff should clean the catheter tubing in a downward motion. Staff should change to a new cloth with each cleansing stroke. 3. During an interview on 05/09/24, at 10:34 A.M., CNA J said that staff should wash their hands before providing incontinent care. Once you've done all the cleaning, staff should remove those gloves, wash their hands again before touching anything else in the room. Staff should don new gloves before putting a fresh brief onto the resident, and then again before pulling up the resident's clothing. 4. During an interview on 05/09/24, at 1:02 P.M., CNA K said that staff should wash their hands prior to performing incontinence care. After hand washing, they should don gloves. After all cleansing is done, staff should remove gloves and wash hands. After providing care, staff should not touch anything in the room until they wash their hands. 5. During an interview on 05/09/24, at 1:52 P.M., LPN C said staff should wash their hands before, in-between, and after providing care. If the gloves become contaminated, staff should remove them, wash hands, and don new gloves. 6. During an interview on 05/10/24, at 11:00 A.M., the DON said staff should wash their hands prior to starting incontinence care, when going from dirty to clean, and after providing care. Once their hands are washed, they should not touch anything else in the room before providing care. 7. During an interview on 05/10/24, at 12:00 P.M., the Administrator said all staff are expected to wash their hands before and after care and before donning or doffing gloves. If something were to become contaminated during the care, he expects staff to wash their hands, and don new gloves. 31464 8. Review showed the facility did not provide a policy related to infection control related to clean laundry. During an observation and interview on 05/08/24, at 11:50 A.M., Laundry Staff P carried three to four garments on hangers down the full length of the A hall to a resident's room on the Rehab hall. The garments were not covered. The staff said they usually deliver the clean laundry on a rolling rack with an attached basket and the carts do not have a cover. The load he/she already delivered was too large, so he/she just hand carried the extra few items to a resident. Observation and interview on 05/08/24, at 1:20 P.M., showed an uncovered wire rolling cart was positioned along the A hall wall. Clean clothing hung on the rack or lay folded in the attached basket underneath. Housekeeping Staff Q delivered the articles into residents' rooms. The staff said the clothing cart did not have a cover. They usually delivered clean laundry from one of the same type carts. Sometimes they just picked up a few articles at a time and carried them to the correct room. During an interview on 05/08/24, at 2:49 P.M., the Housekeeping/Laundry Supervisor said the facility used rolling carts with attached baskets (not covered) to deliver clean laundry to residents. If there were only a few garments on hangers, staff would just hand carry them to the resident's room. During an interview on 05/08/24, at 2:53 P.M., the Director of Nursing (DON) said for delivering clean laundry, the facility used rolling carts with a hang-up rack and attached wire basket below. The carts did not have covers. Linens are taken on a covered cart to transfer to storage shelves on halls. During an interview on 05/08/24, at 3:01 P.M., the Administrator said the staff used rolling metal carts with clothing hung on the upper rod or folded in the wire basket below. Those carts were not covered. Linens are taken out on rolling plastic carts, covered, and transferred to wire shelving on the halls.

