Every finding on record at Springfield Skilled Care Center

Based on interview and record review, the facility failed to obtain a radiology services to meet the needs of all residents when staff failed to obtain an ordered x-ray in a timely manner for one resident (Resident #1) who complained of wrist pain. The facility's census was 107.Review showed the facility did not provide a policy regarding x-rays services. Review of the facility's policy, Physician's Orders, dated 09/28/22, showed the following:-Purpose to provide guidance and ensure physician's orders are transcribed and implemented in accordance with professional stands, state and federal guidelines;-Physician's order sheets (POS) will be maintained with current physician orders as new orders are received. Discontinued orders will be marked as discontinued with the date, and all new order will be written in the appropriate area on the POS with the date the order was received. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 06/19/24;-Diagnoses included cognitive communication deficit (difficulty with thinking skills), guillain-barre syndrome (auto immune disorder where the immune system mistakenly attacks the nerves in the legs), pain, and panic disorder (episodes of fear with shortness of breath). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/01/26, showed the following information:-Cognitively intact;-Impairment on both sides;-Used a wheelchair for mobility;-Required supervision assistance with upper body dressing, toileting hygiene and personal hygiene;-Required partial assistance with showers, and lower body dressing. Review of the resident's nurse practitioner (NP) progress note, dated 06/29/26, showed the following:-Chief complaint of left wrist pain and edema (swelling) following brace removal;-Resident seen today at the request of staff for evaluation of left wrist pain and edema;-Resident is post a recent left wrist fracture and the orthopedic specialists had recently removed the stabilizing brace;-Resident reported active left wrist pain, currently managed with as needed analgesics (painkiller);-Left wrist edema noted with brace no longer in place. Wheelchair used for mobility;-Ordered left wrist x-ray today;-Instructed nursing to apply ice to the left wrist four times daily for swelling;-Continue current pain management regime. Review of the resident's June 2026 showed an order, dated 06/29/26, for a left wrist x-ray, one time only for three days; Review of the resident's June 2026 Medication Administration Record (MAR) showed on 06/29/26, at 4:01 P.M., LPN K signed off the left wrist x-ray was completed Review of the resident's record showed staff did not document regarding completion of the x-ray ordered, results, and physician notification of the x-ray delay Review of the resident's July 2026 POS showed an order, dated 07/07/26, for left wrist 2 view x ray, stat (immediately) one time only for pain for 3 days. During an interview on 07/07/26, at 1:15 P.M., the resident said the following:-His/her wrist had been hurting more the past two weeks;-His/her wrist was swollen, red, and bruised;-He/she rated his/her pain a 9 on a scale from 1 to 10;-He/she saw the NP on 06/29/26, and they ordered an x ray. The x-ray had not been completed; -He/she saw the doctor on 07/06/26, and there was no x ray completed by then. During an interview on 07/08/26, at 10:45 A.M., Certified Medication Tech (CMT) I said when an x-ray is ordered, the nurse will add the order to the resident's Treatment Administration Record (TAR) and those orders were completed by nurses. During an interview on 07/08/26, at 12:41 P.M., LPN K said the following:-If the doctor orders an x ray, staff obtain what views are requested and put this order into the TAR;-The nurse calls the x-ray company and provides them the information on the x-ray, what views, which doctor ordered the x-ray, and the resident's room number;-The x-ray company provided an estimated timeframe of when their tech would be out;-On stat orders it's usually a couple of hours and on non stat orders, probably the next day;-All of the information is put into the resident's medical record;-The resident came to him/her about an x-ray and he/she asked Registered Nurse (RN) J. RN J said one was ordered and it was done on 07/07/26 (eight days after the original order.) During an interview on 07/28/26, at 12:51 P.M., RN L said the following:-When there is an order for an x-ray, staff place it in the medical record;-The nurse will call the x-ray companty, print out the face sheet and the physician's order, and place them in the book;-If the x-ray is ordered stat, it's usually that day. If it's not stat, it's usually completed the following day; -If the x ray is not done the following day, he/she would call the x-ray company to see where the resident is at on the list;-The order is placed on the nurse's TAR and they mark it off as done, when it's done;-If it's placed on the TAR for a three day order, it will fall off after three days whether the x-ray was completed or not;-He/she was not aware of an order prior to the one for 07/07/26;-The resident got his/her x-ray done on 07/07/26. During an interview on 07/08/26, at 1:16 P.M., LPN M said the following:-When an x-ray is ordered by the doctor or NP, the floor nurse, NP, or doctor will put it into the medical record for the nurses to complete;-The nurse will call the x-ray company to give them the order, and the provide the necessary information;-If the order is stat, it normally takes less than two hours;-If the order is not stat, it takes two to four days. If it is not completed within the time frame, the staff will call 24 hours after to follow up;-The doctor or NP put in the order for the resident and it was placed for three days. If it's not completed, it will fall off. During an interview on 07/08/26, at 1:33 P.M., the Assistant Director of Nursing ADON (A) and ADON (B) said the following:-X-rays are put in the orders and nurses are responsible for putting them into the TAR;-The ADONs check the orders from the NP and doctor's daily and add them to the TAR;-When an x-ray is ordered, the nurse is responsible for calling x-ray company and providing them the information and then they print of the order and face sheet and place that in the book;-ADON B provided the book with multiple orders and it did not have any orders for the Resident;-When the x-ray company comes in to do the x-ray, they take the paperwork out of the book;-A non stat order is usually completed the same day, or the following day;-If the x-ray has not been completed in three days, he/she would expect staff to be calling the x-ray company to see when they will be coming;-They expected the staff to notify the doctor to see if they want the resident to be sent out;-The order is listed on the TAR, if it is not completed, and it's only on there for 3 days, it will fall off whether it's done or not;-They did not know the resident had an x-ray ordered on 06/29/26. It should not be marked off as completed if it was not completed. During an interview on 07/08/26, the Director of Nursing (DON) said the following:-When an x ray is ordered, the doctor or NP puts the order in the electronic medical record this pops up when the order is due and the nursing staff confirm the details and call x-ray company;-The nursing staff provide the x-ray company all of the necessary information and they print off the face sheet and order and this is put in the book for x-ray company when they arrive;-Sometimes a non stat order can take several days;-He/she would expect the staff to call the x-ray company if they have not shown up in two to three days;-The x-ray company did not complete the order for the resident's x ray on 06/29/26. He/she looked for the results and did not find them so an order was placed for stat x-ray. During an interview on 07/08/26, the Administrator said the following:-Nurses put orders for x-rays on the TAR in the electronic medical record;-The nurse will call the x-ray company and they are usually out in a reasonable time. If the order, if not stat it usually takes one day;-If the x-ray company did not show up, he/she would expect staff to follow up in three days with the x-ray company;-The staff print off the order and face sheet and this information is placed into the book;-The ADONs are responsible for ensuring the orders are completed;-He/she didn't know why it wasn't done and believed it was overlooked. Complaint #3067770

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable and homelike environment for all resident including (Resident #65, #111, #87, #8, #31, #38, and #82) when the facility failed to eliminate strong urine odors, failed to clean floors in a timely fashion, failed to keep walls clean, failed to repair a faucet timely and failed to remove trash timely. The facility census was 113. Review of a facility policy entitled Basic Cleaning Concepts, undated, showed the following:-General sanitizing: To make a surface or area clean by removing dirt, germs or unwanted substances;-Cleaning: The physical removal of dust, soil, blood and body fluids. Cleaning physically removes germs. It is accomplished with water, detergents and mechanical action;-Surfaces must be cleaned first before applying disinfectant in order to kill germs;-Hospital clean is a measure of cleanliness routinely maintained in care areas of the health care setting; floors are free of stains, visible dust, spills, and streaks. 1. Observations showed the following:-On 06/07/26, at 2:50 P.M., a strong urine odor permeated the entry area to the facility; -On 06/07/26, at 6:46 P.M., the facility entrance lobby smelled strongly of urine; -On 06/08/26, at 8:30 A.M., a strong urine odor present at the front door area of the facility.-On 06/09/26, at 6:00 A.M., a strong urine odor present in the front lobby of the facility. Observation on 06/09/26, at 12:37 P.M., showed a strong urine odor outside of the conference room and into the 100 and 200 hallways. Observation on 06/11/26, at 2:56 P.M., showed Resident #65 and Resident #111 in the common area talking. Resident #65 said, this couch smells like piss to Resident #111 and who nodded in agreement. During an interview on 06/12/26, at 4:18 P.M., Certified Nursing Assistant (CNA) S said the following: -There should not be a strong urine odor throughout the facility; -The aide acknowledged there was a strong urine odor. During an interview on 06/12/26, at 5:02 P.M., the Director of Nursing (DON) said they try to keep the facility clean and odor free, but it is tough because of a resident in the 500 hallway that urinates in the room and trash. During an interview on 06/12/26, at 5:14 P.M., the Administrator said they try to keep the facility clean and without strong foul odors, but a resident in the 500 hall throws urine and did not like to be changed. 2. Observation on 06/07/26 showed the following:-At 3:01 P.M., a trail of a yellow, liquid substance was on the entire length of floor from room [ROOM NUMBER] to room [ROOM NUMBER] on the 200 hallway; -At 3:14 P.M., the trail of a yellow, liquid substance remained on the entire length of floor from room [ROOM NUMBER] to room [ROOM NUMBER] on the 200 hallway. -At 3:20 P.M., the trail of a yellow, liquid substance remained on the floor in the 200 hallway.-At 3:48 P.M., the yellow, liquid substance remained on the 200 hallway floor. An aide pushed a resident in a wheelchair down the 200 hallway. Staff did not clean the floor;-At 4:12 P.M., the yellow, liquid substance remained on the hallway floor. Resident #87 walked on the hall floor bare foot near and around the area of the yellow liquid substance;-At 4:29 P.M., another aide pushed a different resident in a wheelchair down the 200 hallway. The yellow, liquid substance was smeared and partly dried up. 3. Review of Resident #8's face sheet showed the following:-admission date of 09/11/18;-Diagnoses included Parkinson's disease (progressive disorder of the central nervous system that affects movement and worsens over time), severely overweight, depression, bipolar disorder (extreme mood swings), dementia, chronic fatigue, overactive bladder, and urinary incontinence. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/03/26, showed the following:-Cognition intact;-Frequently incontinent of bladder;-Functional limitation to range of motion: upper and lower extremities, both sides;-Manual wheelchair, propelled by self;-Required partial/moderate assist with toileting. Review of the resident's care plan, current as of 06/12/26, showed the resident had frequent bladder incontinence and needed assistance with toileting; resistant to care, but encourage to ask for assistance. Observation and interview on 06/08/26, at 2:35 P.M., showed the following:-A puddle of liquid on the floor of 300 hall outside the doorway of Resident #8;-Resident #31 exited his/her room and walked down the hall. He/she pointed at the puddle, made a face, pointed at the room and the puddle, and said that Resident #8 had urinated onto the floor again and that Resident #8 had urine odor all the time;-Resident #31 continued down the hall and told a staff member about the puddle. The staff member looked down the hall toward the puddle and nodded his/her head at Resident #31. Observation on 06/08/26, at 2:44 P.M., showed the puddle remained outside Resident #8's doorway. Two housekeeping staff walked down the hall toward the puddle but turned onto the 400 hall (two doors away) before reaching Resident #8's room. Observation on 06/08/26, at 2:45 P.M., showed Resident #8 sitting on his/her bed removing his/her wet pants and underwear. The puddle remained on the floor outside his/her room. Four staff conversed in the hallway two doorways away from Resident #8's room. The two housekeeping staff returned from the 400 hall but turned in the opposite direction from the puddle. Observation on 06/08/26, at 2:50 P.M., showed Resident #8 put on dry clothing and sat down in his/her wheelchair. Observation on 06/08/26, at 2:54 P.M., showed Resident #38 exited his/her room. As he/she walked past the puddle in front of Resident #8's room, Resident #38 waved a hand in front of his/her face, pointed at the floor, and said, They need to change (him/her)! That's urine! Observation on 06/08/26, at 2:55 P.M., showed an unknown therapy staff walked to the end of 300 hall, turned around and walked back up the hall the way he/she came, stepping around the puddle. Observation on 06/08/26, at 3:01 P.M., showed the Corporate Nurse Consultant walked down to the end of the 300 hall and looked down at the floor and puddle. The nurse turned and walked back up the hall. Resident #8 approached the puddle in his/her wheelchair from inside his/her room and placed a towel on top of the puddle. The nurse returned at 3:03 P.M. with supplies to clean up the puddle. 4. Observation on 06/10/26, at 8:47 A.M., showed the following:-Resident #82 spilled a cup of soda on the floor around the bed;-CNA Q answered the call light, used a towel to wipe off the soda and placed the resident's dirty cup on top of the roommate's bedside table;-CNA Q did not pick up the wet receipt, straw wrappers, used tissues, empty plastic bag, or food crumbs off the floor. 5. Observation and interview on 06/09/26, at 10:14 A.M., showed Resident #50 pointed out two areas on the floor near the door with a dried orange substance the resident called food. The resident said the substance had been there for days. 6. During an interview on 06/12/26, at 9:35 A.M., the Activity Assistant said the following:-If there was a spill, he/she will lay something over it and then let a housekeeper (HK) know;-If it is urine, then he/she will inform a CNA or nurse;-If it is juice or water, then he/she will let HK know and they do try to find a caution, wet sign. During an interview on 06/12/26, at 4:18 P.M., CNA S said all staff should clean up a spill and put up a wet floor sign. During an interview on 06/12/26, at 3: 54 P.M., CNA R said the following:-Staff should clean up a spill immediately with a towel or something and put up a wet floor sign. Aides do not usually mop. Housekeeping mops. During an interview on 06/12/26 at 1:55 P.M., Certified Medication Technician (CMT) P said the following:-If there is a spill, get a towel and put it over the spill;-If it is not identifiable, then a CNA or he/she or a nurse would clean it up;-If it is not any kind of bodily fluid, then HK is able to clean it. During an interview on 06/12/26, at 1:40 P.M., the Assistant Director of Nursing (ADON) A said the following:-If someone comes across a spill, they should notify a nurse or CNA to clean it up;-HK is only allowed to clean up non-bodily fluid spills;-If it is some kind of bodily fluid, they should notify nursing;-Whoever finds a spill should first put up a wet floor sign for safety. During an interview on 06/12/26, at 4:09 P.M., ADON B (also a charge nurse) said if there was a spill on the floor, staff should place a wet floor sign, clean up immediately, and inform housekeeping. During an interview on 06/12/26, at 2:20 P.M., the Administrator said the following:-Spills need to be addressed as soon as noticed;-The HK department is not allowed to clean up bodily fluids and this is how it is preferred;-If something is from a resident, perhaps they become ill and it got on the floor or a surface, nursing is expected to address that;-If it is a drink or food, HK would take care of those cleaning tasks. 7. During an observation and interview on 06/07/26, at 3:25 P.M., Resident #82 said the following:-The shared shower room faucet was broken. There was hot water continuously running, and the water temperature could not be adjusted;-The shower had mildew on the tiles, grout, and ceiling;-There were no paper towels in the resident's bathroom;-He/she had reported these issues to staff multiple times. Observation on 06/08/26, at 10:23 A.M., showed the following in the shower room in between the 300 and 400 hallways: -Shower head running water at a low, steady pressure;-Unable to shut off the water in the shower. The faucet was broken. Water continously ran; -A thin line of mildew in the corner tiles, all along the bottom where the wall meets the floor, and areas on the ceiling of the shower;-Fan air vents did not work. The fans did not turn on. During an interview on 06/12/26, at 1:50 P.M., CNA M said he/she had worked at the facility for the last nine months and the shower head faucet had been broken and would not turn off the entire time. 8. Observation on 06/08/26, at 10:23 A.M., showed in the shower room in between the 300 and 400 hallways, the trash can was full of dirty briefs and wipes. The trash can did not have a liner in it. 9. During an interview on 06/11/26, at 2:46 P.M., CNA C said the following:-Trash cans should have a liner inside and trash should be taken out of a resident's room before exiting;-All staff should clean noticibly dirty surfaces. During an interview on 06/11/26, at 2:50 P.M., CNA M said the following:-All staff should clean dirty surfaces as needed;-Trash cans should have a liner inside and trash should be taken out when leaving a room. During an interview on 06/12/26, at 4:18 P.M., CNA S said the following: -Staff should take out the trash at the end of the shift and after incontinence care; -Housekeeping should do the daily room cleaning. During an interview on 06/12/26, at 3:54 P.M., CNA R said the following:-Staff should take out the trash at the end of the shift or after a resident was changed;-Trash cans should have liners in them;-All staff should clean a bedside table if he/she noticed it was dirty. During an observation and interview on 06/12/26, at 4:09 P.M., ADON B said the following:-Housekeeping completes the daily cleaning;-He/she expected the aides to take out the trash after incontinence care and to place a liner in the trash can;-He/she expected aides to pick trash up off the floor and to clean dirty bedside tables. During an interview on 06/12/26, at 4:35 P.M., the DON said the following:-He/she expected aides to take out the trash when full or after incontinence care and replace with a new liner; -He/she expected any staff member to clean a spill or dirty area; -Housekeeping and laundry are a combined department. Housekeeping does the deep cleaning; sweep, mop, dust, but do not clean up body fluids. Only aides and nurses can clean up body fluids; -All staff have access to cleaning supplies. There are no housekeepers on the night shift;-He/she expected shower rooms to be cleaned by shower aides in between residents and housekeeping to do the deep cleaning of the shower room at end of the day;-Housekeepers work eight hour shifts. Two shifts per day during the day and evening;-The housekeeping supervisor conducts cleaning follow-ups. Complaint #2980701, #3009095, #3035805, and #3037972

Based on observation, interview, and record review, the facility failed to maintain staff in sufficient numbers with sufficient training to ensure call lights were answered in a timely manner for seven residents (Residents #10, #70, #82, #86, #94, #65, and #61). The facility census was 113.Review of the facility policy Resident Call System, revised 06/02/26, showed the following:-The facility call system relays calls directly to a centralized work area from the resident's bedside, toilet, and bathing areas;-The call system was accessible to residents as required by State/Federal guidelines;-Upon admission, nursing will orientate residents on how to utilize the resident call system;-During rounds, nursing and Interdisciplinary Team (IDT) members will ensure resident call system is within reach of the resident;-Any malfunction, outage, or interruption of the resident call system will be addressed immediately;-Interim measures may include handheld manual bells, increased safety rounds, one-to-one observation, or other measures necessary to ensure resident access to assistance until repairs were completed;-Maintenance Director will complete routine resident call system inspections. 1. Review of Resident #10's face sheet (gives basic profile information) showed the following:-admission date of 10/29/25;-Diagnoses included breathing disorder, diabetes, schizophrenia (a mental health condition that affects how people think, feel and behave), depressive disorder, difficulty in walking, repeated falls, muscle weakness, need for assistance with personal care, and pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/23/26, showed the following:-Moderately impaired cognition;-Required supervision or touch assistance for toileting hygiene, personal hygiene, bathing, dressing, mobility, and walking with the use of a walker. Review of the resident's care plan, current as of 06/12/26, showed the following:-Activities of daily living (ADL) performance deficit;-Encourage use of call bell for assistance;-At risk for and history of falls;-Resident to ask for assistance with ambulating long distances with his/her walker. Observation and interview on 06/08/26, at 2:25 P.M., showed the following:-The resident said he/she needed some assistance with personal care, showering, and sometimes with mobility using his/her walker or a wheelchair;-The resident said he/she used the call bell to request assistance or to ask for pain medication or to tell the nurse if he/she didn't feel well or had another problem;- He/she said sometimes the staff took forever to answer the call bell and sometimes just ignore it;-As a demonstration, the resident activated his/her call bell. The call light outside his/her door lit up. Observation on 06/08/26, at 2:44 P.M., showed the resident's call light remained on. Two housekeeping staff walked from the cleaning supply room through the front half of 300 hall, did not enter the resident's room, and turned onto the 400 hall. Observation on 06/08/26, at 2:45 P.M., showed two housekeeping staff, one certified nursing assistant (CNA), and one additional staff conversed at the front end of 300 hall. Staff did not respond to the resident's call light. Observation on 06/08/26, at 2:50 P.M., showed the resident's call light remained on. No staff had entered the room. Observation on 06/08/26, at 2:55 P.M., showed a therapy staff walked to the end of the resident's hall but did not enter the resident's room. Observation on 06/08/26, at 2:58 P.M., showed a resident knocked on both 300/400 hall shower room doors, received no response, waved his/her arms around, and said, Why can't I ever find a CNA? Observation on 06/08/26, at 3:01 P.M., showed the resident's call light remained on. Observation on 06/08/26, at 3:05 P.M., showed the resident's call light remained on. The Activities Director pointed out the call light equipment in the nurses' office. She said the staff could hear the call lights ring but wasn't sure if the room number could be noted in the office and could not show a room number indicator. Observation on 06/08/26, at 3:13 P.M., showed the resident's call light remained on. No staff had entered the resident's room. Observation on 06/08/26, at 3:15 P.M., showed two certified medication technicians (CMT) stood at a medication cart in the hallway. The resident's call light remained on and visible from the cart. Observation on 06/08/26, at 3:19 P.M., showed the resident's call light remained on. The resident said nobody had answered his/her call light since he/she turned it on. Observation on 06/08/26, at 3:33 P.M., showed the resident's call light remained on (one hour and eight minutes since being turned on). The resident ambulated from his/her room and proceeded up the 300 hall toward the front of the building. He/she said that nobody had responded to his/her call light, but he/she was tired of waiting and wanted to go to the dining room to sit. 2. Review of Resident #70's face sheet showed the following:-admission date of 02/23/26;-Diagnoses included chronic obstructive pulmonary disease (COPD - lung disease), type two diabetes mellitus (DM - metabolic disease), amputation of right leg above knee; cellulitis (deep inflammation of the tissues just under the skin, caused by infection) of left lower limb, depression, and generalized muscle weakness. Review of the resident's care plan, last reviewed/revised on 03/24/26, showed the following:-Dependent on staff for personal hygiene and oral care;-The resident had bowel incontinence and mixed bladder incontinence related to immobility;-Staff should check the resident every two hours and assist with toileting as needed;-Staff should clean the resident's perineal area with each incontinence episode. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Used manual wheelchair;-Dependent on staff for toileting hygiene;-Dependent on staff assistance for personal hygiene. During an interview on 06/09/26, at 10:39 A.M., the resident said the following:-He/she lived in the facility since March 2026;-The call light in his/her room was broken for two months. Recently, staff fixed the call light;-Aides answer the call lights, come into the room, clear the light, say they will be back in soon, but do not come back;-He/she has waited two to six hours in urine and poop filled brief;-Last week, the resident had to propel him/herself to the nurses' station in the wheelchair to tell staff his/her brief needed to be changed. His/her brief was so wet that urine leaked onto the floor down the entire hallway. He/she was humiliated. 3. During an interview on 06/07/26, at 3:25 P.M., Resident #82 said the following:-He/she depended on staff for bathing, incontinence care, and used a Hoyer lift (mechanical lift for non-weight bearing residents) for transfers;-Aides did not answer call lights timely;-One day last week, he/she waited in his/her own urine and feces for three hours for brief to be changed;-He/she must regularly call the main facility phone number to tell a nurse that his/her call light was on and needed help;-Call lights take longer to be answered on night shift. 4. During an observation and interview on 06/08/26, at 11:22 A.M., Resident #86 said the following:-The resident said he/she needed one staff assistance for care, used a manual wheelchair, and propelled the wheelchair with his/her feet;-Call lights can take up to eight hours to be answered;-Often, staff come into the room to answer the call light, clear the call light, and tell him/her staff will be back in a minute and never come back;-The resident pushed his/her call light and the light on the outside of room door was faint and flickered. 5. During an interview on 06/08/26, at 11:43 A.M., Resident #94 said the following:-A call light could take a couple of hours to be answered;-A few weeks ago, the resident's roommate fell so he/she pushed the call light to get help and no one came to answer. Resident #94 had to get out of bed, into his/her wheelchair to tell a nurse. 6. During an interview on 06/08/26, at 3:01 P.M., Resident #65 said aides often come to answer the call light, turn it off, say they will be back in a minute and never come back to the room. 7. During an interview on 06/08/26, at 3:18 P.M., Resident #61 said the following:-It could take an hour for a call light to be answered;-Aides come into the room, clear the call light, say they will be back and do not come back. 8. During an interview on 06/12/26, at 9:35 A.M., the Activity Assistant said any of the CNA's or nurses can answer call lights. During an interview on 06/12/26, at 1:55 P.M., CMT P said the following:-Anyone can answer a call light;-From what he/she was taught, anyone working in the building can answer the light to see what is needed and then get someone to help, if they cannot;-He/she did notice that a lot of staff just walked on past rooms with call lights on while he/she was busy. During an interview on 06/12/26, at 1:40 P.M., the Assistant Director of Nursing (ADON) B said the following:-Anyone working can answer a call light;-The responding staff may not be able to provide personal care, but they are able to help the resident by getting them drinks, a blanket, telling them what was on the day's menu or activity schedule or just giving them some kind of requested/needed information;-They should let nursing know right away and let the resident know that someone will be with them as soon as possible. During an interview on 06/12/26, at 2:20 P.M., the Administrator said the following:-Anyone working in the building can answer a call light at any time and is expected to do so;-He/she answers lights and has seen staff from all departments answering call lights. Complaints #2980701, #3015959, #3022401, and #3033613.