Based on record review, observation, and interview, the facility failed to ensure all bathroom were adequately equipped with a full call light system when call light pull cords were wrapped around the grab bars or missing in the bathrooms of eight residents (Resident #9, #21, #23, #108, #8, #26, #99, and #107) preventing the pull cord accessibility to call for staff assistance. A sample of 29 residents was reviewed in a facility with a census of 115. Review of the facility's policy titled, Call Lights, dated 04/30/24, showed the following: -The center will provide each resident with a functioning call light; -The call light alerts the staff to respond to a resident's request for assistance; -Be sure the call light is always within in reach of the resident. 1. Review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses include stroke, hemiplegia (weak or paralysis on one side of the body), seizure disorder, anxiety disorder, and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/03/24, showed the following: -Cognitively intact; -Impairment on one side of the body; -Independent with toileting hygiene and toilet transfer. Review of the resident's care plan, revised 05/08/24, showed the following: -Resident fall risk related to stroke with left side weakness; -Resident to call for assistance post toileting when he/she feels unsteady; -Keep call light and personal items within his/her reach; -Remind to call for transfer assist. Observations on 05/06/24, at 1:40 P.M., and on 05/07/24, at 8:35 A.M., of the resident's shared bathroom showed the call light pull cord wrapped tightly around the grab bar and tied preventing the resident from easily accessing and activating the call light. During an interview on 05/07/24, at 8:35 A.M., the resident said he/she uses the toilet and sink in his/her bathroom. 2. Review of Resident #21's face sheet showed the following: -admitted [DATE]; -Diagnoses include Type 2 diabetes (body has problem with regulating and using sugar as fuel), chronic kidney disease stage 3 (kidneys have mild damage and are less able to filter waste), and heart disease. Review of the the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Requires partial to moderate assistance with toileting hygiene and toilet transfer; -Impairment on both sides of the body. Review of the resident's care plan, revised 03/06/24, showed the following: -Resident is at increased risk for falls related to generalized weakness/advanced age; -Call light within reach; -Educate on call light use; -One assist with transfers. Observations on 05/06/24, at 1:40 P.M., and on 05/07/24, at 8:35 A.M., of the resident's shared bathroom showed the call light pull cord wrapped tightly around the grab bar and tied preventing the resident from easily accessing and activating the call light. During an interview on 05/06/24, at 1:40 P.M., the resident said he/she does use the toilet in his/her bathroom and he/she has needed to use the call light. 3. Review of Resident #23's face sheet showed the following: -Re-admitted [DATE]; -Diagnoses included Type 2 diabetes with chronic kidney disease stage, dementia (loss of memory), heart disease, major depression disorder, and generalized anxiety. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Requires partial to moderate assistance with toileting hygiene and supervision with toileting transfer. Review of the resident's care plan, revised 04/17/24, showed the following: -Fall risk related to the disease process and drug regimen; -Encourage resident to call for assistance when feeling tired or weak; -Encourage resident to call for assist with toileting, especially during the night when lighting is reduced. Observations on 05/07/24, at 10:10 A.M. and 2:20 P.M., of the resident's shared bathroom showed the call light pull cord was missing. During an interview on 05/07/24, at 2:20 P.M., the resident said he/she does use the toilet in his/her bathroom. 4. Review of Resident #108's face sheet showed the following: -admitted [DATE]; -Diagnoses included wedge compression fracture of fourth lumbar vertebra (back fracture) and type 2 diabetes. Review the resident's admission assessment MDS, dated [DATE], showed the following: -Cognitively intact; -Requires supervision with toileting hygiene and transfer. Review of the resident's care plan, revised 03/23/24, showed the following: -Resident at increased risk for falls related weakness and limited mobility; -Call light within reach; -Educate on call light use; -Transfer assist, one assist. Observations on 05/07/24, at 10:10 A.M. and 2:20 P.M., of the resident's shared bathroom showed the call light pull cord was missing. During interviews on 05/07/24, at 10:10 A.M. and 2:25 P.M., the resident said he/she does use the sink and toilet in his/her bathroom and he/she told the maintenance person a few days ago that the string is missing to the call light. 41787 5. Review of Resident #8's face sheet showed the following: -admitted [DATE]; -Diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), history of falling, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and generalized anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Used walker and/or wheelchair for mobility; -Independent with toileting hygiene; -Independent with upper and lower body dressing; -Supervision with transferring from bed, chair, or toilet. Review of the resident's care plan, reviewed on 05/04/24, showed the following: -Resident at increased risk for falls related to Parkinson's, poor safety awareness, and history off falls; -Staff should re-educate resident to call for assistance when needed; -Staff should keep call light within reach. Observation on 05/07/24, at 10:55 A.M., of the resident's shared bathroom showed the call light cord wrapped around the positioning bar in the bathroom. The cord was wrapped around the bar multiple times and did not extend past the bar and was about four feet from the floor. The cord was not easily accessible for activation by the resident. During an interview on 05/07/24, at 11:00 A.M., the resident said that if he/she was in the bathroom and had a fall on the floor, he/she would not be able to reach the call light because it does not reach past the grab bar or to the floor. 