Based on observation, interview, and record review, the facility failed to ensure residents were free of medication errors greater than 5% when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration per manufacturer's administration instructions for three residents (Resident #10, #38, #97). Three medication errors occurred out of 26 opportunities resulting in an error rate of 11.54%. The facility census was 113.Review of the facility policy titled Medication Administration and General Guideline, dated January 2026, showed the following:-Medications are administered as prescribed;-Medication is administered in accordance with state regulations and using good nursing principles and practices;-Staff familiarize themselves with drug reference material provided by facility. Review of Humalog (rapid acting insulin) Kwik-Pen manufacturer's instructions titled Instructions for Use, instructions on priming the pen, revised 07/2025, showed the following:-Prime before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working properly;-If a person does not prime before each injection, he/she may get too much or too little insulin;-To prime the pen, turn the dose knob to select 2 units;-Hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top;-Push the dose knob in until it stops and 0 is seen in the dose window;-Hold the dose knob in and count to 5 slowly;-Should see insulin at the tip of the needle. Review of the Novolog (rapid acting insulin) Flex-Pen manufacturer's instructions titled Patient Fact Sheet: How to Use Flex-Pen, instructions on priming the pen, revised 02/2023, showed the following:-Prior to each injection, turn the dose selector to 2 units;-Hold the Flex-Pen with the needle pointing upwards;-Tap the cartridge gently to make air bubble collect at the top of the cartridge;-Press the push button all with way in, the dose selector should return to 0;-A drop of insulin should appear at the needle tip. 1. Review of Resident #10's face sheet showed the following:-admit date of 10/29/25;-Diagnosis of diabetes (disease in which the body cannot regulate blood sugar levels). Review of the resident's care plan, last revised on 02/04/26, showed the following:-He/she had diabetes and wore an electronic monitor;-Monitor resident for signs of hypoglycemia / hyperglycemia (low /high blood sugar);-Provide diabetic medication as prescribed by provider. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/23/26, showed the following:-No cognitive impairment;-Required daily insulin injections. Review of the resident's current physician orders, reviewed 06/11/26, showed the following:-An order, dated 02/26/26, for Humalog injection, inject 6 units before meals;-Humalog injection given on a sliding scale based on blood glucose levels,-For blood glucose level of 70-149 milligrams/deciliter (mg/dL), give 0 units;- For blood glucose level of 150-200 mg/dL, give 2 units;- For blood glucose level of 201-250 mg/dL, give 4 units;- For blood glucose level of 251-300 mg/dL, give 6 units;- For blood glucose level of 301-350 mg/dL, give 8 units;- For blood glucose level of 351-400 mg/dL, give 10 units;-Notify physician when blood glucose levels less than 70 mg/dL or greater than 400 mg/dL. Observation on 06/10/26, at 11:58 A.M., showed the following:-Licensed Practical Nurse (LPN) L checked the resident's blood glucose level. It registered a level of 163 mg/dL. The LPN drew up 8 units of Humalog;-The nurse verified the order, identified the resident, and administered 8 units of Humalog insulin through a Humalog Kwik-Pen;-LPN L did not prime the insulin pen. 2. Review of Resident #38's face sheet showed the following:-admission date of 01/25/25;- Diagnosis of diabetes. Review of the resident's care plan, last revised on 02/03/26, showed the following:-He/she had diabetes and wore an electronic monitor, but often refused to wear it;-He/she was non-compliant with diet interventions;-Monitor resident for signs of hypoglycemia / hyperglycemia (low /high blood sugar);-Provide diabetic medication as prescribed by provider. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No cognitive impairment;-Required daily insulin injections. Review of the resident's current physician orders, current as of 06/11/26, showed the following:-An order, dated 04/22/26, for Novolog injection, given on a sliding scale based on blood sugar levels,- For blood glucose level of 141-180 mg/dL, give 1 unit;- For blood glucose level of 181-220 mg/dL, give 2 units;- For blood glucose level of 221-280 mg/dL, give 3 units;- For blood glucose level of 281-340 mg/dL, give 4 unit;,- For blood glucose level of 341-400 mg/dL, give 5 unit;.-Notify physician when blood glucose levels greater than 300 mg/dL. Observation on 06/10/26, at 11:20 A.M., showed the following:- LPN L checked the resident's blood glucose level. It registered high. The nurse called the on-call provider who gave an order to administer 5 units of Novolog insulin. The nurse drew up 5 units of Novolog insulin;-LPN L verified the order, identified the resident, and administered 5 units of Novolog insulin through a Novolog Flex-pen;-LPN L did not prime the insulin pen. 3. Review of Resident #97's face sheet showed the following;-admission date of 05/08/25;-Diagnosis of diabetes. Review of the resident's care plan, last revised on 03/13/26, showed the following:-He/she had diabetes;-Monitor resident for signs of hypoglycemia / hyperglycemia (low /high blood sugar);-Provide diabetic medication as prescribed by provider;-Educate on importance of medication compliance. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No cognitive impairment;-Required daily insulin injections. Review of the resident's current physician orders, current as of 06/11/26, showed the following:-Humalog injection given on a sliding scale based on blood glucose levels;- For blood glucose level of 70-130 mg/dL, give 0 units,- For blood glucose level of 131-180 mg/dL, give 4 units;- For blood glucose level of 181-240 mg/dL, give 8 units;- For blood glucose level of 241-300 mg/dL, give 10 units;- For blood glucose level of 301-350 mg/dL, give 12 units;- For blood glucose level of 351-400 mg/dL, give 16 units;-Notify physician when blood sugar levels are less than 60 mg/dL or greater than 500 mg/dL. Observation on 06/10/26, at 12:10 P.M., showed the following:- LPN L checked the resident's blood glucose level. It registered as 321 mg/dL. The nurse drew up 12 units of Humalog;-LPN L verified the order, identified the resident, and administered 12 units of Humalog insulin through a Humalog Kwik-Pen;-LPN L did not prime the insulin pen. 4. During an interview on 06/10/26, at 12:45 P.M., LPN L said the following:-He/she was supposed to prime insulin pens before administering insulin;-Insulin pens are primed with 2 units;-Priming the insulin pen was important to ensure residents were getting the right dosage of insulin;-The facility had completed education on insulin administration. During an interview on 06/12/26, at 8:35 A.M., LPN O said the following:-Insulin pens should be primed with 1 to 2 units of insulin before administration;-It was important to ensure the air was out of the needle and it was filled to ensure the correct dose;-The facility had completed education with staff on medication administration. During an interview on 06/12/26, at 8:50 A.M., Registered Nurse (RN) N said the following:-Nursing staff should prime insulin pens with two units before administration;-Priming the pen was important to fill the needle and give the correct dose of insulin;-Staff should verify the order and the resident to ensure the correct medication is given. During an interview on 06/11/26, at 12:30 P.M., the Assistant Director of Nursing (ADON) said the following:-Staff were educated to prime insulin pens with 2 units before administration;-Priming the pen was important to ensure the correct dose was given;-He/she expected all staff to prime insulin pens before administering insulin. During an interview on 06/12/26, at 12:00 P.M., the Director of Nursing said she expected all nurses to prime insulin pens before administering insulin. During an interview on 06/11/26, at 8:20 A.M., the Medical Director said the following:-Best practice was to prime insulin pens before administration of insulin;-He expected nursing staff to be priming insulin pens before administration of insulin. During an interview on 06/12/26, at 2:00 P.M., the Administrator said she expected staff to follow manufacturer's guidelines and facility policy regarding medication pass and priming of insulin pens. Complaints #2988862 and #2992581

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration per manufacturer's administration instructions for three residents (Resident #10, #38, #97). Three medication errors occurred out of 26 opportunities resulting in an error rate of 11.54%. The facility census was 113.Review of the facility policy titled Medication Administration and General Guideline, dated January 2026, showed the following:-Medications are administered as prescribed;-Medication is administered in accordance with state regulations and using good nursing principles and practices;-Staff familiarize themselves with drug reference material provided by facility. Review of Humalog (rapid acting insulin) Kwik-Pen manufacturer's instructions titled Instructions for Use, instructions on priming the pen, revised 07/2025, showed the following:-Prime before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working properly;-If a person does not prime before each injection, he/she may get too much or too little insulin;-To prime the pen, turn the dose knob to select 2 units;-Hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top;-Push the dose knob in until it stops and 0 is seen in the dose window;-Hold the dose knob in and count to 5 slowly;-Should see insulin at the tip of the needle. Review of the Novolog (rapid acting insulin) Flex-Pen manufacturer's instructions titled Patient Fact Sheet: How to Use Flex-Pen, instructions on priming the pen, revised 02/2023, showed the following:-Prior to each injection, turn the dose selector to 2 units;-Hold the Flex-Pen with the needle pointing upwards;-Tap the cartridge gently to make air bubble collect at the top of the cartridge;-Press the push button all with way in, the dose selector should return to 0;-A drop of insulin should appear at the needle tip. 1. Review of Resident #10's face sheet showed the following:-admit date of 10/29/25;-Diagnosis of diabetes (disease in which the body cannot regulate blood sugar levels). Review of the resident's care plan, last revised on 02/04/26, showed the following:-He/she had diabetes and wore an electronic monitor;-Monitor resident for signs of hypoglycemia / hyperglycemia (low /high blood sugar);-Provide diabetic medication as prescribed by provider. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/23/26, showed the following:-No cognitive impairment;-Required daily insulin injections. Review of the resident's current physician orders, reviewed 06/11/26, showed the following:-An order, dated 02/26/26, for Humalog injection, inject 6 units before meals;-Humalog injection given on a sliding scale based on blood glucose levels,-For blood glucose level of 70-149 milligrams/deciliter (mg/dL), give 0 units;- For blood glucose level of 150-200 mg/dL, give 2 units;- For blood glucose level of 201-250 mg/dL, give 4 units;- For blood glucose level of 251-300 mg/dL, give 6 units;- For blood glucose level of 301-350 mg/dL, give 8 units;- For blood glucose level of 351-400 mg/dL, give 10 units;-Notify physician when blood glucose levels less than 70 mg/dL or greater than 400 mg/dL. Observation on 06/10/26, at 11:58 A.M., showed the following:-Licensed Practical Nurse (LPN) L checked the resident's blood glucose level. It registered a level of 163 mg/dL. The LPN drew up 8 units of Humalog;-The nurse verified the order, identified the resident, and administered 8 units of Humalog insulin through a Humalog Kwik-Pen;-LPN L did not prime the insulin pen. 2. Review of Resident #38's face sheet showed the following:-admission date of 01/25/25;- Diagnosis of diabetes. Review of the resident's care plan, last revised on 02/03/26, showed the following:-He/she had diabetes and wore an electronic monitor, but often refused to wear it;-He/she was non-compliant with diet interventions;-Monitor resident for signs of hypoglycemia / hyperglycemia (low /high blood sugar);-Provide diabetic medication as prescribed by provider. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No cognitive impairment;-Required daily insulin injections. Review of the resident's current physician orders, current as of 06/11/26, showed the following:-An order, dated 04/22/26, for Novolog injection, given on a sliding scale based on blood sugar levels,- For blood glucose level of 141-180 mg/dL, give 1 unit;- For blood glucose level of 181-220 mg/dL, give 2 units;- For blood glucose level of 221-280 mg/dL, give 3 units;- For blood glucose level of 281-340 mg/dL, give 4 units;- For blood glucose level of 341-400 mg/dL, give 5 units;-Notify physician when blood glucose levels greater than 300 mg/dL. Observation on 06/10/26, at 11:20 A.M., showed the following:- LPN L checked the resident's blood glucose level. It registered high. The nurse called the on-call provider who gave an order to administer 5 units of Novolog insulin. The nurse drew up 5 units of Novolog insulin;-LPN L verified the order, identified the resident, and administered 5 units of Novolog insulin through a Novolog Flex-pen;-LPN L did not prime the insulin pen. 3. Review of Resident #97's face sheet showed the following;-admission date of 05/08/25;-Diagnosis of diabetes. Review of the resident's care plan, last revised on 03/13/26, showed the following:-He/she had diabetes;-Monitor resident for signs of hypoglycemia / hyperglycemia (low /high blood sugar);-Provide diabetic medication as prescribed by provider;-Educate on importance of medication compliance. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No cognitive impairment;-Required daily insulin injections. Review of the resident's current physician orders, current as of 06/11/26, showed the following:-Humalog injection given on a sliding scale based on blood glucose levels;- For blood glucose level of 70-130 mg/dL, give 0 units,- For blood glucose level of 131-180 mg/dL, give 4 units;- For blood glucose level of 181-240 mg/dL, give 8 units;- For blood glucose level of 241-300 mg/dL, give 10 units;- For blood glucose level of 301-350 mg/dL, give 12 units;- For blood glucose level of 351-400 mg/dL, give 16 units;-Notify physician when blood sugar levels are less than 60 mg/dL or greater than 500 mg/dL. Observation on 06/10/26, at 12:10 P.M., showed the following:- LPN L checked the resident's blood glucose level. It registered as 321 mg/dL. The nurse drew up 12 units of Humalog;-LPN L verified the order, identified the resident, and administered 12 units of Humalog insulin through a Humalog Kwik-Pen;-LPN L did not prime the insulin pen. 4. During an interview on 06/10/26, at 12:45 P.M., LPN L said the following:-He/she was supposed to prime insulin pens before administering insulin;-Insulin pens are primed with 2 units;-Priming the insulin pen was important to ensure residents were getting the right dosage of insulin;-The facility had completed education on insulin administration. During an interview on 06/12/26, at 8:35 A.M., LPN O said the following:-Insulin pens should be primed with 1 to 2 units of insulin before administration;-It was important to ensure the air was out of the needle and it was filled to ensure the correct dose;-The facility had completed education with staff on medication administration. During an interview on 06/12/26, at 8:50 A.M., Registered Nurse (RN) N said the following:-Nursing staff should prime insulin pens with two units before administration;-Priming the pen was important to fill the needle and give the correct dose of insulin;-Staff should verify the order and the resident to ensure the correct medication is given. During an interview on 06/11/26, at 12:30 P.M., the Assistant Director of Nursing (ADON) said the following:-Staff were educated to prime insulin pens with 2 units before administration;-Priming the pen was important to ensure the correct dose was given;-He/she expected all staff to prime insulin pens before administering insulin. During an interview on 06/12/26, at 12:00 P.M., the Director of Nursing said she expected all nurses to prime insulin pens before administering insulin. During an interview on 06/11/26, at 8:20 A.M., the Medical Director said the following:-Best practice was to prime insulin pens before administration of insulin;-He expected nursing staff to be priming insulin pens before administration of insulin. During an interview on 06/12/26, at 2:00 P.M., the Administrator said she expected staff to follow manufacturer's guidelines and facility policy regarding medication pass and priming of insulin pens. Complaints #2988862 and #2992581

Based on observation, interview, and record review, facility staff failed to maintain a complete infection prevention and control program when staff did not perform appropriate hand hygiene when providing personal care for three residents (Residents #112, #12, and #19). The facility census was 113. Review of the facility policy titled Standard Precautions, reviewed 10/25/22, showed the following: -The facility will use standard precautions which are the minimum infection prevention practices that apply to all resident care regardless of suspected or confirmed infection status of the resident; -These practices help protect the employees and residents from spreading infections; -Standard precautions include hand hygiene; -Perform hand hygiene before and after direct contact with residents or when hands are visibly soiled and after contact with blood, body fluids, secretions, excretions, patient's intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contact; -Wear gloves when touching blood, body fluids, secretions, excretions, or contaminated items with mucus membranes and non-intact skin; -If hands move from a contaminated site to clean body site during care, wash hands or use hand sanitizer. Review of the facility's policy, dated 04/28/22, titled Hand Hygiene, showed the following: -The facility will provide guidelines to employees on proper handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections; -Employees will be trained and receive ongoing education on the importance of hand hygiene in preventing the transmission of healthcare-associated infections (HAI); -Hand hygiene should be performed before and after providing care; with contact with blood, body fluids, or contaminated surfaces; before and after applying and removing gloves; and after handling soiled linens and items potentially contaminated with blood, body fluids, or secretions; -Employees will perform handwashing with soap and water when hands are visibly soiled; -Employees may use an alcohol-based hand rub when hands are not visibly soiled. 1. Review of Resident #112's face sheet (admission information) showed the following: -admission date of 05/22/20; -Diagnoses included vascular dementia (decline in thinking and memory caused by reduced blood flow to the brain), seizures, and metabolic encephalopathy (brain dysfunction caused by chemical, hormonal, or systemic imbalances in the body). Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment completed by facility staff), dated 06/03/26, showed the following: -Severely impaired cognition; -Required partial/moderate staff assistance with toileting hygiene and upper and lower body dressing; -Always incontinent of urine and frequently incontinent of bowel. Review of the resident's care plan, dated 02/13/26, showed the following: -Activities of Daily Living (ADLs) self care deficit because of dementia; -Required staff assistance for personal hygiene and dressing; -Mixed bladder incontinence related to dementia; -Clean perineal area with each incontinence episode. Observation on 06/09/26, at 6:18 A.M. showed the following: -Certified Nurse Aide (CNA) E assisted the resident to lay down on the bed to change his/her wet brief and do perineal care; -Without performing hand hygiene, the CNA put on gloves and removed the resident's incontinent brief which was wet with urine; -He/she used a wet wipe to cleanse the front perineal area; -He/she removed the gloves, did not perform hand hygiene, and donned new gloves; -He/she applied perineal wash with the wet wipe, turned the resident to his/her side, and wiped down between the buttocks, and then put a clean brief on the resident; -Without removing gloves or performing hand hygiene, the CNA assisted the resident to transfer to the wheelchair by holding the resident under one arm; -Without performing hand hygiene and changing gloves, the CNA changed the resident's shirt and then wheeled him/her out of the room to the dining room; -The CNA then removed his/her gloves and did not perform hand hygiene. 2. Review of Resident #19's face sheet showed the following: -admission date 11/13/19; -Diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease that blocks the air flow and makes it difficult to breathe), major depression, anxiety, seizures, overactive bladder, high blood pressure, and Alzheimer's disease (memory, think and behavior affected that symptoms eventually grow severe). Review of the resident's comprehensive MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Used a wheelchair; -Required partial/moderate staff assistance with toileting hygiene; -Required substantial/maximum staff assistance for upper and lower body dressing and personal hygiene; -Always incontinent of urine and bowel. Review of the resident's care plan, dated 09/22/21, showed the following: -ADL self-care performance deficit related to dementia; -Set-up to extensive assistance with personal hygiene and can wash his/her face; -Extensive staff assist with toileting at times, typically continent during the day and incontinent during the night, and wears briefs. Observation on 06/09/26, at 6:58 A.M., showed the following: -CNA F went into the resident's room, washed hands, and put on gloves; -The CNA assisted the resident to transfer from the bed to the wheelchair; -The CNA took the resident to the bathroom and the resident stood and used the handrail as the CNA pulled down the resident's wet incontinence brief and placed it in the trash can; -Without performing hand hygiene or changing gloves, the CNA put a clean brief on the resident; -Without performing hand hygiene or changing gloves, the CNA put on the resident's shirt and pulled up the resident's pants; -Without performing hand hygiene or changing gloves, the CNA got the resident's toothbrush and asked the resident to brush his/her teeth; -Without performing hand hygiene or changing gloves, the CNA turned on the hot water, left the room, and returned with clean sheets and laid them on the resident's bedside table; -Without performing hand hygiene or changing gloves, the CNA wet a washcloth and handed it to the resident to wash his/her face; -The CNA removed his/her gloves and donned new gloves without performing hand hygiene; -The resident asked the CNA for assistance to wash his/her hands and with the CNA's assistance moved over to wash hands at the sink; -Without performing hand hygiene or changing gloves, the CNA F brushed the resident's hair; -The CNA assisted the resident to the wheelchair, removed the trash bag from the bathroom, helped put the resident's shoes on, and then he/she picked up the bags on the floor, tied them, and removed gloves; -Without performing hand hygiene, he/she removed the trash to the shower room, and then he/she washed hands in shower room sink. 3. Review of Resident #12's face sheet (brief resident profile sheet) showed the following: -admission date of 11/26/25; -Diagnoses included schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder), anoxic brain damage (an injury to the brain that caused brain cells to die due to a lack of oxygen), cellulitis (deep inflammation of the tissues just under the skin, caused by infection) of left lower limb, cognitive communication deficit (difficulty to understand language or to speak due to a thinking impairment), generalized muscle weakness, and need for assistance with personal care. Review of resident's comprehensive Minimum Data Set (MDS – a federally mandated assessment tool filled out by facility staff), dated 04/10/26, showed the following: -Moderate cognitive impairment; -Required substantial assistance from staff with toileting, personal hygiene, and eating; -Dependent on staff for transferring, repositioning, showering, and dressing; -Used manual wheelchair. Review of the resident's care plan, reviewed/revised on 04/30/26, showed the following: -The resident had an activities of daily living (ADL) deficit. The resident was incontinent of bowel and bladder and dependent on staff for personal hygiene; -The resident had impaired physical mobility and required transfer and repositioning assistance. Observation on 06/11/26, at 2:35 P.M., showed the following: -CNA M and CNA C entered the resident room, used hand sanitizer, and applied gloves; -CNA C brought a package of wipes, a brief, and barrier cream from the resident's bathroom and placed items on top of resident's bedside table; -Both aides positioned the resident and pulled down his/her pants; -CNA M unhooked resident's wet brief, pulled it back, folded under the used brief, and pulled out a clean wipe to wash the front perineal area from front to back three separate times. The CNA placed the dirty wipes in the trash; -CNA C turned the resident on his/her left side while CNA M pulled out the used brief and placed it in the trash; -CNA M pulled out several clean wipes (without performing hand hygiene or changing gloves) and performed incontinent care; -Without performing hand hygiene or changing gloves, CNA M unfolded the clean brief and tucked it under the resident; -Without performing hand hygiene or changing gloves, CNA M squeezed tube of barrier cream onto his/her gloves and applied cream to the resident's; -Both aides repositioned the resident; -Without performing hand hygiene or changing gloves, CNA M pulled the clean brief into place and attached the tabs; -Without performing hand hygiene or changing gloves, CNA C and CNA M used the draw sheet to pull the resident up in bed. CNA C repositioned pillow under the resident's head and both aides placed another pillow under the lower legs, and put on protective boots; -CNA C and CNA M removed their gloves, placed them in the trash, and did not perform hand hygiene; -CNA C covered the resident with a sheet and blanket and placed the call light at his/her side; -CNA M moved the bedside table to the resident's right side. Then gathered the package of wipes and barrier cream to place inside resident's bathroom; -CNA C took out the trash liner from trash can, placed a new liner in trash can, and carried trash bag out of the resident's room; -The CNAs used hand sanitizer in the hallway. 4. During an interview on 06/11/26, at 2:46 P.M., CNA C said the following: -Staff should wash hands or use hand sanitizer before and after resident cares; -Should change gloves when going from a dirty area to a clean area; -Should wash hands or use hand sanitizer in between glove changes. During an interview on 06/11/26, at 2:50 P.M., CNA M said the following: -Staff should wash hands before entering the room, before putting on gloves, in between glove changes, and before providing care; -Staff should change gloves in between dirty to clean area cares. During an interview on 06/12/26, at 8:28 A.M., CNA F said the following: -They were to wash hands between glove changes, when they entered and left the room, after they took the resident to the bathroom, and when they made the resident's bed; -He/she did carry hand sanitizer. During an interview on 06/12/26, at 2:53 P.M., Certified Medication Technician (CMT) T said the following: -Staff were to wash hands between glove changes; -When staff went into a resident's room, they were to take off gloves and wash and/or sanitize their hands. During an interview on 06/12/26, at 12:16 P.M., Assistant Director of Nursing (ADON) B said the following: -Staff should wash hands if hands are soiled. Staff may use hand sanitizer or wash hands before and after resident care; -Staff should put on gloves for any direct care or items that could have contact with bodily fluids; -Should change gloves after going from a dirty area to a clean area; -Should perform hand hygiene before putting on gloves, in between glove changes, and after removing gloves. During an interview on 06/12/26, at 3:05 P.M., ADON A said the following: -Staff were to wash hands when they go into a resident's room and when they leave the room; -Staff were to wash hands before applying gloves, and after removing gloves. During an interview on 06/11/26, at 2:40 P.M., the Director of Nursing (DON) said the following: -The nurse aides do training that included hand hygiene; -Staff were to treat everyone as if they were on standard precautions; -Staff were to wash hands when they removed gloves; -Staff were not to walk down halls wearing the same gloves that they performed care with. During interviews on 06/12/26, at 3:15 P.M. and 5:15 P.M., the Administrator said the following: -She expected staff to wash hands and change gloves according to policy; -Staff were to wash hands when changing gloves, before going into a resident's room, before leaving a resident's room, and after removing gloves; -Staff were to wash hands when they removed their gloves during perineal care. Complaint #2980701

Based on observation, interview, and record review, the facility failed promote each resident's right to self-determination when staff failed to honor one resident's (Resident #70) reason shower preference for two showers a week. The facility census was 113.Review showed the facility did not provide a shower policy that addressed frequency of showers. 1. Review of Resident #70's face sheet (brief resident profile sheet) showed the following:-admission date of 02/23/26;-Diagnoses included chronic obstructive pulmonary disease (COPD - lung disease), type two diabetes mellitus (DM - metabolic disease), amputation of right leg above knee, cellulitis (deep inflammation of the tissues just under the skin, caused by infection) of left lower limb, depression, and generalized muscle weakness. Review of the resident's care plan, reviewed/revised on 03/24/26, showed the following:-Required one staff assist with showers; -Dependent on staff for personal hygiene and oral care;-Staff should monitor participation and adjust activity offerings according to the resident's preference and energy level. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/20/26, showed the following:-Cognitively intact;-Used manual wheelchair;-Dependent on staff for toileting hygiene;-Maximal assistance needed for showering;-Dependent on staff assistance for personal hygiene. Review of the resident's Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review, showed staff provided showers to the resident on the following dates:-On 04/10/26;-On 04/16/26 (six days later);-On 04/22/26 (six days later);-On 04/27/26 (five days later);-On 05/02/26 (five days later);-On 05/09/26 (seven days later);-On 05/12/26;-On 05/20/26 (eight days later.).-On 05/25/26 (five days later) -On 06/01/26 (seven days later). During an interview on 06/09/26, at 10:39 A.M., the resident said the following:-He/she received one shower a week. The resident would like to have at least two showers a week;-He/she last received a shower seven days ago;-He/she said I just feel yucky.;-The resident has discussed two or three times with the Administrator about not receiving at least two showers per week. During an interview on 06/12/26, at 11:16 A.M., CNA K shower aide said the following:-Every resident should have a designated shower day. Sometimes the resident's shower schedule changes due to appointments or activities;-CNAs assigned to work the hall providing overall direct care on the hall do not give showers;-CNA K was assigned to give the resident his/her showers. He/she has not been able to give the resident a shower twice a week because he/she was too busy;-Therapy gave the resident a shower last week;-He/she attempted to give the resident a shower on Monday, but the resident had an outside appointment all day; -The resident was the next shower on the schedule. During an interview on 06/12/26, at 1:45 P.M., CNA P said the following:-He/she did not have time to give residents a shower during the shift;-He/she did not give residents a shower while working the general floor as a CNA;-Only shower aides give residents showers. During an interview on 06/12/26, at 12:16 P.M., Assistant Director of Nursing (ADON) B said the following:-He/she expected residents to receive showers at least twice a week and be given a choice;-If a shower aide was not available, an aide should give the resident a shower. During an interview on 06/12/26, at 4:35 P.M., the Director of Nursing (DON) said the following:-He/she expected all residents to receive at least two showers per week and have a choice;-He/she did not know the resident was not getting his/her preference of at least two showers per week. During an interview on 06/12/26, at 3:15 P.M., the Administrator said the following:-There was no shower policy regarding frequency. Showers were given according to resident choice; -The resident had not discussed his/her shower preference of at least twice per week with the Administrator. Complaint #2980701 and #3041981

Based on interview and record review, the facility failed to ensure notifications were made to resident responsible parties and physicians of all resident refusal of a scheduled medical appointments when staff failed to document notification of the one resident's (Resident #1) responsible party and physician when the resident refused to attend a scheduled medical appointment related to the removal of an inserted ureteral stent (thin, flexible tube placed in ureter to keep the passageway open for urine to flow from the kidney to the bladder). The facility census was 105. Review of the facility's policy titled Notification of a Change in Condition, revised 01/20/26, showed the following:-The attending physician/physician extender (nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS)) and the resident representative will be notified of a change in a resident's condition, according to standards of practice and federal and/or state regulations;-Guideline for notification of physician/resident representative (not all inclusive) include significant change in medical or cognitive baseline and refusal to take prescribed medications;-Document in the interdisciplinary team notes physician/physician extender notification and notification of resident representative. 1. Review of Resident #1's face sheet (admission data) showed the following: -readmission date of 05/14/25;-Resident had a guardian (legal document allowing someone to make decisions on your behalf) listed with name and phone number;-Diagnoses included hydronephrosis (swelling of one or both kidneys due to a buildup of urine) with ureteropelvic junction obstruction (blockage where the renal pelvis connects to the ureter (carries urine from the kidney to the bladder)) and cognitive communication deficit.Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 01/14/26, showed the resident had severely impaired cognitive skills. Review of the resident's care plan, revised 01/16/26, showed the following:-The resident had impaired cognitive function/dementia or impaired thought processes related to vascular dementia and history of traumatic brain injury;-Communicate with the resident's responsible party regarding his/her capabilities and needs;-Monitor/document/report to the physician of any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, and level of consciousness and mental status;-The resident had acute renal failure related to kidney disease. Review of the resident's progress note dated 01/19/26, at 7:16 A.M., showed Licensed Practical Nurse (LPN) D documented the following: -Staff notified the on-call provider at 6:44 A.M. after he/she was called to the resident's room because a certified nurse aide (CNA) stated the resident did not act right;-Call placed to the on-call provider who agreed that the resident needed to be sent out;-Staff called emergency medical services (EMS) who picked up the resident at 7:07 A.M.Review of the resident's Emergency Department to Admission hospital paperwork, dated 01/19/26, showed the resident had a history of urinary tract infections (UTIs) and had complicated UTI requiring stent. The resident underwent lithotripsy (uses shockwaves to break stones into small pieces) in October 2025. At that time the resident had a stent exchange. During interviews on 01/23/26, at 12:47 P.M., and on 01/26/26, at 2:49 P.M., the Medical Assistant Staff at the resident's urology clinic said the following:-The resident's follow up appointment scheduled for 11/07/25 was to remove the ureteral stent which was placed 10/28/25;-He/she did not have any documentation in the resident's chart of the facility calling about the resident's 11/07/25 appointment. On 11/07/25, the resident was a no show for his/her appointment;-The urology clinic sent a letter to the facility of the resident's missed 11/07/25 appointment and never heard anything back.During interviews on 01/27/26, at 10:01 A.M. and 1:46 P.M., the resident's Public Administrator's caseworker said the following: -He/she did not have documentation from the facility of the resident refusing the 11/07/25 appointment to remove his/her urinary stent. He/she had a notation, dated 10/27/25, of the resident having surgery for kidney stones and that his/her office gave consent. A notation, dated 10/28/25, showed the resident was at the surgery center to have his/her kidney stone removed and per the surgeon, inserted a stent as a routine surgery;-He/she would want to know the resident refused his/her appointment on 11/07/25;-The resident was under guardianship and did not have the ability to make medical decisions;-For the 11/07/25 appointment, the facility should had notified him/her, and he/she would have told the facility to send the resident out to that appointment, and if the resident refused then send the resident to the hospital to have it removed if he/she became violent or anything;-He/she did not know for sure if the resident would understand the importance of the appointment.During interviews on 01/23/26, at 11:24 A.M. and 12:30 P.M., CNA/Transport Staff B said the following:-The resident had a procedure to place a stent on 10/28/25;-On 11/07/25, the resident refused three times to go to his/her post operative surgery appointment with the surgeon to have the stent removed;-He/she made no other appointments after 11/07/25 for the resident;-He/she was responsible for making appointments and transporting residents to scheduled appointments;-On 11/07/25, he/she went back to the resident three to four times to ask him/her to go to the appointment and the resident refused. A former nurse went down and talked with the resident and the resident said he/she was not going stating they aren't touching me;-The former nurse informed CNA B to call the urology clinic and follow-up. CNA B had another appointment with another resident;-The former nurse said he/she would document the resident's refusal of the appointment;-When he/she (CNA B) returned to the facility, everything was closed. He/she called and left a message with the urology clinic, but they did not call back;-He/she (CNA) B failed to follow-up and call back. He/she was bombarded with all the appointments.Review of the resident's POS, Medication Administration Record (MAR), and Treatment Administration Record (TAR) showed staff did not document an order for a scheduled urology appointment on 11/07/25. Review of the resident's progress notes showed staff did not document notification of the resident's responsible party and physician of the resident's refusal of the scheduled urology appointment on 11/07/25. During an interview on 01/23/26, at 9:13 A.M. CNA A said the following:-Scheduled appointments show up on the home screen on the computer or staff inform the aides;-He/she did not know if the Administrator or nurses entered the appointments in the computer;-Transport staff transport residents to appointments.During an interview on 01/26/26, at 9:05 A.M., Certified Medication Technician (CMT) C said the nurse or aides inform him/her if a resident had an appointment. He/she did not know the resident had missed an appointment. The resident answered yes or no to simple questions to lay down or eat. The resident was not able to make decisions on major questions, like an appointment. He/she believed the resident had a guardian. During an interview on 01/26/26, at 7:44 P.M., LPN D said the following:-Staff finds appointments in the computer system on the dashboard;-He/she did not know who was responsible for entering the appointments in the computer; -If a resident refused an appointment, he/she would call the office to cancel, document in the resident's progress note, and contact the resident's physician;-If the resident had a guardian and refused an appointment, staff should notify the guardian;-If the resident refused the procedure to have the stent removed, staff should notify the physician and the guardian and document in the progress notes and mediprosity (communication to the provider).During interviews on 01/27/26, at 11:15 A.M., and 3:30 P.M., LPN E said the following:-He/she did not remember the resident refusing to go to an appointment on 11/07/25;-The resident did not go to a lot of appointments;-If the resident would have refused to go to an appointment, he/she would have asked the resident why and documented the reason in a progress note. He/she would have notified the resident's guardian and the provider;-The resident understood him/her during their communication, and he/she could understand the resident's needs sometimes, when he/she was not confused;-He/she does not know if the resident was capable of making his/her own decisions because somedays the resident was cooperative and communicated well and some days, he/she was confused.During an interview on 01/27/26, at 8:43 A.M., the Nurse Practitioner (NP) said the following: -If a resident refused an appointment and had a guardian, staff should talk with the resident's guardian and discuss what they want to do;-A resident had a guardian due to the resident cannot make decisions for himself/herself and staff should discuss medical necessity with the guardian;-She did not find out until recently (the last week or so) of the resident refusing his/her 11/07/25 appointment to have the stent removed;-The resident was mentally incapacitated. She expected the staff to notify the resident's guardian and provider and reschedule the appointment. During an interview on 01/27/26, at 12:12 P.M., Care Plan Coordinator I said the following; -Staff discussed appointments in the morning meetings;-He/she would care plan if a resident refused appointments habitually;-He/she was not able to confirm or deny if he/she was aware the resident refused the appointment on 11/07/25. During an interview on 01/27/26, at 12:20 P.M., Social Service Staff H said the following: -He/she did not know the resident refused the 11/07/25 appointment to have his/her urinary stent removed;-He/she did not know if the appointment was rescheduled;-If the resident refused the appointment, staff should have notified the guardian;-The resident was unable to make his/her own decisions.During interviews on 01/23/26, at 11:40 A.M., and on 01/2726, at 10:26 A.M. and 2:46 P.M., the Director of Nursing (DON) said the following:-She did not find any notes or communication to the physician or the NP of the resident refusing the follow up procedure;-Staff should document in the progress note if a resident refuses an appointment;-CNA B was responsible for scheduling resident appointments. If a provider gave a referral, the nurse who received the order gave it to CNA B who scheduled the appointment and entered it into the computer. The scheduled appointment then came up on the dashboard of the computer;-The nurse on duty views any appointments scheduled for the day;-CNA B took residents to appointments and brought paperwork back to give to the nurse along with a quick report;-If a resident refused, CNA B should write a note in his/her binder and try to document in the computer;-Nursing staff should document in the computer if a resident refuses an appointment.\;-Nursing staff should reach out to a resident's family member, guardian and provider if a resident refused an appointment;-She did not know if the resident understood that the 11/07/25 appointment was to have his/her stent removed;-The resident had a history of refusing appointments;-She expected the nurses to document notification of the provider and guardian of the resident's refusal of the 11/07/25 appointment. During an interview on 01/27/26, at 12:21 P.M., the NP said the following: -The resident was to follow up with nephrology and go from there;-Staff should follow the orders to follow up;-She was not aware the resident refused the 11/07/25 appointment;-Staff should have notified the guardian and go by what the guardian said;-Staff should had notified the physician or her. During an interview on 01/27/26, at 2:50 P.M., the physician said he was not sure if the facility notified him of the resident refusing the 11/07/25 appointment. During an interview on 01/27/26, at 4:12 P.M., the administrator said she expected staff to document in the progress notes if a resident refused an appointment and staff should notify the resident's guardian and provider. #2723198

Based on observation, interview, and record review, the facility failed to follow wound physician recommendations to obtain wound cultures and an X-Ray for one resident (Resident #7) with a vascular wound to his/her left shin. The facility census was 106.Review of the facility policy titled, Notification of a Change in Condition, revised on 02/06/25, showed:-The attending physician/nurse practitioner will be notified of a change in the resident's condition;-Responsibility: All licensed nursing personnel, nursing administration, and Director of Nursing (DON). 1. Review of Resident # 7 face sheet showed:-admission date of 9/27/25;-Diagnoses of traumatic ischemia (lack of sufficient blood flow) of muscle, peripheral artery disease (when narrowing of the arteries leads to reduced blood flow to the limbs) and diabetes mellitus, type II. Review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by facility staff, dated 10/06/25, showed:-admitted to the facility on [DATE] from the hospital;-Cognitively intact;-Functional limitation in range of motion to both lower extremities;-Required set up/clean up assistance with eating;-Dependent on staff for assistance with transfers, personal hygiene, and toileting;-Required substantial/maximal assistance with showering;-Always incontinent of bowel and bladder;-Diagnoses of traumatic ischemia of muscle, deep vein thrombosis (blood clot), and peripheral arterial disease;-Presence of venous or arterial ulcer;-Currently on antibiotic therapy. Review of the resident's care plan, created on 11/03/25, showed, the following:-Resident had impairment of skin integrity to the left shin, infected arterial wound;-Perform treatment to wound per current treatment order;-Assess wound for signs/symptoms of infection with each dressing change/treatment;-Report positive findings of redness, warmth, swelling, increased drainage, or increased pain;-Report progress/wound healing to the physician, with any changes or lack of response to treatment Review of the resident's [NAME] wound report, dated 10/02/25, showed the following:-Infected wound to the resident's left shin;-Wound present on admission;-Open area measured 13.0 centimeters (cm) long by 6.5 cm wide by 0.3 cm deep with odor, erythema (redness), moderate amount of purulent drainage (thick, milky discharge), and 100% slough (stringy, yellowish-tan, dead tissue);-Recommendations: Obtain deep wound culture of left shin wound.Review of the resident's medical record showed staff did not document regarding wound culture results. Review of the resident's weekly [NAME] wound report, dated 10/09/25, 10/16/25, and 10/23/25 showed recommendation: wound culture.Review of the resident's medical record showed staff did not document regarding wound culture results. Review of the resident's weekly [NAME] wound report, dated 10/30/25, showed:-Recommendations: X-ray of left shin for evaluation of osteomyelitis (serious infection of the bone) and deep wound culture.Review of the resident's medical record showed staff did not document regarding wound culture results or X-Ray of left shin results. Review of the resident's [NAME] weekly wound report, dated 11/14/25, showed:-A different physician completed the weekly wound report;-Assessment showed left leg arterial wound size 23.0 cm long by 5.0 cm wide by 1.2 cm deep with undermining (tissue destruction under intact skin at the edge of a wound) of 2.5 cm at 12 o'clock;-The wound had black necrotic (dry, leathery, dead) tissue covering 10% of wound bed, devitalized necrotic (any dead tissue, can be moist) tissue covering 70% of wound bed, and 20 % skin;-Progress: Not at goal due to infection and peripheral vascular disease, odor of pseudomonas (a specific type of bacterial infection) in the wound;-Recommendation: Referral to vascular surgeon;-Wound culture and X-ray of left shin for evaluation of osteomyelitis.Review of the resident's medical record showed staff did not document regarding wound culture results or X-Ray of left shin results. Review of the resident's [NAME] weekly wound report, dated 11/21/25, showed recommendation: X-ray of the left leg.Review of the resident's medical record showed staff did not document regarding X-Ray of left shin results. Review of the resident's progress note, dated 11/24/25, showed the Nurse Practitioner P documented the following:-Resident is pending vascular surgeon for consideration of below the knee amputation. Resident reports pain in the left lower extremity is not well managed. Review of the resident's [NAME] weekly wound report, dated 11/26/25, showed:-Recommendations: Culture of wound and X-ray of the left leg;-Awaiting surgical evaluation for possible amputation.Review of the resident's medical record showed staff did not document regarding wound culture results or X-Ray of left shin results. Review of the resident's progress note, dated 11/26/25 at 5:47 P.M. showed the wound nurse, Registered Nurse (RN) J documented the following:-On 11/26/25, the full-thickness arterial wound on the resident's left lower leg was evaluated and remains at goal with palliation focus. The wound measured 23.1 cm long by 6.0 cm wide by 0.5 cm deep with undermining, moderate purulent drainage, and mixed necrotic tissue. A surgical excisional debridement was performed removing 62.37 cm squared of devitalized tissue to viable level with bleeding observed, followed by daily treatment, offloading, and close monitoring;-Diagnostic studies including X-ray, deep wound cultures are pending, and the resident continues under off-loading and repositioning protocols with vascular surgical consult pending for potential below or above knee amputation.Review of the resident's medical record showed staff did not document regarding wound culture results or X-Ray of left shin results. Review of the resident's progress note, dated 11/28/25 (Friday) at 9:34 A.M., showed Registered Nurse (RN) O documented the following:-The resident's wound has declined in condition. The wound had more drainage and foul odor. The resident had more pain during the dressing change. The resident was followed by a wound physician. Will inform the physician of changes on Monday (12/01/25). Review of the resident's progress note, dated 11/29/25 at 10:42 A.M., showed Licensed Practical Nurse (LPN) D documented the following:- The resident had nausea/vomiting and other change in condition;-Vital signs included a blood pressure of 160/80 millimeters/Mercury (mm/Hg) (normal range 900/60-120/80 mm/Hg), heart rate of 113 beats per minute (bpm) (normal range 60-100 bpm), respirations of 20 breaths/minute (normal range 12-18 breaths/minute), and a temperature of 98.8 degrees Fahrenheit (F) (normal range 97.8-99.1 degrees F);-Resident was lethargic, had nausea/vomiting (nausea medication given with effective results), chills, shaking, and wound had excessive green purulent drainage from left shin wound with foul smell. The physician recommended sending the resident to the emergency department. Review of the resident's progress note, dated 11/29/25 at 11:37 A.M., showed Registered Nurse (RN) O documented the following:-The resident's wound dressing was saturated. During the dressing change, an increase in foul smelling drainage and the drainage was pooling up in the wound bed. The wound showed signs of infection, was warm to touch, painful, and had excessive drainage. The resident showed signs of sepsis, felt warm to touch, shaking, and increased respirations. The nurse informed the charge nurse of his/her assessment and findings. Review of the resident's Hospital History and Physical, dated 11/29/25, showed:-Extensive past medical history including left lower extremity claudication (clot) status post mechanical cannulation of the left anterior and posterior tibial arteries and thrombectomy (clot removal) of the popliteal artery (supplies blood to the knee, lower leg, and foot) on 9/21/25;-Diagnoses included Type 2 diabetes mellitus, atrial fibrillation (irregular heart rhythm), high blood pressure, chronic non-pressure skin ulcerations, nicotine dependence;-Recently discharged from the hospital on 9/27/25 after treatment for urinary tract infection and bacteremia (presence of bacteria in the blood stream), treated with antibiotics;-Presented with ongoing leg infection and fever;- Resident informed the ER he/she has a bad wound on his/her leg that has gotten worse and was painful; - The resident will likely need amputation of his/her left leg and resident said he/she was aware and ready for that;-Assessment/plan: Ulcer of left lower extremity with necrosis of muscle, infected skin ulcer with fat layer exposed, cellulitis (infection of the tissue) of left lower leg, fever. peripheral vascular disease:-Plan: Extensive anterior left lower extremity wound with infection, connective tissue visible with areas of necrosis, likely multifactorial in the setting of status post claudication, thrombectomy, diabetes, delayed wound healing in the setting of cigarette nicotine dependence. Emergency physician discussed with vascular surgeon. May proceed with left lower extremity amputation. During interviews on 1/12/26 at 11:45 A.M. and at 2:49 P.M., the wound nurse, Registered Nurse (RN) J said the following:-He/she rounded with the [NAME] wound physician weekly;-Once the wound physician completed his/her after visit summary, the wound nurse reviewed the wound physician notes for any changes/new orders;-He/she placed any new or changed orders in the resident's electronic medical record, in the physician orders section;-He/she checked with the resident's primary care physician if he/she modified any order;-He/she notified the primary care physician of any changes in condition of the wound;-If the resident experienced a significant change in condition, he/she would send the physician a message via secure text message and then document the change of communication and physician response in the progress note;-The resident was admitted to the facility on [DATE] with 3 large wounds to his/her anterior (front of) left leg. The wound was necrotic with bubbling pus/drainage on admission and had an odor;-The wound physician started seeing the resident weekly shortly after admission;-The facility had completed the treatments to the leg as ordered, but the wound physician said the resident's leg would require amputation despite the treatment.-Initially, when the wound physician discussed the probable need for amputation with the resident, the resident did not want to have his/her leg amputated. During an interview on 1/12/26 at 3:45 P.M., Licensed Practical Nurse (LPN) C said the following:-He/she checked the resident's October 2025 treatment administration record (TAR) which showed an order dated 10/02/25 to obtain a culture of the resident's leg wound;-The nurse stated he/she documented NA and after checking the resident's progress notes;-He/she could not locate any culture swabs to obtain the resident's leg wound culture;-The nurse said on 10/03/25, the physician started the resident on an antibiotic, Ciprofloxacin for a wound infection to the left shin;-He/she did not obtain a wound culture of the left shin. During an interview on 01/12/25 at 2:30 PM., the resident said he/she had wounds to his/her legs and feet prior to admission. Due to diabetic neuropathy, he/she had decreased feeling in his/her legs and feet. The resident said that he/she had to have his/her left leg amputated above the knee. During a phone interview on 1/13/26 at 11:00 A.M., Registered Nurse (RN) O said the following:-On Friday (11/28/25) and Saturday (11/29/25), the resident's wound was covered in moist eschar, yellow-green drainage, and a foul odor;-He/she did not call the resident's physician on 11/28/25, because he/she thought the wound physician was aware of what was going on with the resident's leg wound;-He/She thought the resident's leg condition could wait until Monday (12/01/25) and a nurse could notify the physician about the changes to the condition of the resident's leg at that time;-He/she did not recall a wound culture order on the resident. During a phone interview on 01/13/26 at 1:15 P.M., the [NAME] Wound Physician, said the following:-From the first time seeing the wound, the physician felt the wound was beyond what localized treatment would address;-He/she made a suggestion to the resident that the resident would probably require an amputation of his/her leg;-The physician did not feel that failures in the resident's care led to the infection and subsequent amputation, but rather felt the amputation was unavoidable. During an interview on 01/13/26 at 1:24 P.M., LPN D said the following:-He/she evaluated the resident on Saturday (11/29/25) and sent the resident out to the hospital;-RN O reported changes in the resident's condition, he/she did not see the resident's leg, but rather went with what RN O said about the condition of the resident;-He/she recalled the previous wound physician thought the resident would require an amputation;-He/she was not aware of any wound culture. During an interview on 01/13/26 at 2:26 P.M., the Director of Nursing (DON) said the following:-The nurse should have notified the physician or nurse practitioner of changes to the resident's leg wound on 11/28/25 via secure messaging or should have called the on-call physician;-If a wound culture was ordered, the nurse should have obtained the wound culture within the same shift;-He/she believed the wound physician may have collected the culture, but the DON was unable to find any results of the wound culture;-He/she was unable to find an X-ray of the resident's left shin;-The wound nurse should review the [NAME] wound notes when finalized and place any recommended orders in the electronic health record or notify the nurse on duty if X-rays or labs were needed;-The facility should have the wound culture and X-ray results in the resident's medical record. During an interview on 1/13/26 at 3:16 P.M., the Administrator said the following:-If the resident's wound culture order was on the TAR, the nurses should have attempted to obtain the culture. If the nurse was unable to obtain the culture, the nurse should have notified the physician and documented in a progress note;-The facility should obtain wound cultures and X-rays within 24 hours of receiving the order to complete;-The wound nurse should review all [NAME] wound physician's recommendations and notify the primary care physician of the recommendations. Complaint 2714772