6. Review of Resident #26's face sheet showed the following: -admitted [DATE]; -Diagnoses included cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain), malignant neoplasm (cancer) of large intestine (colon), and insomnia (sleep disorder with trouble falling and/or staying asleep). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Use of motorized wheelchair for mobility; -Partial to moderate assistance with toileting hygiene; -Partial to moderate assistance with transfers from bed, chair, or toilet. Review of the resident's care plan, reviewed 03/05/24, showed the following: -Resident is at increased risk for falls related to generalized weakness and advanced age; -Staff should keep call light within reach; -Staff should educate on call light use. Observation on 05/07/24, at 10:55 A.M., of the resident's shared bathroom showed the call light cord wrapped around the positioning bar in the bathroom. The cord was wrapped around the bar multiple times and did not extend past the bar and was about four feet from the floor. The cord was not easily accessible for activation by the resident. During an interview on 05/07/24, at 11:10 A.M., the resident said if he/she was on the floor he/she would not be able to reach the call light in the bathroom. When he/she is on the toilet he/she cannot reach the call light if the cord was not pulled forward as the cord is behind him/her when seated on the toilet. 7. Review of Resident #99's face sheet showed the following: -admitted [DATE]; -Diagnoses included post traumatic stress disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), major depressive disorder, type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), and autoimmune hepatitis (disease that happens when the body's immune system attacks the liver). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with toileting hygiene; -Independent with transfers from bed, chair, and toilet. Review of the resident's care plan, reviewed 04/03/24, showed the following: -Resident was at risk for increased fall related to generalized weakness and history of falls; -Staff should keep call light within reach; -Staff should educate on call light use; -Staff should provide transfer assist as needed. During an observation and interview on 05/10/24, at 10:45 A.M., the resident said he/she would not be able to reach the call light if he/she fell on the floor in the bathroom. The call light was wrapped around grab bar several times on the left side of the toilet. The call light does not reach past the grab bar. 50185 8. Review of Resident #107's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required partial/moderate assistance with toileting hygiene and toileting transfer; -Diagnoses included seizure disorder, high blood pressure, and anemia. Observation on 05/06/24, at 4:06 PM., of the resident's shared bathroom showed the call light about 4 feet from the floor. The call light did not have a string hanging down and was not accessible from the toilet or the floor. Observation on 05/10/24, at 9:25 A.M., of the resident's shared bathroom showed the call light without a string hanging down and was not accessible from the toilet or the floor. During an interview on 05/10/24, at 9:26 A.M., the resident said he/she uses the bathroom on a regular basis. He/she uses his/her room call light instead of the bathroom light since it doesn't have a string. During an interview on 05/10/24, at 10:24 A.M., Certified Nurse Aide (CNA) O said the resident used the bathroom and call light in the bathroom. The resident required assistance with walking back and forth. 9. During an interview on 05/09/24, at 1:02 P.M., CNA K said call lights should always be within reach. He/she directly hands the call lights to the residents and/or will clip It to their blankets. Residents should be able to reach the call lights in the bathrooms, they should not be wrapped around anything in the bathroom. He/she has seen call lights not be accessible in some of the resident's bathrooms. He/she has reported this, if it's not fixed in a timely manner, he/she will fix it his/herself. 10. During an interview on 05/08/24, at 10:21 A.M., CNA A said the following: -Call lights should always be accessible, both at the bedside and the bathroom; -He/she sometimes ties the string around the grab bar so the resident can reach the string since the call light is back pretty far; -Some resident's call lights in the bathroom don't have strings; -Maintenance checks the call lights to see if they work and if they have strings. 11. During an interview on 05/08/24, at 10:27 A.M., CNA B said the following: -Call lights should always be accessible in the room and bathroom; -The call lights should have strings on them. Sometimes the residents aren't able to reach the strings so they wrap them around the grab bar; -All call lights in the bathrooms should have strings; -He/she doesn't tie the strings to the grab bars he/she wraps it around the grab bar if the resident wants them too; -Maintenance checks the strings and to make sure they work, he/she isn't sure how often. 