Based on observation, interview, and record review, the facility failed to follow physician medication orders and/or medication recommendations resulting in significant medication errors for 4 residents (Resident #3, #4, #1, and #8) when staff transcribed Resident #3's medication order incorrectly for digoxin (a cardiac medication used to treat heart failure and irregular heartbeat, which has a narrow therapeutic range requiring careful monitoring for side effects), resulting in digoxin toxicity (dig tox, a condition resulting from taking too much digoxin causing symptoms like nausea, vomiting, confusion, vision changes, and serious cardiac issues) and hospitalization, when staff transcribed Resident #4's order incorrectly for Coumadin (warfarin, an anticoagulant medication/ blood thinner) resulting in elevated blood levels placing the resident at an increased bleeding risk, when staff failed to address/follow physician recommendations for changes to Resident #1's insulin and blood sugar checks, resulting in staff administering less than the recommended dose of insulin and fewer blood checks, placing the resident at increased risk of hyperglycemia (high blood sugar), and when staff failed to administer Resident #8's psychotropic medications as ordered. The facility census was 106. Review of the facility policy titled, Admission/readmission Orders, dated 11/01/18, showed: -Upon admission/readmission, orders for care of the resident are received from attending physician, transcribed onto physician's orders and kept in the medical record; -Admission/readmission orders are obtained on day of admission in one of the following ways: Physician provides written orders, nurse received orders via telephone, in which case via telephone is indicated by nurse signature; -Orders are verified on day of admission with the attending physician for accuracy and completeness prior to care rendered; -All medications and treatments are required to have a diagnosis; -Orders must be dated and co-signed by a nurse during the admission process and signed by the attending physician within 30 days; -If original orders are sent to the physician for a signature, a copy must remain in the medical record until the signed form is returned; -Original admission orders should be retained in the medical record; -re-admission to the facility after hospitalizations voids all previous orders. Therefore, all orders pertinent to the resident must be verified upon re-admission. Review of the facility policy titled, Medication Administration-General Guidelines, revised August 2014, showed: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions; -Five Rights-Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away; -The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If changes in directions, or if there is any other reason to question dosage or directions, the physician's orders are checked for the correct dosage schedule. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions. -If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit; -Medications are administered in accordance with written order of the prescriber; -If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary, contacts the prescriber for clarification. The interaction with pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate; -Monitoring of side effects or medication related problems occurs continually, but particularly after medication administration and especially after the first few doses of a new medication; -The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications; -If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage is initialed and circled. An explanatory note is entered on the reverse side of the record. If a vital medication is withheld, refused, or not available the physician is notified. Nursing documents the notification and the physician's response; -If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation or administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed and may differ slightly from the procedures for using paper MARs. 1.Review of Resident #3's face sheet showed: -Originally admitted to the facility on [DATE]; -re-admitted from the hospital on [DATE]; -re-admission diagnosis of heart attack; -Existing diagnoses of diabetes mellitus, liver disease, chronic obstructive lung disease (COPD-a progressive lung condition causing airflow obstruction, leading to shortness of breath, cough, and wheezing, primarily from lung damage due to smoking or pollution), congestive heart failure, and reduced mobility. Review of the resident's significant change minimum data set (MDS, a federal mandated comprehensive assessment tool completed by facility staff), dated 12/28/25, showed: -Reentered the facility from the hospital on [DATE]; -Severe cognitive impairment; -Rejection of care (1-3 days); -Worsening change in behavior; -Used wheelchair for mobility; -Functional limitation in range of motion to bilateral upper and lower extremities; -Required substantial/maximal assistance of staff with oral hygiene and bathing; -Required partial/moderate assistance of staff with personal hygiene; -Dependent on staff for assistance with toileting, lower body dressing, and transfers; -Frequently incontinent of bowel and bladder; -Diagnoses of heart attack, anemia, congestive heart failure, high blood pressure, and diabetes mellitus; -Received pain medication; -Presence of pain, rated as an '8' on a scale of 0-10, frequent, affecting sleep, day to day activities and therapy. Review of the resident's care plan, dated 12/16/25, and revised on 01/05/26, showed: -The resident is on digoxin therapy; -The resident will be free from discomfort or adverse reactions related to digoxin use; -Administer the medication as ordered by the physician; -Monitor for side effects and effectiveness every shift; -Draw labs per provider; -Increase rounding and vitals should toxicity occur; -Monitor/document/report as needed (PRN) adverse reaction of the medication: Anorexia, nausea, vomiting, diarrhea, extreme headache or visual disturbances; -Notify provider of change in condition; -Record baseline peripheral pulses; -Report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm; -Serum digoxin levels monthly or as ordered by the physician. Review of the resident's progress note, dated 12/22/25 at 2:00 P.M., showed a nurse documented: -The resident returned from the hospital via ambulance; -The facility notified the resident's physician. Review of the resident's hospital After Visit Summary, provided by the facility, and dated 12/22/25, showed the following discharge order: -Start digoxin 125 micrograms (mcg) (0.125 milligrams (mg)) tablet, take 1 tablet by mouth daily (medication last given on December 21, 2025, at 6:01 P.M.) Review of the resident's physician order sheet showed: -A physician's order, dated 12/22/25 for digoxin 125 mcg give 1 tablet by mouth 4 times a day for heart failure. This order was discontinued the same day, 12/22/25; -This did not reflect the hospital discharge order of one time per day. Review of the resident's progress note, dated 12/22/25 at 2:21 P.M. showed the following note signed by Licensed Practical Nurse (LPN) A: -This order is outside of the recommended dose or frequency; -Digoxin tablet 125 mcg, give 1 tablet by mouth four times a day for heart failure; -The dosing regimen of 1 tablet 4 times per day exceeds the usual dosing regimen of 0.5 tablet every 2 days to 2 tablets daily; -The frequency of 4 times per day exceeds the usual frequency of every 2 days to daily; -The nurse did not document any follow up with the physician about the medication order. Review of the resident's December 2025 Medication Administration Record (MAR) showed: -An order, dated 12/22/25, with a start date of 12/22/25, for digoxin tablet 125 microgram (mcg) give one tablet by mouth four times per day (at midnight, 6:00 A.M., noon, and 6:00 P.M.) for heart failure; -Staff initialed administration of the medication one time on 12/22/25 at 6:00 P.M. and then the order changed. Review of the resident's progress note, dated 12/22/25 at 11:19 P.M. showed the following note signed by LPN K: -This order is outside of the recommended dose or frequency; -Digoxin tablet 125 mcg, give 1 tablet by mouth four times a day for heart failure; -The dosing regimen of 1 tablet 4 times per day exceeds the usual dosing regimen of 0.5 tablet every 2 days to 2 tablets daily; -The frequency of 4 times per day exceeds the usual frequency of every 2 days to daily; -The nurse did not document any follow up with the physician about the medication order. Review of the resident's physician order sheet showed: -A physician's order, dated 12/22/25 for digoxin 125 mcg, give 1 tablet by mouth 4 times a day for heart failure. Review of the resident's December 2025 MAR and MAR notes, showed an order, dated 12/22/25, with a start date of 12/23/25 at 10:30 P.M., for digoxin tablet 125 microgram (mcg) give one tablet by mouth four times per day (7:00 A.M., 12:30 P.M., 5:30 P.M., and 10:30 P.M.) for heart failure with the following administration entries: -On 12/23/25, at 10:30 P.M., staff documented NA (Not administered, see nurses notes), on the MAR note, staff documented waiting for pharmacy to receive orders; -On 12/24/25, at 7:00 A.M., 12:30 P.M., and at 5:30 P.M., staff documented NA. On the MAR note staff documented medication unavailable nurse notified. -On 12/24/25 at 10:30 P.M., staff left the dosage blank. -Staff did not document administration of any digoxin on 12/23/25 or 12/24/25 and did not document physician notification about not administering the medication. Review of the resident's December 2025 MAR and MAR notes, showed an order, dated 12/22/25, with a start date of 12/23/25 at 10:30 P.M., for digoxin tablet 125 microgram (mcg) give one tablet by mouth four times per day (7:00 A.M., 12:30 P.M., 5:30 P.M., and 10:30 P.M.) for heart failure with the following administration entries: -On 12/25/25, at 7:00 A.M., 12:30 P.M., and at 5:30 P.M., staff initialed administration of the medication three times, and at 10:30 P.M., staff left the dosage blank; -From 12/26/25 through 12/30/25, staff initialed administration of the medication four times each day. Review of secure messaging between facility nursing staff and the resident's physician showed: -On 12/30/25 at 1:59 P.M., nursing staff messaged: Resident has slept a lot today, he/she has easily aroused. Vital signs are blood pressure = 86/52 millimeters of mercury (mm/Hg) (normal range 90-120/60-80), pulse = 62 beat per minute (normal range 60-100), respiratory rate = 22/minute (normal range 12-20). The resident has not wanted to eat today and has no energy. Resident is drinking fluids. Labs have already been collected. This nurse is concerned. Resident is a full code. Please advise; -On 12/30/25 at 3:07 P.M., the physician messaged: Were the labs ordered STAT (immediately); -On 12/30/25 at 3:22 P.M., nursing staff responded: Not the ones drawn today, the ones last week were and have been reviewed. The resident has not been very energetic since returning from the hospital this last time, but did have a heart attack; -On 12/30/25 at 4:06 P.M., the physician messaged: Can we recheck the manual BP and pulse now and recheck STAT complete blood count (CBC, a blood test that measures white and red blood cells and platelets) and comprehensive metabolic profile (CMP, a blood test that measures fluid/electrolyte balance, kidney/liver function, metabolism, and blood sugar levels). Review of the resident's December 2025 MAR showed an order, dated 12/22/25, with a start date of 12/23/25 at 10:30 P.M., for digoxin tablet 125 microgram (mcg) give one tablet by mouth four times per day (7:00 A.M., 12:30 P.M., 5:30 P.M., and 10:30 P.M.) for heart failure with the following administration entries: -On 12/31/25, at 7:00 A.M. staff initialed administration of the dose, at 12:30 P.M. and at 5:30 P.M., staff documented NA; staff did not document the reason for not administering this medication). Review of secure messaging between facility nursing staff and the resident's physician showed: -On 12/31/25 at 7:21 P.M., nursing staff messaged, unable to obtain blood return for labs, please advise; -Staff did not document any further attempt to reach the physician on 12/31/25. Review of the resident's December 2025 MAR showed an order, dated 12/22/25, with a start date of 12/23/25 at 10:30 P.M., for digoxin tablet 125 microgram (mcg) give one tablet by mouth four times per day (7:00 A.M., 12:30 P.M., 5:30 P.M., and 10:30 P.M.) for heart failure with the following administration entries: -On 12/31/25 at 10:30 P.M., staff documented NA (staff did not document reason for not administering this medication). Review of secure messaging between facility nursing staff and the resident's physician showed: -On 1/01/25 at 7:35 A.M., the physician responded, please push fluids and reschedule for tomorrow. Review of the resident's January 2026 MAR showed: -An order, dated 12/22/25, with a start date of 12/23/25 for digoxin tablet 125 microgram (mcg) give one tablet by mouth four times per day (7:00 A.M., 12:30 P.M., 5:30 P.M., and 10:30 P.M.) for heart failure; -On 01/01/26, staff initialed administration of all four doses of digoxin; -On 01/02/26, staff initialed administration of the 7:00 A.M. and 12:30 P.M. doses. Review of secure messaging between facility nursing staff and the resident's physician showed: -On 1/02/26 at 1:39 P.M., nursing staff messaged: Resident's digoxin level came back greater than 5 nanograms per milliliter (ng/ml) with a reference range of 0.9-2.0 ng/ml. The resident is currently getting 125 micrograms (mcg) four times a day. The nurse practitioner is in the facility and held the digoxin until Monday (1/05/26) with a recheck of the digoxin level on Monday. Please advise if you would like anything else done; -On 01/02/26 at 1:50 P.M., the physician responded: Any chest pain/palpitations (racing, fluttering, or pounding heart), nausea, or vomiting? Do we have a recent CMP? -On 1/02/26 at 2:28 P.M., the nurse messaged: Most recent CMP was on 1/01/26 and is attached. The resident has had no complaints of palpitations. The resident will not answer about chest pain. The resident is very confused and crying about the physician telling him/her to run applesauce on him/herself and talking about heel pain. The resident said he/she has had some nausea/vomiting. The resident's roommate said the resident's last meal was 4 days ago and the resident has thrown up everything since. -On 1/02/26 at 2:32 P.M., the physician responded: Discontinue the digoxin; Review of the resident's vital signs showed the following pulse entries for 01/02/26: -On 01/02/2026 at 2:42 P.M., pulse = 62 beats per minute (bpm); Review of secure messaging between facility nursing staff and the resident's physician showed: -On 1/02/26 at 4:50 P.M., the nurse messaged: After looking into this further, it was found the resident's digoxin order from the hospital discharge was 125 mcg once every day. The admission nurse accidentally entered the order for 125 mcg four times a day. Just wanted to report this medication error. -On 1/02/26 at 4:51 P.M., the nurse messaged: The digoxin was discontinued as ordered today. Review of the resident's physician order sheet showed: -The physician's order, dated 12/22/25 for digoxin 125 mcg give 1 tablet by mouth 4 times a day for heart failure was placed on hold starting 1/02/25 and discontinued on 1/02/25. Review of the resident's vital signs showed the following pulse entries for 01/02/26: -On 01/02/2026 at 11:07 P.M., pulse = 68 bpm (Regular); -On 01/02/2026 at 11:17 P.M., pulse = 86 bpm (Regular); Review of the resident's vital signs showed the following pulse entries for 01/03/26: -On 01/03/2026 at 7:50 A.M., pulse = 79 bpm (Regular) -On 01/03/2026 at 7:51 A.M., pulse = 79 bpm (Regular) -On 01/03/2026, on 11:45 A.M., pulse = 56 bpm (Regular) Review of secure messaging between facility nursing staff and the resident's physician showed: -On 1/03/26 at 2:45 P.M., the nurse messaged: The resident has continued to be very lethargic and confused today. Respirations =14 per minute, BP = 80/58 mm/Hg, Pulse = 62, beats per minute, but very difficult to find radial (wrist) or carotid (neck) pulses. Pulse is very thready. One nurse was able to slightly feel the radial pulse and stated it was irregular. The resident wakes to verbal stimuli but falls back to sleep pretty immediately. Heart tones very distant and difficult to hear. Please advise; -On 1/03/26 at 3:11 P.M., the physician responded: Can we get a peripheral intravenous (IV) access and start the resident on Normal Saline (NS) IV fluids. Hold all sedating medications; -On 1/03/26 at 4:41 P.M., the nurse responded: I put all sedating medications on hold and was able to get an IV started, I have NS running at 100 milliliters (ml) per hour; -On 01/03/26 at 4:53 P.M., the physician responded: Administer a bolus of 500 ml, then continue 100 ml per hour; -On 01/03/26 at 4:54 P.M., nurse responded: Doing that now. Review of the resident's vital signs showed the following pulse entries for 01/03/26: -On 01/03/2026 at 10:14 P.M., pulse = 60 bpm. Review of the resident's vital signs showed staff documented the following pulse entries for 01/04/26: -On 01/04/2026 at 12:25 A.M., pulse = 56 bpm (Irregular – unable to determine (UTD) onset); -On 01/04/2026 at 6:22 A.M., pulse = 58 bpm (Irregular – UTD onset); -On 01/04/2026 at 8:45 A.M, pulse = 49 bpm; -On 01/04/2026 at 9:13 A.M. pulse = 49 bpm (Regular); -On 01/04/2026 at 9:14 A.M., pulse = 49 bpm (Regular). Review of secure messaging between facility nursing staff and the resident's physician showed: -On 1/04/25 at 11:39 A.M., a nurse messaged: The resident's IV went bad. The resident has poor veins. May we have an order for a peripherally inserted central catheter (PICC, an IV that runs from the arm to a large vein near the heart) or midline (an IV that runs from the arm to an arm pit area large vein for IV fluids) please; -On 1/04/25 at 11:45 A.M., the nurse added: Or may we discontinue the IV fluids; -On 1/04/26 at 12:01 P.M., the physician messaged: Condition update and assessment please; -On 1/04/26 at 1:12 P.M., the nurse responded: Resident is still lethargic but easily aroused. Weak pulse, rate = 49/beats per minute and blood pressure =101/48 mm/Hg; Review of the resident's vital signs showed the following pulse entries for 01/04/26: -On 01/04/2026 at 1:49 P.M., pulse = 51 bpm (Regular). Review of secure messaging between facility nursing staff and the resident's physician showed: -On 1/04/26 at 4:47 P.M., the physician responded: Holding Metoprolol for blood pressure less than 100/60 and pulse less than 60? -On 1/04/26 at 4:48 P.M., the physician asked: What is the resident's blood sugar; -On 1/04/26 at 4:53 P.M., the physician messaged: No PICC or midline-push oral fluids; -On 1/04/26 at 5:13 P.M., the nurse messaged: Update, the family was informed of the resident's condition and requesting the resident be sent to the hospital. Will send to hospital; -On 1/04/26 at 5:13 P.M., the physician responded: Noted. Review of the resident's hospital physician progress note, dated 1/05/26, showed: -Resident admitted to the hospital on [DATE] with altered mental status. Family reports resident was in a nursing home and was given too much digoxin over the last few days and was given IV fluids to counteract. Upon arrival to the emergency room resident was found to be hypotensive (low blood pressure); -Digoxin toxicity, digoxin level = 6.6 ng/mL); -Resident was given Digibind (an antidote used to treat life-threatening overdose or toxicity from digoxin) and Levophed (norepinephrine, a potent medication administered IV to treat dangerously low blood pressure that does not improve with fluid replacement); -Resident is now admitted to the intensive care unit (ICU) for further evaluation and management; -Overnight no acute events resident continues on multiple doses of vasopressors (medications to raise blood pressure). During an interview on 1/06/26 at 11:57 A.M., the NP said the following: -On Friday, 1/02/26, one of the nurses notified him/her that the resident's digoxin level was greater than 5 ng/ml; -He/she checked the resident's digoxin order and said he/she had never seen that much digoxin given to a resident; -He/she placed the medication on hold, told the nurse to send a message to the resident's physician, and monitor the resident's vital signs; -The NP assessed the resident, and he/she appeared baseline, the resident had some memory issues, but not a new issue; -On 1/03/26, he/she asked the nurse to start the resident on IV fluids because the resident's blood pressure was 80/58 mm/Hg; -Nurses should notify the physician or NP if the resident's blood pressure or pulse is low. During an interview on 1/06/26 at 1:00 P.M., LPN A said the following: -When Resident #3 returned from the hospital on [DATE], he/she reviewed the resident's hospital discharge orders and reviewed the medications; -He/she then placed an order for digoxin into the resident's electronic health record as a physician order; -He/she did not realize the order he/she entered for digoxin did not match the hospital discharge order; -He/she did not notify the physician of the resident's return, but assumed the physician would review the resident's medication orders; -He/she assumed management notified the resident's physician when a resident returned from the hospital; -When a nurse entered an order that was outside of the recommended dosage, a warning message generally popped up and the nurse had to click on the message to confirm after reading the message and then the message would become a progress note; -When he/she entered the digoxin order, he/she did not see the warning message pop up about the dosage; -After his/her error entering the incorrect digoxin order, the director of nursing spoke with the nurse about the correct process for entering orders. During an interview on 1/7/26 at 9:40 A.M., the Director of Rehabilitation (DOR) said the following: -On Wednesday, 12/31/26, the resident said he/she had vomited and complained of nausea. The DOR saw an emesis basin at the resident's bedside. Since the resident was not feeling well, therapy did not work with the resident; -On Thursday, 1/01/26, and on Friday, 1/02/26, he/she noticed a change in the resident; -The resident showed very little participation in therapy; -He/she was not eating or drinking much, despite encouragement from staff; -On 1/02/26, the resident was sleepy; -The DOR looked at the resident's medical record and saw the resident had a critically high digoxin level, he/she went and informed the nurse, Registered Nurse (RN) E, who was previously unaware of the lab result. The nurse then reported the lab result to the nurse practitioner. During a phone interview on 1/07/26 at 3:34 P.M., the facility physician said the following: -The facility notified him/her that the resident's digoxin level was greater than 5 ng/ml; -The resident was non-compliant with taking medication and was difficult to manage; -The physician said nursing informed him the resident did not initially want to go to the hospital when the high digoxin level was discovered, and the resident was his/her own responsible party; -The physician said to prevent medication errors, the facility should have checks and balances in place and the pharmacy should have caught the medication error and should not have filled the unusually high dose of digoxin without checking with the facility/physician; -The physician said the pharmacy should catch medication errors; -The physician said he believed he saw the resident, but did not notice the digoxin order. During an interview on 1/07/26 at 1:05 P.M., Certified Medication Technician (CMT) F said the following: -Digoxin should be given one time per day. During an interview on 1/07/26 at 1:24 P.M., the Assistant Director of Nursing (ADON) said the following:-On Friday, 1/02/26, staff realized Resident #3's digoxin was critically high and discovered the resident was on the wrong dose of the medication; -Some signs of digoxin toxicity included low vital signs, which the nurse found when reviewing the resident's medical record after the resident went to the hospital; -He/she was not aware of any condition changes with the resident, except the resident was not super engaged during therapy, but that was not unusual for the resident; -He/she was unsure if the nurses communicate admission/re-admission order to the facility physician; -He/she was unsure if nurses did any type of second check on physician orders to ensure accuracy. 2. Review of Resident #4's face sheet showed: -Originally admitted to the facility on [DATE], readmitted on [DATE] from the hospital; -Diagnoses of paraplegia (impairment in motor or sensory function of the legs), lumbar spina bifida (a condition occurring during embryonic development when the spine/spinal cord does not form properly), and history of thrombosis (a stationary blood clot) and embolism (a traveling blood clot that gets stuck causing a blockage). Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Functional limitation in range of motion to bilateral lower extremities; -Presence of a urinary catheter; -Frequently incontinent of bowel; -Required partial/moderate staff assistance with toileting, hygiene and showers; -Required set-up/clean up assistance with eating and oral hygiene; -Diagnoses of spina bifida and paraplegia; -Resident is on anticoagulants. Review of the resident's care plan, revised on 11/11/25, showed the following: -Anticoagulant medication use: At risk for abnormal bleeding, hemorrhage and/or increased/easy bruising related to anticoagulant medication use; -Deep vein thrombosis prophylaxis (prevention); -Goal will be free from signs and symptoms of abnormal bleeding; -Lab values will be maintained within therapeutic range. As determined by their physician; -Administer anticoagulant as currently prescribed by the resident's physician (see current physician orders); -Observe and report any of the following signs and symptoms of bleeding: Bleeding gums, nose bleeds, unusual bruising, black stools, pink or discolored urine; -Report to nursing any unusual bleeding or bruising; -Schedule lab tests as ordered by the physician to monitor coagulation factors. Report results to the physician. Review of the resident's hospital Discharge summary, dated [DATE], showed the following order: -Warfarin (coumadin), 1 milligram (mg) tablet, staff to administer 3 tablets on Mondays, and 2 tablets all other days, by mouth daily; -Hold today, physician to recheck prothrombin time (PT, a test measuring how long it takes for blood to clot)/International Normalized Ratio (INR, a standardized measurement used in a PT blood test to monitor how long it takes for blood to clot, crucial for people taking blood thinning medication like warfarin to ensure they are within safe range (typically 2-3) to prevent excessive bleeding or clotting) on 12/24/25. Review of the resident's physician order sheet showed the following orders: -Warfarin sodium oral tablet 1 mg, give 3 tablets (total 3 mg) by mouth one time a day related to complete paraplegia, order dated 12/23/25, with a start dated of 12/24/25; -This order did not match the hospital discharge order of 3 mg on Mondays and 2 mg all other days. Review of the resident's December 2025 MAR showed the following order: -Warfarin sodium oral tablet 1 mg, take 3 tablets by mouth one time a day at 9:00 A.M. related to paraplegia, start date 12/24/25. -Staff initialed administration of the medication daily from 12/24/25-12/31/25. Review of the resident's December 2025 Nurse MAR showed the following order: -Monitor for anticoagulant side effects two times a day on 7:00 A.M.-3:00 P.M. shift and on 11:00 P.M.-7:00 A.M. shift; -Staff initialed monitoring of side effects one time on 12/23/25 during the 11:00 P.M.-7:00 A.M. shift and two times a day from 12/24/25-12/31/25. Review of the resident's physician order sheet showed the following orders

Based on observation, interview, and record review, the facility failed to maintain an effective system of reconciliation for all controlled substances, when nursing staff failed to maintain signature sheets for counting of the controlled substances at the beginning and end of each nurse shift for two of two nurse carts. These two carts were referred to as Skilled 1 and Skilled 2 which contained all as needed (PRN) controlled resident medications. The facility census was 106. 1. Review of the controlled medication books located on each cart showed no sheet for nurses to sign when counting controlled medications at the beginning and end of each shift.Observation on 01/13/26 at 2:00 P.M., showed two medication carts located inside the locked nurse station. During an interview on 1/13/26 at 2:00 P.M., Licensed Practical Nurse (LPN) B said the following:-The two carts located in the nurse station are the nurse carts and are referred to as Skilled 1 and Skilled 2 carts;-The carts contain all PRN controlled medications for the residents;-At the beginning and end of each shift the off going and oncoming nurses count the quantity of each controlled medication and the total number of controlled medication packages;-The nurses do not sign to confirm the shift count;-He/She has worked at the facility for approximately 3 months and has never signed to confirm the beginning and end of shift count.During an interview on 1/13/26 at 2:05 P.M., Licensed Practical Nurse (LPN) C said the following:-At the beginning and end of each shift, the off going and oncoming nurses count the quantity of each controlled medication and the total number of controlled medication packages;-The nurses do not sign to confirm the shift count;-He/She has worked at the facility for approximately 6 months and has never signed to confirm the beginning and end of shift count.During an interview on 1/13/26 at 2:26 P.M., the Director of Nursing said the following:-Nurses should count all controlled medications in each card or package and the total number of controlled medication packages in their assigned cart at the beginning and end of each shift;-The nurses should sign the signature sheet to confirm they have counted and the count was correct;-He/she was not aware the nurses were not signing to confirm the controlled medication count. He/she had not been auditing to ensure nurses were signing to confirm the narcotic count each shift. During an interview on 1/13/26 at 3:16 P.M., the Administrator said the following:-Nurses should be signing for completion and accuracy of the narcotic count at the beginning and end of each shift.Complaint 2714772

Based on observation, interview, and record review, the facility failed to ensure staff administered resident medications as ordered by the physician, when during medication administration observation for Residents # 5 and #6, staff made 4 errors out of 27 opportunities for error, resulting in a medication error rate of 6.75%. The facility census was 106.Review of the facility policy titled, Medication Administration-General Guidelines, revised August 2014, showed:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions;-Five Rights- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away;-The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If changes in directions, or if there is any other reason to question dosage or directions, the physician's orders are checked for the correct dosage schedule. When a medication order is changed and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions.-If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit;-Medications are administered in accordance with written order of the prescriber;-If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse should call the provider pharmacy for clarification prior to the administration or the medication or if necessary, contacts the prescriber for clarification. The interaction with pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate;-Monitoring of side effects or medication related problems occurs continually, but particularly after medication administration and especially after the first few doses of a new medication;-The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications;-If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage is initialed and circled. An explanatory note is entered on the reverse side of the record. If a vital medication is withheld, refused, or not available the physician is notified. Nursing documents the notification and the physician's response;-If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation or administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed and may differ slightly from the procedures for using paper MARs. 1.Review of Resident #5's face sheet showed:-admitted to the facility on [DATE];-Diagnoses of diabetes mellitus type II, restless leg syndrome, and fibromyalgia (chronic disorder with muscle fatigue, pain, sleep disturbance, and cognitive issues). Review of the resident's current physician order sheet showed:-Order for Rosuvastatin Calcium oral tablet 20 mg. Give one tablet by mouth (po) in the morning for hyperlipidemia (high cholesterol), order dated 10/24/25;-Order for Ropinirole Hydrochloride (HCl) extended release (ER) 4 milligram tablet by mouth. Give one tablet one time a day for diagnosis of restless leg syndrome, order dated 10/29/25. Observation on 1/09/26 at 8:54 A.M., showed CMT G administering the following medications to Resident #5:-Rosuvastatin 20 mg 1 po, staff pulled a 20 mg tablet from a plastic strip of medications and pulled a 20 mg tablet from a bubble pack (both labeled for resident use, both with the same prescription) and placed the 2 tablets into the medication cup for administration, instead of the 1 tablet dose as ordered;-Ropinirole 4 mg 24-hour release, the CMT looked for the medication, but the medication was not available in the medication cart and was not in the emergency kit when that CMT looked. The CMT told the nurse the medication was not available. The nurse said he/she would contact the pharmacist. The medication was not available for administration as ordered;This observation equaled a total of 15 medications administered with 2 medication errors. Review of the resident's January 2026 Medication Administration Record (MAR) showed:-Order for Rosuvastatin Calcium oral tablet 20 mg. Give one tablet by mouth in the morning. Give one tablet in the morning between 7:00 A.M. and 11:00 A.M. for a diagnosis of hyperlipidemia (high cholesterol), order dated 10/24/25;-On 1/07/26, CMT G initialed administration of the Rosuvastatin dose.-Order for Ropinirole Hydrochloride (HCl) extended release (ER) 4 milligram tablet by mouth. Give one tablet one time a day at 8:00 A.M., for a diagnosis of restless leg syndrome, order dated 10/29/25;-On 1/07/26 at 8:00 A.M., CMT G charted 'NA' (Not administered. See nurse note). Review of the resident's progress notes/nurse notes showed no coinciding note with the date/time/reason for not administering the Ropinirole. 2. Review of Resident #6's face sheet showed:-admitted to the facility on [DATE];-Diagnoses of Insulin dependent diabetes type II and chronic obstructive pulmonary (lung) disease. Review of the resident's physician orders showed:-Advair Diskus (medication used in treatment of lung disease by opening airways) 250/50 micrograms (mcg)/actuation (operation). One inhalation, inhale orally two times per day for COPD, dated 12/06/25.-Prednisone (corticosteroid used to treat severe inflammation, allergies, autoimmune diseases, and certain cancers by suppressing the immune system and reducing swelling) oral tablet 5 milligrams (mg) by mouth in the morning for COPD order dated 12/22/25. Observation and interview on 1/07/26 at 9:26 A.M., showed CMT N, made the following medications errors while administering medications to Resident #6:-Advair Diskus, the CMT looked for but could not locate the inhaler for the resident and stated he/she was going to make sure the medication was ordered from the pharmacy;-Prednisone 5 mg tablet, the CMT said he/she did not have the 5 mg prednisone, but the facility had ordered the medication from the pharmacy and was waiting on delivery of the medication;-Niether of these medications were available for administration as ordered; observation equaled a total of 12 medications administered with 2 medication errors. Review of the resident's January 2026 medication administration showed:-Advair Diskus 250/50 micrograms (mcg)/dose. One inhalation, inhale orally two times per day for COPD, dated ;12/06/25-On 1/07/26, for the 7:00 A.M-11:00 A.M. dose, CMT N documented NA (not administered. See nurse note).Review of the resident's progress notes, dated 1/07/26, showed, medication on order. Review of the resident's January 2026 medication administration showed:-Prednisone oral tablet 5 milligrams (mg) by mouth in the morning for COPD order dated 12/22/25;-On 1/07/26, for the 6:00 A.M.-11:00 A.M. dose, CMT N documented HD (Hold. See nurse note). Review of the resident's progress notes, dated 1/07/26, showed medications on order. During an interview on 10/7/26 at 9:30 A.M., CMT N said the facility had issues with medication availability. During an interview on 1/07/26 at 3:00 P.M., Certified Medication Technician (CMT) M said the following:-Resident medication availability was an issue at times;-Some of the CMTs did not re-order medications when resident supply ran low;-At times, the pharmacy took longer than expected, up to 2 days or more, to deliver ordered medications;-The facility was in the process of changing to a different pharmacy;-He/she was unsure if the nurses double checked the physician orders to ensure the medication orders were correct. During an interview on 1/07/26 at 3:20 P.M., LPN B said the following:-The facility had an issue with medication availability from the pharmacy;-There were issues with the communication between the pharmacy and the physician for ordering and re-ordering of controlled medication;-These issues caused delays in residents receiving ordered medications timely;-When the physician gave a new order, the nurse should ensure the order is placed correctly into the physician orders the same day. During an interview on 1/07/26 at 12:06 P.M., LPN C said the following:-If a resident did not have an ordered medication, the nurse or CMT should contact the pharmacy and order the medication or pull the medication from the facility's emergency supply;-If a resident's medication was not available at the time of administration, the nurse should call the physician or send the physician a message and ask for a substitution and document the response in a progress note. During an interview on 1/07/26 at 1:05 P.M., CMT F said the following:-Sometimes the pharmacy sends duplicates of the same medications. At times, the pharmacy sent the same medication in a bubble card and in a plastic strip. This happened more often with a new prescription;-He/she said CMTs were not allowed to order medications stat (immediately) from the pharmacy. The CMTs were supposed to notify the nurse when a medication was not available for administration and the nurse would contact the pharmacy;-He/she tried to order the medications enough ahead of time so the resident would not run out of the medication. During an interview on 1/07/26 at 2:25 P.M., the DON said the following:-If a nurse or CMT did not have a resident medication available for administration, the nurse should contact the pharmacy and contact the physician to notify and see what the physician wants the staff to do and document all in a progress note. During an interview on 1/13/26 at 3:16 P.M., the Administrator said the following:-If a CMT could not locate an ordered medication for a resident, he or she should check the back up supply or notify the nurse when the medication was not available;-The nurse should contact the pharmacy and the physician for any needed medication. This should be done timely, within the same shift;-If the nurse had an issue obtaining the medication, or had questions, they should reach out to the DON of Administrator;-If a CMT did not give a medication to a resident, the CMT should document a note, explaining which medication and why the medication was not administered;-The nurse should document the follow up in the progress notes;-Nurses should complete the 5 rights of medication administration as per the facility policy, to ensure residents received the correct dose of each medication. Complaint 2699464, 2707177, 2707414, 2707810, 2712161, and 2714772.

Based on interview and record review, the facility failed to honor residents' request for funds as soon as possible, but no later than the same day for amounts of $50.00 for Medicaid residents, for two residents (Resident #1 and Resident #2). The facility census was 106.Review of the undated facility's policy titled Business Office-Resident Trust Fund Policy and Procedure, showed the following: -Residents of a Skilled Nursing Center are to have their funds managed and personal spending money available to them. Regardless of payment source, residents have the right to choose whether or not to open a Resident Trust Fund account with the Center. If the choice to open a trust fund account is made, the resident has the right to have their money safeguarded and accounted for by the Center. The residents have the right to have any funds deposited with the center, in an interest-bearing account, according to state guidelines. All resident account balances over $50.00 will accrue interest. The Administrator ultimately will be responsible for the oversight and management of resident funds;-For the benefit of its residents, the Center shall provide a Resident Trust Cash Box and a separate bonded interest bearing bank account for all residents who choose to have their personal money safeguarded and managed by the Center. The Center will have, at all times, a current copy of the surety bond, per state regulations, to cover resident trustfunds. The resident or their legal guardian are the only ones who can designate what the monies are spent on and have the right to request their Resident Trust Fund Ledger at any time;-The Center will honor any request of resident funds $50.00 ($100.00 for Medicare residents) or less that same day and any request of resident funds over $50.00 ($100.00 for Medicare residents) within 3 business days of the request. 1. Review of Resident #1's face sheet, a document that gives a patient's information at a quick glance, showed the following: -The resident admitted on [DATE];-The resident was his/her own responsible party. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 01/01/26, showed the following: -The resident was cognitively intact. During an interview on 01/06/26, at 12:17 P.M., the resident said: -He/she kept his/her funds in a resident trust account;-He/she had to go to the facility bank twice to get his/her $50.00;-He/she could get $35.00 one day and the remaining $15.00 the next day;-If he/she wanted to withdraw $50.00, he/she had to fill out a form for the Business Office Manager (BOM) and wait two days;-He/she was not denied access to his/her funds unless he/she requested more than $35.00 and then had to fill out a form and wait for the money. 2. Review of Resident #2's face sheet showed the following: -The resident admitted on [DATE];-The resident was his/her own responsible party. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact. During an interview on 01/07/26, at 9:17 A.M., the resident said: -He/she received $50.00 per month;-If he/she needed more than $35.00, he/she had to fill out a request form 48 hours in advance;-If he/she needed the full $50.00 without advance notice, he/she did not know what he/she would do. 3. During an interview on 01/06/26, at 3:08 P.M., the Business Office Assistant said the following: -If a resident had money in their resident trust account, they were allowed to withdraw $35.00 per day;-He/she did not know why residents could only withdraw $35.00 a day;-If a resident wanted to withdraw more than $35.00, they filled out a request form 48 hours prior to needing the money;-He/she did not deny residents money unless they did not have money in their account. 4. During interviews on 01/06/26, at 2:52 P.M. and 01/07/26, at 11:32 A.M., the BOM said the following: -Residents withdrew money from the window by the activity room and can withdraw up to $35.00 a day;-If residents wanted more than $35.00, they filled out a request form and he/she went to the bank to get the money because the facility's cash box could not hold that much money;-He/she did not deny residents money from their trust unless the resident did not have money in their account;-The facility could only hold $2,000.00 in the cash box and if they allowed residents to pull their full $50.00 out on the first of the month, the facility would run out of money in the cash box fast;-He/she did not think $35.00 a day was regulation, but it was the facility's policy due to being a liability to have so much money in the facility;-If a resident did not have two days to wait for their money and the facility had the money on hand, the resident could get their full $50.00. 5. During an interview on 01/07/26, at 1:24 P.M., the Assistant Director of Nursing (ADON) said he/she believed if a resident wanted to withdraw their $50.00 at once, the facility should allow that. 6. During an interview on 01/07/26, at 4:30 P.M., the Director of Nursing (DON) said if a resident received $50.00 a month, they should be able to withdraw in one lump sum. 7. During an interview on 01/13/26, at 3:16 P.M., the Administrator said: -When residents came to the facility bank, they could not give every resident their full $50.00;-She was told by her corporation if the facility was the payee for the resident's social security, the facility was only allowed to give the resident $10.00 a day and that social security rules were followed over Centers for Medicare and Medicaid Services (CMS) guidelines. Complaint #2706058

Based on interview and record review, the facility failed to document a change in condition and discharge to the hospital in one resident's (Resident #8) progress notes. The facility census was 106.1. Review of Resident #8's face sheet showed the following:-The resident admitted on [DATE];-The resident was his/her own responsible party;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive lung condition causing airflow obstruction, leading to shortness of breath, cough (often with mucus), and wheezing, primarily from lung damage due to smoking or pollution), bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity), extrapyramidal and movement disorder (EPS-involuntary movement disorders, often caused by medications like antipsychotics), anxiety and insomnia. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident required supervision or touching assistance for all activities of daily living. Review of the resident's discharge return anticipated MDS, dated [DATE], showed the following:-The resident did not require assistance for eating, oral hygiene, toilet hygiene, upper body dressing and personal hygiene;-The resident required supervision or touching assistance to shower, lower body dressing and putting on and taking off footwear;-Diagnoses included diabetes mellitus, malnutrition, anxiety disorder and bipolar disorder;-The resident received scheduled and as needed pain medications;-The resident had shortness of breath;-The resident received antipsychotic, antianxiety and antidepressant medications. Review of the resident's care plan, revised 12/15/25, showed the following:-The resident had episodes of hypoglycemia (low blood sugar);-Monitor, document and report as needed signs and symptoms of hypoglycemia such as sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination and staggering gait;-Monitor, document and report as needed any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep, rapid, labored and consistent breating pattern that signals severe metabolic acidosis, most commonly diabetic ketoacidosis (DKA-a severe, life-threatening condition where the body cannot use sugar for fuel, breaking down fat instead, which produces acid ketones)), acetone breath (smells fruity), stupor or coma;-Monitor, document and report as needed any signs or symptoms of infection to open areas such as redness, pain, heat, swelling or pus formation;-The resident used antipsychotic medications related to bipolar disorder;-Monitor and record occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence or aggression towards staff or others and document per facility protocol;-The resident used antidepressant medication related to depression;-Monitor, document and report as needed adverse reactions to antidepressant therapy such as change in behavior, mood or cognition, hallucinations or delusions, social isolation, suicidal thoughts, withdrawal, decline in activity of daily living ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle [NAME], falls, dizziness, vertigo, fatigue, insomnia, appetite loss, weight loss, nausea and vomiting, dry mouth or dry eyes;-The resident used antianxiety medications related to anxiety disorder;-Monitor and record occurrence of behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence or aggression towards staff or others and document per facility protocol. Review of the resident's census showed the resident had hospital leave on 12/27/25. Review of the resident's nurse's progress notes showed no documentation of a change in condition or notification of physician for need to send the resident to the hospital on [DATE]. 2. During an interview on 01/07/26, at 1:24 P.M., the ADON said the following:-If a resident was sent to the hospital, the charge nurse should document a nurse's note in the chart that contained the residents symptoms, concerns, vitals and notifications of the physician and responsible party. 3. During an interview on 01/12/26, at 12:00 P.M., RN J said if a resident was sent to the hospital the charge nurse documented in a nurse's progress note. 4. During an interview on 01/12/26, at 12:57 P.M., LPN C said the following:-If a resident needed to go to the hospital, he/she called EMS, printed a medication list and filled out a transfer form;-He/she documented in a nurse's progress note or change in condition transfer form the residents symptoms that required hospitalization and notification of the physician and resident's responsible party or next of kin. 5. During an interview on 01/13/26, at 3:16 P.M., the Administrator said the following:-When residents went out to the hospital, nurses documented the residents change in condition and notification of the resident's physician and responsible party.