12. During interviews on 05/08/24, at 10:35 A.M., and on 05/09/24, at 1:52 P.M., Licensed Practical Nurse (LPN) C said the following: -Call lights should always be accessible to residents; -Call lights in the bathroom should have a string and it should be hanging down; -It would not be appropriate to tie the string around the grab bar; -If the string is tied to the grab bar the resident couldn't pull it if they were on the floor; -When he/she sees a call light wrapped up, he/she unwraps it. If any staff member sees a call light without a string, they should tell maintenance. 13. During an interview on 05/10/24, at 11:00 A.M., the Director of Nursing (DON) said call lights should be easily accessible from the resident's bed, the bathroom, and the floor. 14. During an interview on 05/10/24, at 12:00 P.M., the Administrator said that call lights are to always be within reach of the resident. Call lights being wrapped up and not accessible to the residents is not acceptable.

Based on observation, interview, and record review, the facility failed to determine all residents who self-administered medications were clinically appropriate to do so when staff left medications at bedside for one resident (Resident #99) to administer to his/herself unattended without an assessment, order, or care plan to do so. The facility census was 115. Review of the facility policy titled Specific Medication Administration Procedures, revised 01/01/19, showed the following information: -Administer medication and remain with resident while medication is swallowed. Do not leave medications at bedside, unless specifically ordered by prescriber; -Chart medication administration on Medication Administration Record (MAR) immediately following each resident's medication administration. 1. Review of Resident #99's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included post traumatic stress disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), major depressive disorder, type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), and autoimmune hepatitis (disease that happens when the body's immune system attacks the liver). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/09/24, showed the resident was cognitively intact. Review of the resident's care plan, reviewed 04/03/24, showed the following: -Resident was prescribed clonazepam (used to treat seizures, panic disorder, and anxiety) and duloxetine (used to treat depression and anxiety) to help manage her anxiety and depression; -Staff should administer psychoactive (drug affecting the mind) medications as ordered; -Staff should observe for potential adverse effects; -Resident may experience intermittent generalized pain; -Staff should administer medications as ordered and assess for effectiveness. (Staff did not care plan self-administration of medications by the resident.) Review of the resident's record showed the facility did not have documentation of an assessment to determine if the resident was to safely able to self-administer his/her medications. Review of the resident's current Physicians' Orders showed no order for the self-administration of medication by the resident. Review of the resident's May 2024 MAR showed on 05/08/24, at 10:19 A.M., staff documented medications as administered at 10:19 A.M. The medications administered included aldactone (used to treat high blood pressure and heart failure) tablet 50 milligram (mg), duloxetine capsule 60 mg, lisinopril (used to treat high blood pressure) tablet 5 mg, polyethylene glycol 3350 powder 17 gram/dose (used to treat constipation), and sennosides-docusate sodium tablet 8.6-50 mg (used to treat constipation). During an interview and observation on 05/08/24, at 1:14 P.M., the resident was seated in his/her bedside chair. The resident said he/she had returned from a medical procedure at about 11:30 A.M. and had not been given his/her 9:00 A.M. medications yet. The resident then looked at his/her bedside table and said Oh, I remember they brought the pills and left on bedside table when I returned at about 11:30 A.M. I just had not taken them yet. There were four tablets in the medication cup. During an interview and observation on 05/10/24, at 10:45 A.M., the resident rested in bed with eyes open facing away from the bedside table. The resident arranged self to sit on the side of the bed. There were four pills in cup on the bedside table. The resident rested in bed with eyes open. The resident said that staff trust him/her to take the medications, so they leave until he/she is more awake to take the medications. During an interview on 05/10/24, at 9:53 A.M., Licensed Practical Nurse (LPN) F said staff should not leave medications with residents. During an interview on 05/10/24, at 11:10 A.M., Registered Nurse (RN) D said that staff should not leave any medications in resident rooms or at the dining room table for residents to take later. During an interview on 05/10/24, at 12:00 P.M., LPN G said medications are not left with residents to take later. Staff can take medications out of the rooms and return when resident would prefer. During an interview on 05/10/24, at 12:32 P.M., the Director of Nursing (DON) said staff should not leave medications in a resident's room unless there is a physician's order to do so. Staff should not leave medications with a resident to take later. Staff should watch residents take their medications. It is not permissible for staff to leave medications at bedside or at the dining room table. Staff could step back and still observe a resident take the medications. During an interview on 05/10/24, at 1:32 P.M., the Administrator said medications should not be left at bedside or at table in dining room. Staff should monitor the resident taking the medication.

Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority when one resident (Resident #100), a previously identified by the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings) as having a mental disorder, experienced a significant change. The facility census was 115. Review of the facility's policy titled Pre-Admission Screening and Resident Review (PASARR), dated 11/2016, showed the center should refer any patient for Level II resident review upon a significant change in status/condition such as newly evident or possible serious mental disorder, intellectual disability, or a related condition. 1. Review of Resident #100's face sheet (gives basic profile information at a glance) showed the following information: -admitted [DATE]; -Admission diagnoses included major depressive disorder (persistent feelings of sadness), generalized anxiety disorder (persistent worry or anxiety), and unspecified dementia with other behavioral disturbances. Review of the resident's Level 1 Nursing Facility Pre-Admission Screening for Mental Illness/Mental Retardation or Related Condition, dated 08/11/2023, showed the following information: -Identified mental illness of major depression disorder; -Primary reason for nursing facility placement not due to dementia; -Had not had serious problems in levels of functioning in the last six months; -Had not received intensive psychiatric treatment in the past two years; -Not known or suspected to have mental retardation that originated prior to age 18; -Not known or suspected to have a related condition. Review of the resident's progress notes showed the following: -On 01/23/24, resident had been telling the staff to go f--- themselves and calling everyone a bunch of thieves and accusing staff of not caring about him/her; -On 01/23/24, resident refusing all cares and not allowing staff to change his/her soiled clothing; -On 01/23/24, staff told the resident if he/she changed his/her mind about being changed the staff would help. The resident kicked at the staff in the air and told them he/she would not change his/her mind and just leave him/her the f--- alone; -On 01/23/24, resident threatened another resident and was throwing things in his/her room destroying things and cussing staff. Resident was reported to be combative, agitated, yelling, cursing staff, and refusing cares. Staff could hear resident threatening to kill him/herself, kill the housekeeper, and kill his/her roommate. The resident attempted to throw his/her television; -On 01/23/24, staff updated the nurse practitioner and staff was told to send the resident out to the hospital. Staff called 911 and police officers showed up first and approached the resident. Resident yelled and cursed at the police officers. Emergency medical technicians were able to get the resident on the stretcher and out of the facility; -On 01/24/24, family called and informed facility that the resident was transferred to a geriatric psychiatric facility and will remain there for at least five days; -On 01/30/24, social services spoke with resident's family requesting records from the resident's hospitalization to determine if the facility could still meet the resident's needs. Review of the resident's medical record showed staff did not refer the resident after a significant change in status, for a Level II PASARR review. During interview on 05/10/24, at 8:56 A. M., the Social Service Director, Long Term Care Social Worker, and Rehabilitation Social Worker said the following: -Level I screenings are completed prior to facility admission on all residents; -Level II screenings are completed when the level I indicates the need for a level II; -The resident had a level one screening completed in 2023 with a diagnosis of major depression and anxiety disorder, there was no level II recommended; -The resident had a hospitalization in January 2023 for threatening to harm him/herself and others, and a level II was not completed and probably should have been done; -Social Services received information from COMRU that indicated a level II could be done after a significant change. During an interview on 05/10/24, at 10:40 A.M., the Director of Nursing (DON) said the following: -He/she doesn't handle PASARR's and doesn't know about a level I screening; -He/she knows there is a level II screening done on mentally incapacitated residents and social services takes care of those. During interview on 05/10/24, at 10: 50 A.M., the Administrator said the following: -Level I screening for PASARR's are done per regulation at the hospital; -Level II is done with there is a positive level I screening; -Would need to check when a level II screening needs to be completed a second time; -He/she doesn't know if one would need to be completed for the resident after being hospitalized at a geriatric psych unit; -Social services takes care of the level II screenings and he/she would need to check with them.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights for one resident (Resident #1) when one staff (Social Worker C) became the resident's Durable Power of Attorney (DPOA-an appointed individual to act on your behalf, granting the person the power to do all things you might do) and failed to use the resident's funds in the best interest of the resident. The facility census was 111. Record review of the facility's policy titled Professional Relationships with Patients, undated, showed the following: -All partners are expected to maintain a professional relationship with patients at all times in order to assure the highest quality of patient care; -Partners are discouraged from personal contact, out of the facility, with current or former patients including phone calls and letters; -Partners are not permitted to provide or accept from patients or their family members, or from former patients and their family members, money, or improper gifts. 1. Record review of Resident #1's face sheet (a one page summary of important information about resident) showed the following: -Admission to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/28/19, showed the following information: -Resident is cognitively intact. Record review of the resident's Durable Power of Attorney (DPOA) paperwork, dated 08/15/19, showed the following: -Social Worker (SW) C was appointed as the DPOA by Resident #1; -This Durable General Power of Attorney is created in accordance with Missouri law and, in addition to the general powers granted by statute (including, but not limited to, the ability to access bank accounts, safe deposit boxes, deposit funds, withdraw funds, draft checks, perform any other financial transaction); -The DPOA is to provide an additional fiduciary power or authority; to limit fiduciary powers or authority; to make other administrative changes so long as such changes are in the resident's best interest or in the best interest of the resident's beneficiaries. Record review of the resident's bank statement, dated 09/12/19, showed the following transactions: -Check #1001, Exact Cleaning, LLC, 08/13/19, $500; -Check #1010, Exact Construction and Cleaning, 08/23/13, $20,000; -Check #1012, Furniture Row, 08/25/19, $2337.68; -Check #1011, Furniture Factory Outlet, 08/25/19, $1787.98; -Debit transaction, Comenity Pay, $61.31; -Check #1013, Hometown Furniture, 08/29/19, $2450; -Debit transaction, Dillards, 08/30/19, $59.77; -Debit transaction, withdraw from ATM, $400.00; -Debit transaction, Urban Air, 09/03/19, $24.49; -Debit transaction, Wendy's, 09/03/19, $35.19; -Debit transaction, At Home, 09/03/19, $391.59; -Debit transaction, Dillards, 09/03/19, $397.79; -Debit transaction, Dillards, 09/03/19, $63.24; -Debit transaction, Krispy Kreme, 09/03/19, $20.88; -Debit transaction, Cedar Creek Dulcimer, 09/03/19, $20.41; -Debit transaction, Silver Dollar City, 09/03/19, $98.72; -Debit transaction, Chick-Fil-A, 09/04/19, $49.07; -Check #1000, Cardin's, 09/04/19, $1197.06; -Check #1001, Exact Cleaning and Construction, LLC, 09/05/19, $4950.00; -Debit transaction, Home Goods, 09/09/19, $266.76; -Check #1002, CS of S, 09/10/19, $200.00. Record review of the resident's Revocation of Power of Attorney, dated 09/16/19, showed the following: -Resident #1 revoked all powers of attorney that had been granted to SW C; -SW C no longer has the authority to act on Resident #1's behalf and any authority