Based on observation, interview, and record review, the facility failed to provide wound prevention and treatment per standards of practice when staff failed to complete a full assessment and obtain treatment orders timely upon discovery of a wound, failed to follow physician orders for interventions, completion of wound treatments and labs, and failed to care plan interventions for one resident (Resident #95) who developed facility acquired pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The resident developed infection and was referred to a surgeon for possible amputation of the right lower leg. The facility census was 98. The Administrator was notified on 02/07/25, at 4:59 P.M., of an Immediate Jeopardy (IJ) which began on 12/05/24. The IJ was removed on 02/07/25, as confirmed by surveyor onsite verification. Review of a facility policy titled Wound Management, dated 11/15/22, showed the following: -The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatment will be provided in accordance with physician's order; -Charge nurse will notify the physician in the absence of treatment orders; -Wound characteristics and documentation will included location of the wound; pressure injury and stage; size (shape, depth, tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), and/or undermining (the destruction of tissue or ulceration extending under the skin edges); volume and exudate (drainage) characteristics; pain evaluation; presence of infection; condition of the wound bed and wound edges; condition of the peri wound (skin surrounding wound); and resident preference and goals. -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of treatments will be monitored through ongoing evaluation of the wound. Review of a facility policy titled Comprehensive Person-Centered Care Plan, dated 10/23/19, showed the following: -Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -The interdisciplinary team (IDT), along with the resident and/or resident representative, will identify resident problems, needs, strengths, life history, preferences, and goals; -For each problem, need, or strength a resident centered measurable goal is developed; -Staff approaches are to be developed for each problem, need, and strength. Assigned disciplines will be identified to carry out the intervention; -The comprehensive person-centered care plan can be reviewed and/or revised at quarterly intervals; -Upon a change in condition the care plan will be updated if applicable: -The care plan is updated to reflect risk/occurrences with a problem area, including goals and interventions to reduce the risk/occurrence. 1. Review of Resident #95's face sheet (document that gives resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included encephalopathy (brain disease that alters brain function and structure), cerebral infarction (when blood flow to the brain is blocked leading to brain tissue death), non-pressure ulcer of the right foot with fat layer exposed (skin breakdown or open sore that develops due to a cause other than pressure), and type two diabetes mellitus (the body has trouble controlling blood sugar and using it for energy). Review of the resident's current care plan showed on 09/05/24, staff care planned following: -Resident had potential impairment to skin integrity related to deconditioning and incontinence; -Staff to follow facility protocols for treatment of injury; -Staff to educate resident/family/caregivers of causative factors and measures to prevent skin injury and encourage good nutrition and hydration in order to promote healthier skin. Review of the resident's skin assessment, dated 09/12/24, showed resident had no wounds and a rash to the groin area. Review of the resident's record, dated 09/13/24 to 10/18/24, showed staff did not document completion of skin assessments. Review of the resident's skin assessment, dated 10/19/24, showed the following: -An unstageable pressure ulcer to the right heel, measuring 5 centimeters (cm) by 3 cm; -Drainage noted when staff assisted resident to get dressed; -Bordered gauze dressing applied and heel offloaded; -Staff notified the Director of Nursing (DON), physician, and family. Record review of the resident's medical record, dated 10/19/24 and 10/21/24, showed no wound orders in place for the unstageable pressure ulcer on right heel. Review of the resident's physician progress note, dated 10/21/24, showed the nurse practitioner evaluated the resident due to staff report of a right heel wound. Resident found to have a stage 3 full thickness wound with eschar (dead tissue that forms over healthy skin). New orders included to cleanse with house wound cleanser, apply calcium alginate (absorbent wound dressings made from seaweed (alginate)) to wound and cover with bordered gauze and change daily, wound care consult, and Tylenol (pain reliever) 325 milligrams (mg) two tablets every six hours. Review of the resident's October 2024 Physician Order Sheet (POS) showed an order, dated 10/22/24, to cleanse with house wound cleanser, apply calcium alginate to wound and cover with bordered gauze and change daily. (The order did not specify the location of the wound.) Review of the resident's initial wound evaluation from the wound care provider, dated 10/24/24, showed the following: -Stage 3 full thickness pressure wound of the right heel; -Wound size 4.0 cm by 1.8 cm with depth not measurable; -Depth not measurable due to nonviable tissue and necrosis (death of body tissue); -Wound had moderate amount of serous (clear, watery fluid that leaks from a wound); -Wound had 80% necrotic (dead or non-viable tissue) and 20% slough (dead, yellow or white tissue that covers wound). Review of the resident's care plan showed staff did not update the care plan regarding the right heel wound. Review of the resident's October 2024 POS showed a new order, dated 10/26/24, was received to cleanse the right heel with house wound cleanser, apply calcium alginate to wound and cover with bordered gauze and change daily. Review of the resident's wound evaluation and management summary from the wound care provider, dated 10/31/24, showed the following: -Resident had wounds on the right posterior (back of body) heel and right plantar (sole of foot) heel; -Full thickness pressure wound of the right posterior heel measured 2.9 cm by 1 cm by 0.1 cm with moderate serous drainage; -Right posterior heel was improved; -Wound covered in 25% slough and 75% granulation tissue (soft, pink-red tissue that forms as wound heals). -Unstageable deep tissue injury (DTI) of the right plantar heel measured 1.7 cm by 1.8 cm by non-measurable depth with no drainage. Review of the resident's care plan showed staff did not update the care plan regarding the two identified wounds. Review of the resident's nursing progress notes, dated 10/19/24 to 10/31/24, showed staff did not document related to the resident's unstageable pressure ulcer or right heel stage 3. Review of resident's November 2024 POS showed the following: -An order, dated 11/01/24, for stage 3 right posterior heel to cleanse with house wound cleanser, apply calcium alginate to wound and cover with bordered gauze and change daily; -An order, dated 11/01/24, for unstageable DTI to right heel to cleanse with facility choice wound cleanser and apply bordered gauze daily until healed. Review of resident's November 2024 TAR showed the following: -Staff did not document completion of the wound treatment to stage 3 right posterior heel 11/01/24 and 11/02/24. -Staff did not document completion of the wound treatment to the unstageable right heel wound on 11/01/24 and 11/02/24. Review of the resident's wound evaluation and management summary from the wound care provider, dated 11/06/24, showed the following: -Stage 3 pressure ulcer of the right posterior heel measured 2.5 cm by 1.0 cm by 0.1 cm and was improved; -Wound had moderate serous drainage with 25% slough and 75% granulation tissue in wound bed; -Unstageable DTI to right heel measured 1.5 cm by 1.8 cm by 0.1 cm with light serous drainage was improved. Review of resident's November TAR showed the following: -Staff did not document completion of the the wound treatment to the stage 3 right posterior heel on 11/07/25. -Staff did not document completion of the wound treatment to the unstageable right heel on 11/07/24. Review of resident's November 2024 POS showed the following orders -An new order, dated 11/08/24, for stage 3 right heel to cleanse with normal saline, apply Santyl (medication used to remove damaged skin) to wound and cover with bordered gauze and change daily; -An new order, dated 11/08/24, for unstageable right heel to cleanse wound with normal saline, apply small amount of Santyl to wound and cover with bordered gauze daily and as needed. Review of the resident's care plan showed staff did not update the care plan with the wounds or change in treatment. Review of resident's November 2024 TAR showed the following: -Staff did not document completion of the wound treatment to the stage 3 right posterior heel on 11/08/24 and 11/10/24. -Staff did not document completion of the wound treatment to unstageable right heel on 11/08/24 and 11/10/24. Review of the resident's wound evaluation and management summary from a wound care provider, dated 11/13/24, showed the following: -Stage 3 pressure ulcer of the right posterior heel measured 2.4 cm by 0.9 cm by 0.1 cm and was improved. Wound had light serous drainage with 20% slough and 80% granulation tissue in wound bed; -Unstageable DTI to right heel measured 0.9 cm by 1.4 cm by 0.1 cm with light serous drainage. Wound bed with 25% slough and 50% granulation tissue and not at goal. Review of resident's November 2024 POS showed the following orders: -An new order, dated 11/15/24, for stage 3 right heel to cleanse with normal saline, apply small amount of Santyl to wound and cover with bordered gauze daily and as needed; -An new order, dated 11/15/24, for unstageable right heel to cleanse with normal saline, apply small amount of Santyl to wound bed, cover with bordered gauze daily and as needed. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/06/24, showed the following: -Cognitively intact; -Resident had impairment to lower extremities; -Required partial to moderate assistance with dressing, showers, hygiene, bed mobility, and transfers; -At risk for development of pressure ulcers; -Had one stage 3 (full thickness tissue loss, fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer; -Had one unstageable (full thickness pressure injury in which the base is obscured by eschar (dead tissue that forms over healthy skin) or slough (dead, yellow or white tissue that covers wound)) pressure ulcer due to a non-removable dressing or device that was present on entry to facility; -Pressure reducing device for chair and bed. Review of the resident's care plan showed staff did not update the care plan with the wounds or change in treatment. Review of the resident's November 2024 TAR showed the following: -Staff did not document completion of wound treatment to stage 3 right posterior heel on 11/14/24, 11/16/24, and 11/17/24. -Staff did not document completion of wound treatment to unstageable right heel on 11/14/24, 11/16/24, and 11/17/24. Review of the resident's wound evaluation and management summary from a wound care provider, dated 11/20/24, showed the following: -Stage 3 pressure ulcer of the right posterior heel measured 2.2 cm by 0.8 cm by 0.1 cm and was improved; -Wound had moderate serous drainage with 25% slough and 75% granulation tissue in wound bed; -Unstageable DTI to right heel measured 0.5 cm by 0.5 cm by 0.1 cm with light serous drainage; -Wound bed with 25% slough, 25% necrotic tissue and 50% granulation tissue and not at goal. Review of the resident's care plan showed on 11/20/24 staff updated the care plan with the following: -Resident had a stage 4 (full thickness skin loss that exposes muscle, bone, and other tissue) pressure wound to the right heel. -Administer vitamins and minerals per order; -Off load affected area as resident allows; -Provide nutrition and hydration per current orders; -Provide treatment per current order. Review of the resident's weekly wound observation, dated 11/21/24, showed the following: -Pressure ulcers to right posterior heel and right plantar heel acquired on 10/30/24; -Stage 3 to right heel is improved and measured 2.2 cm by 0.8 cm by 0.1 cm; -Stage 3 right heel had moderate serous drainage with epithelial tissue and slough visible; -DTI to right planter heel is now a stage 3 pressure ulcer measuring 0.5 cm by 0.5 cm by 0.1 cm; -Right plantar heel has serous drainage and wound bed is covered in 25% slough, 25% necrotic tissue, and granulation tissue. Review of resident's November 2024 TAR showed the following: -Staff did not document completion of wound treatment to stage 3 right posterior heel on 11/22/24 and 11/23/24. -Staff did not document completion of wound treatment to the unstageable right heel on 11/22/24 and 11/23/24. Review of the resident's wound evaluation and management summary from a wound care provider, dated 11/26/24, showed the following: -Stage 3 pressure ulcer of the right posterior heel measured 2.5 cm by 1.2 cm by 0.1 cm and was not at goal. Wound had moderate serous drainage with 25% viable tissue and 75% granulation tissue in wound bed; -Unstageable DTI to right heel measured 0.7 cm by 0.8 cm by 0.1 cm with light serous drainage. Wound bed with 5% slough, 75% necrotic tissue and 20% granulation tissue and not at goal. Review of resident's November 2024 TAR showed the following: -Staff did not document completion of wound treatment to stage 3 right posterior heel was on 11/27/24. -Staff did not document completion of wound treatment to unstageable right heel on 11/27/24. Review of resident's November 2024 POS showed the following orders: -An new order, dated 11/28/24, for stage 3 right heel to cleanse with wound cleanser and apply Medi honey (dressing that removes necrotic tissue and aids in healing) to wound bed, cover with bordered gauze daily and as needed; -An new order, dated 11/28/24, for unstageable right heel, cleanse with wound cleanser, skin prep with wound area, apply Medi honey to wound bed, cover with bordered gauze dressing daily and as needed. Review of a resident's weekly wound observation, dated 11/28/24, showed the following: -Pressure ulcers to right posterior heel and right plantar heel acquired on 10/30/24; -Stage 3 to right heel is improved and measured 2.5 cm by 1.2 cm by 0.1 cm; -Stage 3 right heel had moderate serous drainage with 25% slough visible; -DTI to right plantar heel is now a stage 3 pressure ulcer measuring 0.7 cm by 0.8 cm by 0.1 cm; -Right plantar heel had light serous drainage and wound bed was covered in 5% slough and granulation tissue. Review of resident's December 2024 TAR showed the following: -Staff did not document completion of the wound treatment to the stage 3 right posterior heel on 12/01/24. -Staff did not document completion of the wound treatment to unstageable right heel on 12/01/24. Review of the resident's wound evaluation and management summary from a wound care provider, dated 12/05/24, showed the following: -Stage 3 pressure ulcer of the right posterior heel was now unstageable due to necrosis and measured 2.4 cm by 1.4 cm by 0.2 cm and was exacerbated (worse) due to infection. Wound had moderate purulent (thick, yellowish fluid containing pus) drainage with 25% slough, 10% necrotic, and 40% granulation tissue in wound bed. -Unstageable DTI to right plantar heel was now a stage 3 and measured 1.5 cm by 1.0 cm by 0.1 cm with moderate serous drainage. Wound bed with 100% granulation tissue and not at goal. -The provider recommended the following tests white blood cell (WBC - measures amount of blood cells to detect infections); erythrocyte sedimentation rate (ESR - blood test to check for inflammation), C-reactive protein (CRP - test to check for inflammation); deep swab wound culture on right posterior heel (test used to diagnose a suspected deep wound infection), and hemoglobin A1C (HBA1C - measures average blood sugar over the past couple months). Review of the resident's December 2024 POS showed the following: -A new order, dated 12/05/24, for unstageable right heel to cleanse wound with Dakin's (solution used to prevent and treat skin and tissue infections) and half normal saline, cut to size sterile Dakin's moistened gauze and apply to wound bed, cover with bordered gauze twice daily and as needed; -A new order, dated 12/06/24, for stage 3 right heel to cleanse wound with normal saline, apply calcium alginate with silver (cut to size) to wound bed, cover with bordered gauze daily and as needed. Review of the resident's care plan showed staff did not update the care plan to reflect the new treatment interventions. Review of the resident's December 2024 POS showed staff did not place labs on the resident's order sheet of completion. Review of the resident's nurses' notes, dated 12/05/24, showed staff did not document why the labs orders were not placed on the POS. Review of resident's December 2024 TAR showed the following: -Staff did not document wound treatment to the stage 3 right posterior heel on 12/05/24, 12/06/24, 12/10/24, and 12/11/24. -Staff did not document wound treatment to unstageable right heel on 12/05/24 and 12/11/24. Staff documented completion of wound treatment once daily (instead of the twice daily as ordered) on 12/06/24, 12/09/24, and 12/10/24. Review of the resident's wound evaluation and management summary from a wound care provider, dated 12/12/24, showed the following: -Stage 3 pressure ulcer of the right posterior heel was now unstageable due to necrosis and measured 3 cm by 3.5 cm by unmeasurable depth and was not at goal. Wound intact with purplish discoloration with no drainage; -Unstageable DTI to right plantar heel was now a stage 3 and measured 1.6 cm by 1.2 cm by 0.3 cm with moderate serosanguinous (fluid containing blood and serum (liquid part of blood) drainage. Wound bed with 80% granulation tissue and 20% slough and not at goal; -The following tests recommended on 12/05/24 visit still pending including WBC, ESR, C-Reactive Protein, Deep swab wound culture on right posterior heel, and HBA1C. Review of the resident's December 2024 POS showed labs were not placed on the resident's order sheet of completion. Review of the resident's nurses' notes, dated 12/12/24, showed staff did not document why the labs orders were not placed on the POS. Review of resident's December 2024 TAR showed the following: -Staff did not document completion of the wound treatment to the stage 3 right posterior heel on 12/12/24. -Staff document completion of the unstageable wound once (instead of the order twice daily) on 12/12/24. Review of the resident's nursing progress note, dated 12/17/24, showed resident noted with increased pain with treatment. Physician called and new order for Ultram (pain medication) 50 milligrams (mg) four times daily ordered. Review of December 2024 POS showed an order, dated 12/18/24, for an air mattress, pressure relief. Review of the resident's care plan showed staff did not update the care plan with the new intervention. Review of the resident's wound evaluation and management summary from the wound care provider, dated 12/19/24, showed the following: -Unstageable pressure ulcer of the right posterior heel was now stage 3 and measured 3.5 cm by 3 cm by 0.1 cm and exacerbated due to infection and resident noncompliance with wound care. Wound bed 50% necrotic, 30% slough, and 20% granulation with moderate serosanguinous drainage; -Stage 3 to right plantar heel measured 2 cm by 1.4 cm by 0.2 cm with moderate serosanguinous drainage. Wound bed with 100% granulation tissue and improved; -The following tests still pending WBC, ESR, CRP, deep swab wound culture on right posterior heel, and HBA1C. Review of the resident's medical record showed staff did not document why the labs were not completed. Review of resident's December 2024 TAR showed the following: -Staff did not document completion of the wound treatment to stage 3 right posterior heel on 12/20/24, 12/21/24, and 12/22/24. -Staff did document completion of the unstageable heel once daily (instead of the ordered twice daily) on 12/20/24 and 12/21/24. Staff did not complete a treatment to the unstageable heel on 12/22/24. Review of a the resident's wound evaluation and management summary from the wound care provider, dated 12/23/24, showed the following: -Stage 3 pressure ulcer of the right posterior heel measured 4.1 cm by 3.9 cm by 0.1 cm and not at goal;. Wound bed 50% necrotic, 30% slough, and 20% granulation with moderate serosanguinous drainage; -Stage 3 to right plantar heel measured 1 cm by 1.5 cm by 0.2 cm. Wound bed with 100% granulation tissue and improved; -The following tests still pending WBC, ESR, CRP, deep swab wound culture on right posterior heel, and HBA1C. -Wound care physician discussed offloading, obtaining lab results, and further management with resident and facility wound nurse. Review of resident's December 2024 POS showed the following: -A new order, dated 12/24/24, for stage 3 right heel to cleanse wound with Dakin's and half normal saline, cut to size sterile Dakin's moistened gauze, and apply to wound bed, cover with bordered gauze twice daily and as needed. Record review of the resident's care plan showed staff did not address the new treatment/intervention on the care plan. Review of resident's December TAR showed the following: -A new order, dated 12/24/24, for wound care to stage 3 pressure wound of the right plantar heel, to cleanse wound with Dakin's and half normal saline, cut to size sterile Dakin's moistened gauze, and apply to wound bed, cover with bordered gauze twice daily and as needed every day shift for wound care. (The POS showed the order to be completed twice daily.) Review of resident's December 2024 TAR showed staff documented completing the treatment to the unstageable heel once on 12/25/24 and 12/29/24. Review of the resident's record showed the resident was discharged to the hospital on 12/29/24 for seizures. Review of the resident's hospital facility to facility discharge paperwork, dated 01/10/25, showed a diagnosis of acute osteomyelitis (bone infection) of the right ankle and foot. New order to paint right heel with betadine (antiseptic solution), cover with ABD pad and wrap with kerlix (gauze bandage) daily. Facility to make appointment with the vascular surgeon for follow up in 3 to 4 weeks. Review of the resident's admission note, dated 01/10/25, showed resident returned from hospital for suspected seizure activity and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). The right heel has eschar present with 1.3 cm by 0.5 cm open area, betadine applied to eschar and calcium alginate applied to open area after cleaning with normal saline. Review of the resident's January 2025 POS showed an order, dated 01/11/25, to paint right heel with betadine and cover with ABD pad and wrap with kerlix daily. Review of the resident's physician progress note, dated 01/13/25, showed resident seen due to readmission from hospital. Resident reported pain in right heel with odor and drainage noted on exam. Cellulitis (bacterial infection of the skin and underlying tissues. It typically causes redness, swelling, pain, and warmth in the affected area) of right heel and will order clindamycin (antibiotic) 300 mg twice daily for 10 days. Review of the resident's January 2025 POS showed an order, dated 01/11/25, to paint right heel with betadine and cover with ABD pad and wrap with kerlix daily. -An order, dated 01/13/25, for clindamycin capsule 300 mg twice daily for right heel cellulitis for 10 days. Review of the resident's wound evaluation and management summary from a wound care provider, dated 01/16/25, showed the following: -Right posterior heel wound resolved; -Pressure wound to right heel measured 7 cm by 9 cm by 0.2 cm with moderate serosanguinous drainage. Wound bed is 40% necrotic, 30% slough, 30% granulation tissue. Exacerbated due to infection. -Physician discussed starting antibiotic for wet gangrene (condition where tissue dies due to lack of blood flow and bacterial infection); -The following tests recommended on 12/05/24 visit were still pending: WBC, ESR, CRP, deep swab wound culture on right posterior heel, and HBA1C. Review of the resident's medical record showed staff did not address the need for the ordered labs or why they were not completed. Review of the resident's care plan showed staff did not update the care plan upon readmission to the facility. Review of the resident's nurse practitioner progress note, dated 01/17/25, showed right heel eschar present with two areas that have now joined, 2 cm by 2 cm, open area distally with foul odor. Resident currently taking clindamycin. Obtain right foot x-ray for concern of osteomyelitis. Review of the resident's January 2025 POS showed an order, dated 01/17/25, for a right foot x-ray. Review of the resident's nurse progress note, dated 01/17/25, showed x-ray results reviewed and no acute findings noted. Review of radiology report, dated 01/17/25, showed foot suspicious for acute osteomyelitis and cellulitis. Review of the resident's skin/wound note, dated 01/20/25, showed the following: -Stage 3 pressure wound of the right posterior heel in resolved. -Stage 3 pressure wound of the right heel measured 7.0 cm by 9.0 cm by 0.2 cm with moderate serosanguinous drainage. Wound progress exacerbated due to infection. Surgical debridement done to remove infected and necrotic tissue. No treatment changes this visit. -Pending labs of CRP, deep wound culture on pressure wound of heel, ESR, WBC, and HBA1C. Review of the resident's medical record showed staff did not address the need for the ordered labs or why they were not completed. Review of resident's January 2025 TAR showed staff did not document completion of the wound treatment to right heel on 01/20/24. Review of the resident's physician's progress note, dated 01/20/25, showed resident seen due to right heel and osteomyelitis noted on x-ray. Patient requested to go to emergency room for evaluation and treatment of osteomyelitis and wound. Review of the nurse's progress note dated 01/21/25, at 12:28 P.M., showed results from x-ray noted and per physician send resident to emergency room for follow up (the day after physician noted the order to transfer). Review of the resident's nurse progress note dated 01/21/25, at 6:18 P.M., showed the resident returned from hospital. Staff did not document any new diagnoses or orders. Review of the resident's physician progress note, dated 01/22/25, showed resident returned from the emergency room with decision to make regarding amputation of right leg or palliative care. On exam resident stated, I want to see a surgeon, I would rather lose my leg then my life. Treatment plan indicated patient to consult with vascular surgeon and continue cipro 50 mg (antibiotic) twice daily until evaluation for osteomyelitis. Review of the resident's January 2025 POS showed the following: -An order, dated 01/22/25, for ciprofloxacin tablet 500 mg, one tablet twice daily for infection with no end date. Review of resident's January 2025 TAR showed the following: -Staff did not document completion of the wound treatment to right heel on 01/22/25; -An order dated 01/27/25, for a vascular surgeon consult documented as completed on 01/27/25. Review of resident progress notes showed staff did not document an appointment made with vascular surgeon. Review of the resident's January 2025 POS showed the following: -An order, dated 01/23/25, to cleanse right heel with Dakins and normal saline, apply Dakin's gauze to area, cover with ABD pad and kerlix three times weekly. Review of the resident's wound evaluation and management summary from a wound care provider, dated 01/23/25, showed the following: -Pressure wound to right heel measured 5.6 cm by 6.8 cm by 0.3 cm with moderate serosanguinous drainage. Wound bed is 60% necrotic, 20% slough, 20% granulation tissue. Exacerbated due to infection. -The tests recommended on 12/05/24 visit still pending ESR and CRP. Review of the resident's medical record showed staff did not document regarding the need for the labs or why they were not completed. Review of resident's January 2025 TAR showed staff did not document completion of the wound treatment to right heel on 01/24/25. Review of the resident's January 2025 POS showed the following: -A new order, dated 01/25/25, to cleanse right heel with Dakin's, apply calcium alginate with silver and cover with ABD pad and kerlix, skin prep peri wound. Review of the resident's wound evaluation and management summary from a wound care provider, dated 01/30/25, showed the following: -Pressure wound to right heel measured 5 cm by 7 cm by 0.3 cm with moderate serosanguinous drainage. Wound bed is 60% necrotic, 20% slough, 20% granulation tissue. -The tests recommended on 12/5/24 visit still pending ESR and CRP. Review of the resident's medical record showed staff did not document regarding the need for the labs or why they were not completed. Review of resident's January 2025 TAR showed staff did not document completion of the wound treatment to right heel on 01/31/25. Observation and interview on 02/05/25, at 10:01 A.M. showed the resident resting in bed on a regular mattress (not an air mattress as ordered on 12/18/24). Resident reported he/she was unsure how long he/she had the wound on right heel, but staff clean it and change the bandage on it. The wound was not improving and he/she was seeing a vascular physician about amputation. He/she was on antibiotics due to an infection to the right foot, but was unsure how long. Resident reported pain to the right foot and that he/she was currently receiving pain medication to help. During an interview on 02/07/25, at 11:27 A.M., the wound care physician said the following: -The wound care company had been seeing the resident for right heel pressure wound for 93 days; -The right heel was non purulent (not containing or producing pus) and did not have an infection on initial consult; -The resident had two wounds that merged into one during treatment; -The wound was currently malodorous (unpleasant-smelling) and had bone exposed; -He/she was unsure when osteomyelitis started, but spoke with the nurse practitioner about starting antibiotics related to wet gangrene and osteomyelitis; -If wound treatments are missed it can cause a wound to deteriorate; -The resident's wound would get worse due to heavy exudate that could cause maceration (softening of the skin) and infection; -Missing wound treatments could have contributed to infection or osteomyelitis. Observation of the resident's wound to right heel on 02/07/25, at 12:04 P.M., s[TRUNCATED]