previously conferred by any Power of attorney is revoked, canceled, and terminated as of this date and time. During an interview on 10/22/19, at 9:00 A.M, the Assistant Administrator said staff are not allowed to be a DPOA for a resident. He/she is unaware of any staff acting as a resident's DPOA. During an interview on 10/22/19, at 10:30 A.M., the Social Service Director (SSD) said social services will assist residents with DPOA paperwork. Staff are not allowed to be a resident's DPOA. He/she is unaware of any staff acting as a resident's DPOA. During an interview on 10/22/19, at 1:30 P.M., SW C said he/she was the DPOA for Resident #1 for approximately a month to a month and a half. He/she said Resident #1 had a DPOA, but was not happy with them. Resident #1 contacted her attorney and requested for SW C to be her DPOA for both health and finances. SW C advised Resident #1 that he/she could only be his/her DPOA while he/she was at the facility and when he/she was discharged he/she would no longer be his/her DPOA. SW C said he/she did not scan or turn in to be scanned to medical records the updated DPOA paperwork appointing him/her as the DPOA. He/she does not know why he/she did not scan or have the paperwork scanned or make a note regarding the new DPOA paperwork in the resident's file. During an interview on 10/29/19, at 10:00 A.M., Social Worker (SW) D said he/she will witness residents with DPOA paperwork occasionally, and will scan in the paperwork. He/she would not agree to be a resident's DPOA as it is against company policy. He/she was not aware of any staff serving as a DPOA for any residents. If a resident did request him/her to serve as a DPOA, he/she would advised against policy and he/she would notify their supervisor. During an interview on 10/29/19, at 10:15 A.M., SW E said he/she is unaware of any staff serving as a resident's DPOA. If asked to be a DPOA by a resident, he/she would advise the resident he/she was unable to be a DPOA, and then would notify the resident's family and his/her supervisor. During an interview on 10/29/19, at 10:45 A.M., SW F said he/she has not been asked by a resident to serve as a DPOA. If asked, he/she would advise the resident it is not allowed, and he/she would notify their supervisor. During an interview on 10/29/19, at 11:30 A.M., with the acting Administrator, Director of Nursing, and the SSD, the Assistant Administrator said an employee acting as a resident DPOA is strictly prohibited by company policy. If a resident was to ask an employee to be the DPOA they would need to advise the resident they cannot be the DPOA and notify the Administrator. The SSD said social services discusses DPOA paperwork with the resident. If they already have a DPOA in place, or if they would like to fill out the paperwork, social services will assist them, and then will scan the DPOA paperwork into the electronic file. During an interview on 10/31/19, at 9:30 A.M., Resident #1 said he/she became unhappy with his/her previous DPOA. Resident #1's attorney advised due to his/her declining health, he/she should have a DPOA in place. He/she trusted SW C, as he/she was nice and seemed to care about him/her, therefore he/she asked SW C to be his/her DPOA. On 08/15/19, Resident #1's attorney came to the facility, and the attorney, SW C, and Resident #1 were in Resident #1's room. Resident #1 signed the paperwork making SW C his/her DPOA. He/she was not aware that a facility staff could not be a resident's DPOA. SW C never advised Resident #1 that he/she would no longer be Resident #1's DPOA once she left the facility. Resident #1 planned on SW C continuing to be his/her DPOA indefinitely. Resident #1 was unaware that SW C had placed his/her name on Resident #1's bank account. It was not until Resident #1 went to the bank on 09/06/19, that he/she became aware that SW C had placed his/her name on the account and had been writing checks and been using Resident #1's debit card. Resident #1 did not give SW C permission to place her name on the account, nor was he/she aware of the purchases SW C had made. None of the purchases made by SW C were for or on the behalf of Resident #1. MO 715/MO 242