Based on observation, record review, and interview, the facility failed to provide care per physician's orders and professional standards of practice for all residents when staff failed to document complete and thorough assessments, provide care per physician's orders, and to care plan treatment of a burn for one resident (Resident #2). The facility census was 98. Review of the facility's policy titled, Accident and Incident Documentation and Investigation, revised 04/26/23, showed the following: -The licensed nurse at the time of an incident is responsible for documenting the incident in the resident's medical record; -The licensed nurse shall document the incident and notify the supervisor and Director of Nursing (DON) for follow through as needed; -The licensed nurse may complete a nurses' note and update the resident's care plan as needed; -The nurse's notes may contain clear objective facts of what occurred; an evaluation of the resident's condition at the time of the accident/incident; description of the resident; vital signs; other physical characteristics apparent as a result of the accident/incident; any treatment provided; notification or attempts to notify the resident's physician, family, and/or legal representative, or any other health care professional or individuals involved with the resident's care; and the charge nurse's signature, date, and time of the documentation. Review of a facility policy titled Wound Management, dated 11/15/22, showed the following: -The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatment will be provided in accordance with physician's order; -Charge nurse will notify the physician in the absence of treatment orders; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of treatments will be monitored though ongoing evaluation of the wound. Review of a facility policy titled Comprehensive Person-Centered Care Plan, dated 10/23/19, showed the following: -Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -The interdisciplinary team, along with the resident and/or resident representative, will identify resident problems, needs, strengths, life history, preferences, and goals; -For each problem, need, or strength a resident centered measurable goal is developed; -Staff approaches are to be developed for each problem, need, and strength. Assigned disciplines will be identified to carry out the intervention; -The comprehensive person-centered care plan can be reviewed and/or revised at quarterly intervals; -Upon a change in condition the care plan will be updated if applicable: -The care plan is updated to reflect risk/occurrences with a problem area, including goals and interventions to reduce the risk/occurrence. 1. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included burn of unspecific degree of left thigh, subsequent encounter, epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of involuntary movements, loss of consciousness, or altered awareness), and unspecified open wound, left hip, burn of first degree (a minor injury that affects only the top layer of skin) of left lower leg. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/01/24, showed the following: -The resident was cognitively intact; -The resident required supervision or touching assistance with meals; -The resident can use a manual wheelchair to wheel 50 feet with two turns with supervision or touching assistance. Review of the resident's current care plan showed the following: -On 08/19/24, staff care planned the resident will remain free from injury related to seizure activity through the review date; -On 09/30/24, staff care planned the resident continued to have seizures, however, they are noted to be becoming further apart and vary; -On 09/30/24, staff care planned to not leave the resident alone during a seizure. Protect him/her from injury. If he/she is out of bed, help to the floor to prevent injury and remove or loosen tight clothing. Do not attempt to restrain the resident during a seizure as it could make convulsions more severe, protect onlookers, draw a curtain etc; -On 09/30/24, staff care planned seizure documentation should include location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity; -On 09/30/24, staff care planned to give seizure medication as ordered; -On 08/23/23, staff care planned the resident has an activities of daily living (ADL) self care performance deficit due to impaired cognition and staff to assist with ADLs. Staff updated the care plan on 09/30/24 with resident is able to eat without assistance. Review of an incident report dated 12/29/24, at 4:30 P.M., showed the following: -The resident was in the dining room having a cup of coffee before dinner when it spilled in his/her lap causing burns to develop to the anterior (front of the body) and posterior (back of the body) aspects of the left thigh. The resident believed as he/she reached to place the coffee cup on the dining table, he/she experienced a mild seizure which caused him/her to spill the hot liquid from his/her cup; -Staff removed resident from the dining room, assessed for injury, and notified physician. Assistant Director of Nursing (ADON) present and notified. Staff contacted the wound doctor and a treatment order was received, noted, and completed. Staff assessed resident for pain and the ADON initiated new pain management orders; -No injuries were observed at the time of the incident; -The resident was alert and level of pain was a seven; -The resident was oriented to person, place, and situation; -Anterior and posterior left thigh were red, hot to the touch, and painful; -No injuries observed post incident. During an interview on 02/13/25. at 11:36 A.M., the Director of Nursing (DON) said he/she added an incident report regarding the burn on 02/07/25, at 11:13 A.M., after speaking with a Department of Health and Senior Services (DHSS) staff and realizing there was not one. Staff should have completed it on 12/19/24 after the incident. Review of the resident's December 2024 Physician's Order Sheet (POS) showed an order, dated 12/19/24, to cover blistered area of the right thigh with a thin layer of Silvadene (topical treatment to prevent and treat wound infections in second and third degree burns) and cover with telfa (non-adherent dressing) BID (two times a day) for superficial burn from spilled coffee. Review of the resident's medical record showed staff did not document a full assessment of the resident's wound on 12/19/24. Review of the resident's care plan showed staff did not update the care plan with the burn or ordered treatment from 12/19/24. Review of the resident's December 2025 Treatment Administration Record (TAR) showed the following: -An order, dated 12/19/24, to cover blistered area of the right thigh with a thin layer of Silvadene and cover with telfa BID for superficial burn from spilled coffee; -On 12/19/24, staff coded treatment as HD (HD - hold see nurses notes); -On 12/21/24 staff did not document completion of the morning treatment; -On 12/22/24 staff did not document completion of the treatment. Review of the resident's nurses' notes, dated 12/19/24 to 12/22/24, showed staff did not document why the ordered treatments were not completed. Review of the resident's physician note, dated 12/23/24, showed the resident was seen at the request of nursing staff for a coffee burn to his/her left leg. The resident believed he/she had a seizure causing him/her to spill his/her coffee onto his/her leg. He/she reported being amnestic (experiencing or relating to a partial or total loss of memory) prior to spilling coffee. He/she had superficial burns along with two partial thickness burns. The wound physician will be asked to examine and give recommendations for treatment. Review of the resident's nurse's note, dated 12/23/24, at 8:33 A.M., showed Registered Nurse (RN) A noted the resident was sent to the hospital for treatment of a burn received from spilling coffee on 12/19/24. The wound worsened since the incident. Staff notified the physician and guardian of the transfer. Review of the resident's Skilled Nursing Facility/Nursing Facility (SNF/NF) to hospital transfer form dated 12/23/24, at 9:00 A.M., showed the reason for transfer was burn to the thigh on 12/19/24 and need for wound evaluation and management. Review of the resident's hospital records, dated 12/23/24, showed the following: -The resident said he/she spilled hot coffee on his/her leg around five days ago; -He/she was concerned that he/she may have had a seizure which caused the spill; -The burn was located on the lateral left hip; -Initially the leg was only red, but it has since worsened and developed blisters; -The facility assessed the burn a few days ago after the incident and applied bandages; -The burn was discussed with the on-call trauma surgeon. The burn was debrided and the wound was dressed with an antibiotic ointment placed on the wound. The resident was referred to the burn clinic and discharged back to the facility; -Diagnosis of burn involving less than 10% of body surface-left thigh; -Order to change dressing daily and apply triple antibiotic ointment and sterile gauze. Review of the resident's wound physician's note, dated 12/23/24. showed the following: -Resident presented with wounds to his/her left proximal (situated near the center of the body) anterior(near the front of the body) thigh and left posterior (near back of the body) thigh; -The facility physician requested a thorough wound care assessment and evaluation performed; -Burn wound of the left proximal, anterior thigh full thickness, wound size 8.3 centimeter (cm) x 5.2 cm x .2 cm with 20% slough (soft yellow or white material that builds up on the surface of a wound) and 80% granulation tissue (new, pink or red soft tissue that forms in the healing process of wounds); -Surgical excisional debridement (removing non-viable tissue) procedure, removal of necrotic tissue to establish the margins of viable tissue; -Burn wound of the left, posterior and lateral (away from the middle of the body) thigh with undetermined thickness 28.5 cm x 36.2 cm with depth not being measurable with fluid filled blister. Open ulceration area of 928.53 squared cm; -The resident was requiring an increased level of care and was being sent to the hospital. The resident has 18% second degree burn (an injury that damages the outer layer of skin (epidermis) and part of the underlying layer (dermis)) on his/her thigh area. Review of the resident's December 2024 POS showed the following: -An order, dated 12/24/24, for Silvadene external cream 1%, apply to left thigh two times a day for burn cleanse with normal saline, cover with telfa; -An order, dated 12/24/24, for left thigh at left posterior thigh to cleanse with the wound cleanser, pat dry, and apply triple antibiotic cream to area. Review of the resident's December 2024 TAR showed staff did not complete the order for Silvadene the evening of 12/25/24 and 12/26/24. Staff entered a code of HD. Review of the resident's nurses' notes, dated 12/25/24 and 12/26/24, showed staff did not document why the Silvadene order was not completed. Review of the resident's hospital records showed the following: -On 12/27/24, the resident presented to the burn unit office for status post burn from hot coffee; -The resident is an epileptic and thinks he/she may have had a seizure. The resident does now have burn cellulitis (a bacterial infection of the skin), thick eschar (dead or devitalized tissue), and a fairly deep burn. Diagnosis of deep partial thickness burn of thigh, cellulitis, burn any degree involving less than 10 percent body surface; -On 01/07/25, preoperative diagnosis of full thickness burn (third-degree - involve all of the layers of skin and sometimes the fat and muscle tissue under the skin) of the left proximal thigh measuring 19 cm x 13 cm. Postoperative diagnosis of full thickness burn (third-degree) of the left proximal thigh measuring 19 cm x 13 cm. Patient had developed burn cellulitis. He/she was admitted to the hospital and the cellulitis was treated. He/she had been receiving local wound care, but the wound failed to heal. Given these findings we discussed the optic of proceeding with operative intervention. A graft was applied over the burn wound, cut to size, secured with skin staples. -On 01/13/25, resident returned to the facility. Review of the resident's nurse's notes, dated 01/13/25, at 5:07 P.M., showed the resident was readmitted to the facility from the hospital for a burn of the left outer thigh. The resident had a dressing around his/her left thigh. On 01/07/25, he/she had a skin graft to burn on left outer thigh from a donor site on the left inner thigh. It was reported to be healing well. The dressing is intact and will be changed tomorrow. Review of the resident's care plan showed the staff did not update the care plan to reflect the burn or new treatments upon the resident's return from the hospital. Review of the resident's January 2025 POS showed an order, dated 01/14/25, for Bacitracin (prevents infection in cuts and burns) zinc external ointment 500 unit/gram, apply to affected area topically two times a day for wound care. Review of the resident's physician note, dated 01/15/25, showed the resident was seen for readmission to the facility after recent hospitalization for 2nd and 3rd degree burns to the left thigh. The resident underwent a skin graft and has a donor site on the anterior left thigh with silver dressing in place to be removed by surgeon. Review of the resident's January 2025 TAR showed staff did not complete the Bacitracin treatment on 01/15/25 and 01/18/25 evening treatments. The staff entered a code of HD. Review the resident's nurses' notes, dated 01/15/25 and 01/18/25, showed staff did not document whey the Bacitracin treatment was not completed. Review of the resident January 2025 POS showed an order, dated 01/16/25, for calcium alginate-honey 4 x 5, apply four each to affected area for three days every day shift, every three days for wound care. Review of the resident's January 2024 TAR showed staff did not complete the calcium alginate wound treatment on 01/16/25 and 01/19/25. Staff entered a code of HD. Review of the resident's nurses' notes, dated 01/16/25 and 01/19/25, showed staff did not document the reason the wound treatment was not completed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had a moderate cognitive impairment; -Resident had second or third degree burns; -Resident had a surgical wound. Review of the resident's January 2025 POS showed the following: -An order, dated 01/19/25, for Bacitracin zinc external ointment 500 unit/gram, apply to affected area topically weekly seven days for wound care, cover with xeroform (petroleum-impregnates gauze dressing used to cover wounds) gauze and abdominal pad as needed; -An order, dated 01/21/25, for donor site, to wash wound bases with wound cleanser, apply a thin layer Bacitracin and xeroform, secure with gauze, and gentle compression as needed, one time a day for burn left thigh; -An order, dated 01/21/24, for graft site, for dry dressing daily until scab is formed, one time a day. Review of the resident's January 2025 TAR showed the following: -On 01/25/25, staff did not document completion of the 01/21/25 order to donor site or graft site orders; -On 01/26/25 staff did not complete the Bacitracin wound treatment (order 01/19/25) and entered a code of HD; -On 01/26/25 and 01/27/25, staff did not complete the wound treatment to the donor cite and coded with a HD; -On 01/27/25, staff did not complete the graft site order and coded as HD. Review of the resident's nurses' notes, dated 01/25/25 to 01/27/25, showed the staff did not document why the wound treatments were not completed. Review of the resident's medical record, 01/13/25 to 02/06/25, showed staff did not document a full assessment of the wound. Review of the resident's current care plan showed staff updated the care plan on 02/07/25, with the following: -The resident has a burn and donor site to his/her left thigh; -The resident will remain free from complications related to wound healing and infection; -Encourage good nutrition and hydration in order to promote healthier skin; -Follow wound care as ordered by provider; -Monitor/document location, size and treatment of the wound; -Offer resident lids with hot liquids, resident does remove lids his/herself; -Use caution during transfers and bed mobility. During an interview on 02/05/25, at 11:12 A.M., the resident said the following: -He/she got a burn on his/her left thigh in December 2024 after spilling hot coffee on him/herself. He/She thinks he/she had a seizure which caused the spill; -The staff treated the burn and he/she was sent to the hospital a few days after. It was a pretty bad burn and was painful; -He/she had to have a skin graft; -It was a third degree burn. Observations on 02/05/25, at 11:12 A.M., showed the resident lifted up his/her clothing to show a large scarred reddish pink area with a few scabs that appeared to be closed on her left thigh spanning from just above his/her knee cap to close to his/her abdomen. A dressing was covering a small portion of the top of the healing burn. There was a rectangular smaller area that was reddish but also appeared closed on his/her lower leg. The resident said the smaller area on the lower leg was from the skin graft. During an interview on 02/05/25, at 11:20 A.M., Certified Nurse Aide (CNA) I said the following: -On 12/19/24, he/she went to change the resident around 7:00 P.M. and saw that the resident's left thigh appeared to be covered with a burn and there was a large blister; -He/she told the nurse; -He/she believed the burn was being cared for and the resident was sent to the hospital sometime after that. During an interview on 02/05/25, at 12:36 P.M., CNA K said the following: -He/she was aware the resident burned his/her thigh from hot coffee; -He/she did not remember who assisted the resident; -The resident was sent to the hospital and then returned a day later, but was sent a second time and stayed. He/she believed the burn was being treated. During an interview on 02/7/25, at 12:14 P.M., Licensed Practical Nurse (LPN) G said the following: -The resident spilled coffee on him/herself. The resident was sent to the hospital at one point and had to get skin grafts. He/she did not do any of the treatments or assessments until after he/she returned from the hospital; -He/she was not aware that treatments had not been completed; -The resident's burn should have been assessed and documented in a nurse's note. The nurse should also document communication with the physician. During an interview on 02/06/25, at 10:25 A.M., RN A said the following: -The resident spilled coffee on him/herself on 12/19/24 around 5:00 P.M.; -He/she was informed by a CNA who was pushing the resident back to her room in a wheelchair. He/she believed the resident got the coffee herself and then spilled it after having a seizure; -He/she assessed the resident's burn and it was originally just a reddish, pink area that was warmer to the touch than the outlying skin. The redness was from just above the knee to his/her abdomen/groin and it wrapped around to the back of the thigh. There was about an inch strip of skin that was shriveled and wrinkled with loose skin on the back of the thigh. He/she did not measure it. He/she sent a picture of the burn to the resident's physician, and he/she provided orders for treatment of the burn and pain medication; -He/she put in the orders for wound care and completed the wound care and left the facility. He/she did not remember what documentation he/she completed; -The resident's physician requested that the wound physician see the resident's burn on 12/23/24 due to the burn being significantly worse. The burn was found to be completely covered in a blister; -The wound physician assessed and debrided the burn and then recommended the resident go to the hospital. The resident was sent to the emergency room and was sent back to the facility the same day with a follow-up scheduled with the burn center for 12/26/24; -He/she did notify the wound physician that he/she had returned, and he/she gave new orders for treatment. The treatment was being completed as far as he/she knew; -He/she did not recall making any nurses' notes, incident reports, events or documenting any assessments regarding the burn; -The nurse should documented assessments and a nurse's note in the chart. The nurse should document any changes in condition and communication with the physician in a nurses note; -The resident went to his/her appointment on 12/26/24 and was sent to the hospital burn unit where he/she stayed for a few weeks and had to have a skin graft; -He/she believed the new orders from the hospital were completed as ordered and as far as he/she knew the burn was improving; -He/she is not sure if anything was added to the care plan. During an interview on 02/06/25, at 3:23 P.M., the ADON said the following: -He/she saw the resident's burn on either Saturday or Sunday (12/21/24 or 12/22/24); -He/she believed he/she assessed the burn on the front of the thigh. He/she thought he/she made a nurse's note; -The burn covered most of the outer thigh and was blistered. It progressively was getting worse; -He/she did not look at the back of the leg/thigh; -He contacted the physician, but could not recall what instructions were given if any; -He/she used nursing judgement and chose not to complete the wound treatment as ordered or any treatment because he/she was worried it might stick to the blister and cause it to pop; -The burn should have been measured and any observations documented; -The resident ended up going to the hospital and getting a skin graft for the burn. During an interview on 02/07/25, at 3:33 P.M., the resident's physician said the following: -The resident spilled coffee on him/herself. The resident said he/she had a seizure, but he/she did not think the resident had a seizure due to the resident not having any seizure's recently and they are well controlled; -He/she believed the burns were only partial thickness and not full thickness initially; -The burn was at least 5 cm x 10 cm. The burn initially was just redness, but burns can continue to decline for 4 to 5 days; -He/she was made aware that the burn was declining and he/she had the wound physician look at the burn on 12/23/24; -The resident was sent to the hospital and then came back and went back to the hospital due to continued decline; -The facility staff should document assessments and change in condition in the chart; -Wound treatments should be completed as ordered and if not there should be a documented reason why given. During interviews on 02/05/25, at 1:57 P.M., and on 02/13/25, at 11:36 A.M., the DON said the following: -The resident was in the dining room, around dinner time and had a mug with a handle. The resident wheeled him/herself in front of the table and either had a seizure or fell asleep. He/she spilled coffee on him/herself; -He/she believed this occurred on 12/19/24 based on an order for pain medication and wound care for the burn placed on that date; -He/she was unable to find any nurses notes, assessments, or an incident/event report regarding the burn or incident from 12/19/24 until 12/23/24; -The nurse should have completed an assessment of the burn, including measurements and a description of what it looked like; -RN A did look at the wound and it was reported to the DON and it was just a red area that was warmer than the surrounding area to the touch; -He/she saw the wound on 12/20/24 and had redness that went from just below the mid-thigh to the groin and then back behind the leg. There was a blister approximately the size of a hot dog bun. He/she did not look at the back of the leg; -On 12/23/24, the burn was more extensive and the resident was assessed by the wound physician and sent to the hospital; -RN A should have documented an assessment and communication with physician in the computer. He/she should have completed an incident report. During an interview on 02/13/25, at 12:38 P.M., the MDS Coordinator said the following: -He/she responsible for care plans; -Burns and wounds should be on the care plan with the appropriate interventions; -Wounds should be treated per the physicians orders. During an interview on 02/06/25, at 2:45 P.M., the Administrator said the following: -He/she was informed that the resident had spilled coffee on him/herself when he/she fell asleep or had a seizure; -The resident was assessed by nursing staff after the incident. -Wound care should be completed as ordered. New wounds should be assessed by the nurse. 50185 36974

Based on interview and record review, the facility failed to ensure all residents were free from significant medication errors. The facility failed to ensure physician orders were entered and/or reviewed by nurses, failed to document monitoring of medication side effects, and failed to follow physician orders to discontinue Xanax (a drug in a class of medications called benzodiazepines (class of medications that act as central nervous system (CNS) depressants) that works by decreasing abnormal excitement in the brain) for one resident (Resident #94) who suffered a hospitalization due to a benzodiazepine overdose. The facility staff failed to notify management and the physician of the medication error. The facility census was 98. Review of the facility's policy titled Physician Orders, dated 09/28/22, showed the following information: -Physician orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record and must include date and time, name of practitioner providing the order, name and strength of the medication, quantity and duration, dosage and frequency, route of administration, indication, and stop date if indicated; -Discontinued orders will be marked as discontinued with the date and all new orders will be written in the appropriate area on the physician order sheet with the date the order was received; -Telephone/Verbal orders may only be received by a licensed nurse and are required to be signed by the ordering physician within 30 days; -Written/Faxed orders must be documented and entered into the medical record by a licensed nurse. Review of the facility's policy titled Psychotropic Management Guidelines, dated 07/26/23, showed the following information: -A licensed nurse will implement the physician order for the medication including an approved diagnosis or targeted behavior, a psychoactive medication consent and review, and standardized behavior tracking monitoring to identify targeted behaviors, documentation of episodes, and documentation of interventions and outcomes. -Care plans will be individualized. Review of the facility's policy titled Medication Administration-General Guidelines, dated 12/2017, showed the following information: -Medications are administered in accordance with written orders of the prescriber; -If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy or prescriber and the resulting order should be documented in the nursing notes. 1. Review of the Resident #94's face sheet (brief look at resident information), showed the following information: -admitted [DATE]; -Diagnoses included Guillain-Barre syndrome (condition in which the immune system attacks the nerves), bi-polar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), low blood pressure, and restless legs syndrome. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 11/27/24, showed the following information: -Cognitively intact with no episodes of delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings); -Required substantial to maximum assistance from staff for mobility; -Received antipsychotic (drugs that treat psychotic disorders), antianxiety (drugs that treat anxiety disorders), antidepressant (drugs that treat depressive disorders), hypnotic (drugs that promote and induce sleep by depressing the CNS system), and opioid (a class of natural, semi-synthetic, and synthetic drugs that are used for treatment of pain) medications; -Antipsychotics received on a scheduled basis with no gradual dose reductions attempted. Review of the resident's care plan, initiated on 08/30/24, showed the following information: -The resident takes several Black Box Warning (the highest safety-related warnings that medications can have assigned by the Food and Drug Administration (FDA). These warnings are intended to bring the consumers attention to the major risk of the drugs, including potential risks of death, serious injury, and/or disability. The severe risk is associated with the mechanism of action and its undesired effects on the body. These warnings emphasize the need for careful monitoring.) medications and will not sustain any harm from the use of the medications; -The resident took antidepressant medications. Staff to monitor and document any side effects and effectiveness every shift; -The resident took antianxiety medications. Staff to monitor and document any side effects and effectiveness every shift. Review of the resident's Physician Order Sheet (POS), dated 01/01/25, showed the following medication orders: -An order, dated 12/11/24, for Cymbalta capsule delayed release (antidepressant that belongs to a group of medicines called serotonin- norepinephrine reuptake inhibitor (SNRI)), 30 milligram (mg) tablet. Staff to give three capsules po (by mouth) daily at 7:00 A.M., for bipolar disorder; -An order, dated 07/28/24, for Effexor XR (antidepressant that belongs to a group of medicines called SNRI), 75 mg. Staff to give three capsules po at bedtime for depression; -An order, dated 10/28/24, for lorazepam (controlled substance that belongs to the benzodiazepine drug class) 0.5 mg. Staff to give 1 tablet po three times a day (tid) as needed for anxiety; -An order, dated 12/16/24, for amitriptyline (tricylic antidepressant that increases certain chemicals in the brain) 100 mg tablet. Staff to give two tablets po at bedtime for depression; -An order, dated 01/01/25, for amitriptyline 50 mg tablet. Staff to give one tablet po at bedtime for insomnia, give with 200 mg tablet to equal 250 mg dose; -An order, dated 12/18/24, for Seroquel (antipsychotic that balances dopamine and serotonin in the brain) 50 mg tablet. Staff to give two tablets po one time a day in the morning for bipolar disorder; -An order, dated 12/18/24, for Seroquel 50 mg tablet. Staff to give two tablets po in the afternoon for bipolar disorder; -An order, dated 10/04/24, for Lyrica (FDA approved as an antiepileptic drug that works by slowing down impulses to the brain) 50 mg capsule. Staff to give one capsule po after meals for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet); -An order, dated 08/26/24, for Norco (opioid pain medication that contains acetaminophen and hydrocodone) 5-325 mg tablet. Staff to give one tablet po four times a day (qid) at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., for pain; -An order, dated 07/28/24, for Seroquel 300 mg tablet. Staff to give two tablets po at bedtime for panic disorder; -An order, dated 12/18/24, for Ambien (a controlled substance that belongs to the hypnotic drug class) 5 mg tablet. Staff to give one tablet po at bedtime for insomnia; (Staff did to obtain orders to monitor for adverse effects of antipsychotic, antidepressant, antianxiety or hypnotic medications. Cymbalta, Effexor ER, lorazepam, amitriptyline, Seroquel, and Norco carried black box warnings.) Review of the resident's nurse's note, dated 01/09/25, showed the medical records personnel documented the following: -The resident was seen on this day by the psychiatrist via telehealth visit; -New order received to start Xanax (controlled substance that belongs to the benzodiazepine drug class) 1 mg po q (every) six hours as needed; -New order received to lower amitriptyline to 100 mg po at bedtime; -New order received to increase Seroquel to 600 mg po at bedtime; -New order received to discontinue Ativan (lorazepam) once Xanax starts. Review of the resident's January 2025 MAR and POS showed the following: -An order, dated 01/09/25, for Xanax 1 mg tablet. Staff to give one tablet po every six hours as needed for severe anxiety with first administration on 01/12/25; -An order, dated 01/09/25, to decreased previously ordered amitriptyline 100 mg tablet. Staff to give one tablet po at bedtime for depression; dated 01/09/25 -An order, dated 01/10/25, to discontinue lorazepam. -An order, dated 07/28/24, for Seroquel 300 mg tablet. Staff to give two tablets (600 mg) po at bed time for panic disorder continued. The prior order for 50 mg was discontinued. Review of the resident's nurses' notes, dated 01/10/25, showed a system generated, moderate drug interaction warning between lorazepam, Xanax, and Norco for coadministration may cause Central Nervous System (CNS, refers to the brain and spinal cord) depression especially in misuse/overdose situations. Staff did not document regarding contacting the prescribing physician for the triggered drug interaction. Review of the resident's nurse's note, dated 01/22/25, showed the resident's Nurse Practitioner ordered Depakote (anticonvulsant used to treat psychiatric disorders) 500 mg po in the morning. The system generated the following following drug interaction warning: -Coadministration with Seroquel may increase the risk for neutropenia (low white blood cell count) and leukopenia (low white blood cell count); -Coadministration with amitriptyline may cause plasma concentrations (agent becomes concentrated in the plasma) and toxic effects of amitriptyline. -Staff did not document regarding contacting the prescribing physician for the triggered drug interaction. Review of the resident's January 2025 MAR and POS showed the following: -An order, dated 01/22/25, for Depakote 500 mg tablet. Staff to give two tablets po each night; -An order, dated 01/23/25, changed Depakote 500 mg tablet, Staff to give one tablet po in the morning. Review of the resident nurse's note, dated 01/22/25, showed the medical records personnel noted the resident was seen by the psychiatrist via telehealth with several new orders. Staff noted see POS for orders and follow up in 4 to 6 weeks. Review of the Psychiatrist's POS, dated 01/23/25, showed the following new orders: -An order, dated 01/23/25, for Valium (controlled substance that belongs to the benzodiazepine drug class) 10 mg po qid. -An order, dated 01/23/25, for once Valium began, discontinue the as needed Xanax; -An order, dated 01/23/25, to discontinue Depakote; -An order, dated 01/23/25, to begin Lamictal (an antiepileptic medication) 25 mg po each night for two weeks, then increase to 50 mg po each night for two weeks, then increase to 100 mg po at night for three nights, then increase to 100 mg po every morning and each night; -An order, dated 01/23/25, to restart trazodone (antidepressant) 150 mg po at night; -Medication changes were phoned into the pharmacy and follow up in the next 4-6 weeks. Review of the residents January 2025 MAR showed the following information: -An order, dated 01/24/25, for Valium 10 mg po qid at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8 P.M., administered as order with the first dose administered on 01/24/25, at 8:00 P.M.; -The order for Xanax was continued and administered on 01/24/25, at 1:56 A.M., 8:32 A.M., and 4:30 P.M., on 01/25/25, at 2:15 A.M., and on 01/26/25, at 4:12 A.M., and 12:19 P.M.; -The order for Depakote was discontinued on 01/23/25; -An order, dated 01/24/25, for Lamictal 25 mg po each night for two weeks, then increase to 50 mg po each night for two weeks, then increase to 100 mg po at night for three nights, then increase to 100 mg po every morning and each night; -An order, dated 01/24/25, for trazodone 150 mg po each night. (Staff did not obtain orders regarding monitoring of adverse effects of antipsychotic, antidepressant, antianxiety or hypnotic medications.) Review of the resident's nurse's note, dated 01/23/25, showed the following: -System generated warning for moderate to severe drug interactions with coadministration of Cymbalta, trazodone, Effexor, and amitriptyline, which could result in serotonin syndrome (potentially life-threatening condition that occurs when you take medications that affect serotonin levels) and toxicity may be increased. CNS depression may also occur; -System generated warning for coadministration of Norco, Xanax, and Valium that may cause additive CNS depression especially in misuse/overdose situations. -Staff did not document contacting the prescribing physician regarding the triggered drug interaction warnings. Review of the residents' nurses notes, dated 01/23/25 through 01/25/25, showed no entries regarding the resident's behavior and/or any care concerns. Review of the resident's nurse's note, dated 01/26/25, showed Licensed Practical Nurse (LPN) D noted he/she nurse sent resident to the hospital due to altered mental status. The resident was alert and oriented to self, slurred speech, and pupils slowly reactive. Resident had weak grips. Staff notified the Director of Nursing (DON) notified and the medical provider. Review of the resident's nurse's note, dated 01/26/25, showed the DON noted charge nurse called the DON and requested him/her to assess the resident as he/she wasn't acting like his/herself. The DON responded to the smoke area to see the resident up in the motorized wheelchair, fidgeting with his/her clothes, which were wet from him/her spilling his/her drink. The peripheral spontaneous movements he/she was experiencing previously have minimized significantly; however, the resident was having difficulty holding his/her head up and with fine motor movement. The resident could follow simple commands and completed a neurological assessment. The resident's pupils were dilated and he/she was not aware of the year and had slurred speech. The resident was taken to his/her room to lay down. The DON instructed the certified medication technician (CMT) to hold all narcotic medications. The DON attempted to call the psychiatrist as he/she had ordered valium recently with no answer. The DON attempted to call the primary care physician with no answer. The DON returned to bedside and provided sternal rubs to the resident alongside a cold washcloth. DON was unable to make out any words the resident attempted to communicate. The resident was unable to sit up. Staff called emergency medical services (EMS) for emergent response for altered mental status. The resident left the facility awake, but disoriented. Review of the resident's admitting hospital's documentation, dated 01/26/25, showed the following information: -At the time of the examination the resident was comatose and minimally responsive only to painful stimulus; -Diagnosis of benzodiazepine overdose, accidental (unintentional). Hospital staff to admit to inpatient, place in step-down for close monitoring. Once resident has recovered from acute ingestion, psychology referral in place to review and restart home medications once reconciled; -The resident required intubation with mechanic ventilation (a procedure that uses a breathing machine to help the patient breathe when they can't on their own) on admission; -The resident was extubated (breathing machine removed) on 01/29/25 and was adamant he/she did not intentionally overdose his/herself and the facility administered his/her medications. Review of the residents' nurses note, dated 01/31/25, showed the resident arrived back to the facility on this date, via ambulance. The resident was alert and oriented with fine motor skills intact. Review of the resident's nurses notes, dated 01/26/25 to 01/31/25, showed staff did not document regarding the medication errors of Xanax not being discontinued and coadministered with Valium. Staff did not document any notifications to the physician regarding the medication errors. During an interview on 01/30/25, at 12:11 P.M., Certified Nursing Assistant (CNA) B, said the following: -The resident started to complain about not feeling well and experiencing extra anxiety around the middle of January 2025; -The resident suffered from panic attacks at baseline; -The staff spoke to the resident's doctor about the increased anxiety and this CNA believed the doctor had made some medication changes; -He/she believed that two of those medications were Xanax and Valium; -After starting the medication the resident began getting increasingly confused and had to be sent out to the hospital; -Some of the symptoms the resident started to experience leading up to the hospitalization were jitteriness and slurring of the words; -The resident was alert and oriented to self, time, and place at baseline. By the time the resident needed to be sent to the hospital he/she was only alert to him/herself and could not communicate his/her needs. During an interview on 01/30/25, at 12:26 P.M., LPN C said the following: -If a resident exhibited a change of condition, he/she would document it in the progress notes, notify the physician and DON, and begin monitoring the resident; -He/she was not aware of who entered new medication orders into the electronic medical record. He/she was a new nurse and did not know if certain medications such as antipsychotics should be monitored for adverse effects; -Nurses do monitor for adverse effects of medications, they just aren't the ones who put the orders in. -All he/she knows in regard to the resident, he/she was alert and oriented at baseline, then had a change of condition, and was sent to the hospital. During an interview on 02/05/25, at 11:45 A.M., CMT F said he/she was not the resident's CMT, but did see the resident up at the nurses' station at one point between 01/24/25 and 01/26/25, and the resident was slurring his/her words and talking about how the doctor was not prescribing the right medication. During this time the resident was also running into walls with his/her electric wheelchair and had poor fine motor skills. During an interview on 01/30/25, at 12:40 P.M., CMT E said the following information: -Charge nurses enter physician orders into the electronic medical record. When new orders are put into the system, the system will alert that person putting the order in with any possible drug interactions; -If a drug interaction is triggered, the nurse should contact the physician and address the concerns, but physician's orders trump the interaction in most cases; -CMT's do not have drug side effect monitoring on their MAR's. CMT's only monitor for pain; -The resident had a lot of anxiety and the doctor increased his/her Valium to four times a day, plus his/her Norco four times a day, and Lyrica three times a day; -He/she thought the resident was receiving a lot of medication and believed it to be too much for the resident; -The resident was on the increased medication for two days prior to having to be sent to the hospital. During an interview on 01/30/25, at 1:16 P.M., LPN D, said the following information: -He/she was the nurse on duty the day the resident had to be sent to the hospital; -He/she was familiar with the resident and the resident appeared to be acting within normal limits for most of the day (01/26/25); -Later in the evening, the nurse took the resident out for a smoke break around 6:00 P.M. During the smoke break the resident was acting funny and was confused. He/she completed a neuro assessment and found the resident was not oriented and did not know where he/she was and was only oriented to his/herself. Previously the resident was alert and oriented to person, place, and time; -The nurse believed the resident had been administered an as needed dose of Xanax around 12:00 P.M. At that time the resident had an order for Xanax, but he/she was pretty sure the Xanax was discontinued after that; -After seeing the change in condition in the resident, the nurse contacted the DON who came and assessed the resident. After the DON assessed the resident, he/she told the LPN that the resident had some recent mediation changes and maybe that was why the resident was acting this way; -He/she did think it was a lot of medication to administer to the resident; -He/she was shocked at the amount of Valium the resident was ordered; -The CMTs did not bring any concerns to the nurse throughout the day; -Nurses put medication orders into the electronic medical record and the system does trigger for any interactions or contraindications at the time of the medication being entered; -If he/she were the nurse whom entered the medication, he/she would have caught it and immediately called the physician. During interviews on 02/05/25, at 11:50 A.M., and on 02/11/25, at 11:20 A.M., LPN G said the following; -The resident was experiencing increased anxiety and had seen the psychiatrist and was prescribed new medication for it; -The medical records personnel rounds with the physician and entered new orders into the EMR. The charge nurses should sign off on those orders. He/she did not recall the medical records personnel bringing him/her any orders or interactions to sign off. -If a CMT were to make a medication error, they would report it to the charge nurse, the charge nurse would then go and assess the resident, notify the physician, and do an incident report. The physician would tell the staff to begin monitoring the resident for any adverse effects; -Antipsychotics, antianxiety, antidepressants, and hypnotics should be monitored for adverse side effect. The use of these should also be care planned. During an interview on 02/04/25, at 10:10 A.M., the resident said the following: -He/she came back to the facility on [DATE]; -He/she was experiencing a lot of anxiety, and he/she believed the doctors put him/her on too much medication which led him/her to being hospitalized ; -When he/she started taking the Valium, two days prior to being sent to the hospital, he/she was having trouble speaking. The medical records personal was aware of this and told the resident that he/she needed to speak with the psychiatrist again. He/she was also experiencing vomiting so much to the extent that he/she did not even eat the day he/she was hospitalized ; -He/she believed the amount of Valium he/she was prescribed and given was too much for his/her body to handle. During an interview on 02/04/25, at 11:44 A.M., the DON said the following information: -The resident was starting to experience some spontaneous movements of his/her extremities. The psychiatrist then seen the resident via telehealth and ordered Valium; -Before the ordering of Valium the resident was and had always been very anxious; -The resident started taking Valium on the night of 01/24/25; -He/she was not aware the Xanax was ordered to be discontinued so it was administered as well; -On Sunday, 01/26/25, the DON was called to the smoke break area by the charge nurse, LPN D, and upon assessment the resident was noted to have a hard time articulating words and following commands; -The DON told the CMT on duty to hold all narcotics at this time and attempted to contact the physician and psychiatrist without success; -The DON and LPN D took the resident to his/her room and laid him/her down onto the bed. The resident immediately went into a sleep. The resident would respond to sternal rubs, but would not keep his/her eyes open; -Paperwork was gathered and the resident was sent to the hospital for altered mental status; -Charge nurses are the only staff members to enter physician orders into the electronic medical record (EMR); -The medical records personal was a CMT and he/she was the one who entered the Valium order, as he/she was the one who rounded with the psychiatrist; -Two Black Box Warnings did trigger with the entering of Valium and the DON would have expected that to be addressed by the person entering the order. During an interview on 02/04/25, at 12:49 P.M., the Medical Records Personal/CMT said the following information: -The policy and procedure for entering orders is that the physician's nurse enters it into the EMR, then one of the facility staff nurses confirm the order; -He/She was not able to enter physician orders at this time. He/she used to be able to, but that was taken away about a week ago, around 01/28/25. He/she was not sure why he/she was not able to enter physician orders anymore; -When he/she was able to enter orders, he/she would do so, and any drug interactions or warnings that populated were the charge nurse's responsibility to double check and follow up on; -There were warnings and interactions when she entered the Valium order, but the charge nurse should have followed up on those; -The nurses were able to see that order and alerts within the system and should have followed up; -He/she did feel that the resident was on an excessive amount of medication. During interviews on 02/04/25, at 1:45 P.M., and on 02/05/25, at 1:25 P.M., the resident's physician said the following information: -He was aware of the new orders by the psychiatrist, and tries not to interfere with psychiatry; -All drugs have interactions and/or warnings and those interactions should be monitored for; -Coadministering Valium and Xanax is not a great idea; -He was not notified of the medication error; -Staff should always monitor for any adverse effects related to medication. During interviews on 02/04/25, at 5:01 P.M., and 02/05/25, at 2:38 P.M., the resident's psychiatrist said the following: -The medical records personnel rounds with him/her and he/she explained the orders to him/her, as well as faxing them to the facility and the pharmacy; -Anytime a resident was on these types of medications, staff should be monitored for adverse effects; -No staff member expressed any concerns to him/her, regarding the medication. He/she did expect to be notified of any concerns. -He/she was not aware that Xanax had not been discontinued and/or was administered with the Valium. Coadministering the two would not do the resident any favors; -No one notified him of the medication error; -Administering two benzodiazepines could lead to increased sedation and is not a good practice. During an interview on 02/13/25, at 9:15 A.M., the DON said the following; -If a medication error was made, the charge nurse should be notified immediately; -The charge nurse would notify the physician, family, and monitor the resident for any adverse side effects. -Antipsychotics, antianxiety, antidepressants, and hypnotics should be monitored for adverse side effects, and the use of these should be care planned; -He/she assumed the Valium is what led the resident to overdose and wished the documentation in the residents chart were better; -The medical records personnel use to be able to input physician orders. He/she no longer had that ability as of 01/28/25. This was a decision that came from corporate, no other reasoning; -He/she was not aware there was an order to discontinue the Xanax, nor of the medication error that occurred six times. During an interview on 02/13/25, at 1:00 P.M., the Administrator said the following: -Physician orders should be followed; -He expected medication errors to be addressed, notifications to be made, and follow up of the residents adverse effects; -Antipsychotics, antianxiety, antidepressants, and hypnotics should be monitored for adverse side effects, and the use of these should be care planned. MO00248656

Based on record review and interview, the facility failed to have the required minimum of six staff members attend the Quality Assessment Committee (QAA) meetings. The facility census was 98. Review of the facility's Quality Assurance Process Improvement (QAPI) policy showed the following: -QAPI takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. -Responsibility of the interdisciplinary team to meet at a minimum of quarterly and as needed; -Best practice is to meet monthly; -The QAPI members shall include representatives from all departments in the interdisciplinary teams; -This also includes seeking input from residents, residents representatives, and frontline care staff. 1. Review of the facility's QAA minutes log showed the following QAA meetings held in 2024: -On 01/17/24, the Administrator, the Director of Nursing (DON), the Infection Preventionist (IP), and the Medical Director attended the QAA meeting; -On 02/14/24, the Administrator, DON, IP, and the Medical Director attended the QAA meeting; -On 03/13/24, the Administrator, DON, IP, and the Medical Director attended the QAA meeting; -On 04/10/24, the Administrator, DON, IP, and the Medical Director attended the QAA meeting; -On 05/08/24, the Administrator, DON, IP, and the Medical Director attended the QAA meeting; -On 06/12/24, the Administrator, DON, and IP attended the QAA meeting; -On 07/10/24, the Administrator, DON, and IP attended the QAA meeting; -On 08/14/24, the Administrator, DON, IP, and the Medical Director attended the QAA meeting; -On 09/11/24, the Administrator, DON , IP, and the Medical Director attended the QAA meeting; -On 10/16/24, the Administrator, DON, IP, and the Medical Director attended the QAA meeting; -On 11/13/24, the Administrator, DON, IP, and the Medical Director attended the QAA meeting. During an interview on 02/11/24, at 3:30 P.M., the Administrator said the following: -The QAA members include the Administrator, the DON, MDS Coordinator, the Medical Director at least quarterly, and most department heads; -He was not aware there was a required number of staff who must attend the QAA meetings.

Based on observation, interview, and record review, the facility failed to document an ongoing evaluation of bed rails and failed to complete regular inspections of the bed frame and side rails for risk of entrapment for one resident (Resident #2) whose side rails were loose. The facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to care plan side rail use; and failed to complete initial and ongoing assessments to ensure the side rails were appropriate for use for two residents (Resident #12 and # 93 ). The facility census was 98. Review of the facility procedure titled, Restraints: Bed Rail Safety Check, undated, showed the following: -When using bed rails, close attention must be given to the design of the rails and the relationship between rails and other parts of the bed. Entrapment may occur in flat or raised bed positions with the rails fully or partially raised; -The bars within the bed rails should be closely spaced to prevent a resident's head from passing through the openings and becoming entrapped; -The mattress to the bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering; -Mattresses may shrink overtime or after cleaning and causing space between the rails and the mattress; -Check for compression of the mattress's outside perimeter. Easily compressed perimeters can increase the gaps between the mattress and the bed rail; -Ensure the mattress is appropriately sized for the bed frame. Not all bed and mattresses are interchangeable; -The space between the bed rails and the mattress and the headboard and the mattress should be filled by the mattress or by the added firm inlay. This creates an interface with the bed rail that prevents an individual from falling between the mattress and the bed rails; -Latches securing bed rails should be stable so that the bed rails will not fall when shaken; -Maintenance and monitoring of the bed, mattresses, and accessories should be ongoing. Review of the facility procedure titled, Device Care Planning Process, undated, showed the following: -The use of any device requires a care plan; -Document a detailed history of the symptom for using the device; -Document ability to purposely remove the device and resident to perform activity of choosing; -Identify likely causes for using the device; -Monitor impact of device on resident and problems or risks for which it is used; -Document why continued use was needed despite complications; -Maintain ongoing monitoring for safety hazard; -Periodically (as least quarterly) reassess the resident for continued need for device and document in care plan. 1. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included muscle weakness, abnormalities of gait and mobility, unsteadiness on feet, cognitive communication deficit, and unspecified dementia (a decline in mental abilities, including memory, thinking, and reasoning, severe enough to interfere with daily life, and is caused by damage to or changes in the brain). Review of the resident's current care plan showed the following: -On 03/06/20, staff care planned the resident had a grab bar in his/her bed to use for positioning as he/she needed. Staff are to encourage him/her to use this for bed mobility and positioning; -On 09/20/24, staff care planned staff will ensure adaptive equipment is provided, is present, and is functional. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/19/25, showed the resident had moderate cognitive impairment and required substantial/maximal assistance with transfers. Review of the resident's Restraints: Bed Rail Safety Check, dated 11/22/19, showed the following: -Use the bed rail safety check to determine if the resident's bed meets the safety measurement requirements suggested by the Food and Drug Administration (FDA); -For each side, go through every zone and measure according to the FDA's instructions found online on the FDA's website; -Measurements for quarter side rails on either side of the bed were documented and passed the assessment. Review of the resident's record showed staff did not document any completion of additional bed rail safety checks. Review of the resident's February 2025 Physicians Order Sheet (POS) showed an order, dated 02/25/22, for the resident may have half side rail/grab bar for positioning. Review of the resident's Assistive Device Consent Form, dated 09/30/24, showed the following: -The form addressed understanding of the use of the device and the potential risks and benefits of using the assistive device; -The name of the resident representative was typed in the signature box with no date given; -The staff completing and witnessing the form was typed in the signature box with no date given. Observation on 02/05/25, at 11:11 A.M., showed the following: -The resident's bed had quarter bed rails towards the head of each side of the bed; -The bed rails were loose with at least one inch of give when the bed rail was pushed down on the side towards the head of the bed or the end of the bed. The bed rail was able to turn side to side in a steering type motion one to two inches. -The resident told Certified Nurse Aide (CNA) I his/her bed rails were loose and CNA I shook the bed rails to show they were loose. During an interview on 02/05/25, at 11:11 A.M., the resident said the following: -He/she had bed rails for awhile. He/she used them to move around in bed and to get out of bed; -His/her bed rails have been loose on both sides for at least two weeks. They have been loose before and maintenance had to tighten them back up at least four times, but they just keep getting loose. It makes him/her scared to use them; -He/she told a nurse about it at least a week ago. During an interview on 02/05/25, at 11:14 A.M., CNA I said the following: -The resident used the bed rails to help him/her move around in the bed; -He/she believed the bed rails were maintained by maintenance staff; -He/she was aware the resident's bed rails were loose and reported it to Registered Nurse (RN) A about two weeks ago. The bed rails should not be loose. The resident was concerned for his/her safety; -Generally, the nurse lets maintenance know if bed rails need adjusted; -He/she thought maintenance staff had fixed the rails. During an interview on 02/05/25, at 10:25 A.M., RN A said he/she was not sure who was in charge of assessing the residents for bed rails. If a bed rail was loose or broken staff should let maintenance know. He/she was not aware of any loose bed rails. During an interview on 02/11/25, at 9:40 A.M., RN J said side rails should be checked daily and if loose, reported to the physician. During an interview and observation on 02/11/25, at 11:02 A.M., the Maintenance Director said the following: -He/she was not aware the resident's bed rail was currently loose; -He/she had to tighten the resident's bed rails periodically because they got loose; -The bed rails cannot be changed due to being the ones that work for that bed; -He/she does not monitor or have a maintenance schedule to check any of the residents' bed rails; -He installs the bed rails and use to measure for entrapment, but he/she stopped doing that when he/she got new maintenance staff that did not know how to do it; -He/she was not sure who is responsible for that; -He/she would fix the bed rail if the nursing staff made a request; -There was no request made for the resident's bed rail recently. During an interview on 02/11/25, at 2:50 P.M., the Assistant Director of Nursing (ADON) said he/she was not aware of any measurements done on side rails, but they should be checked daily. During an interview on 02/13/25, at 11:36 A.M., the Director of Nursing (DON) said maintenance staff should be checking and monitoring bed rails regularly to make sure they are not becoming a hazard. Staff should report any loose bed rails to maintenance. During an interview on 02/13/25, at 12:31 P.M., the Administrator said maintenance staff measure the bed/bed rails and check them regularly. 49585 2. Review of the Resident #12's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke that occurs when the blood supply to part of the brain is blocked or reduced), hemiplegia (paralysis or weakness on one side of the body) of the left side, foot drop, and left ankle contracture. Review of the resident's current February 2025 POS showed an order, dated 11/21/22, for grab bars for mobility. Review of the resident's Safety Device Evaluation Tool, dated 11/13/24, showed staff indicated no safety device was present, used, or indicated. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent with transfers, and mobility. Observations on 02/04/25, at 1:52 P.M., on 02/06/25, at 10:19 A.M., and on 02/10/25, at 10:02 A.M., showed two half side rails at head of bed in upright position. Review of the resident's care plan, revised on 12/20/24, showed the following: -Required maximum assistance for transfers; -At risk for falls related to gait and balance problems; -Required two staff assist with bed mobility. -Staff did not care plan related to the use of side rails. Review of resident's current medical record showed staff did not document related to the use of possible alternatives prior to use of the side rails, assessing risk versus benefits of side rail use, an informed consent, or of an initial or ongoing assessment to ensure the side rails were appropriate and safe to use. During an interview on 02/06/25, at 2:25 P.M., the Licensed Certified Occupational Therapy Assistant (COTA/L) L said the resident had been assessed by physical therapy and side rails were recommended to assist with mobility and position change. 3. Review of the Resident #93's face sheet showed the following: -admitted [DATE]; -Diagnoses included Guillain-Barre syndrome (condition in which a person's immune system attacks the peripheral nerves) and muscle weakness. Review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's Safety Device Evaluation Tool, dated 10/09/24, showed no safety device was present, used, or indicated. Observation on 02/04/25, at 3:35 P.M., showed two U-shaped grab bars at head of bed in upright position. Review of the resident's care plan, revised on 09/04/24, showed the following: -Required one staff assistance for transfers and mobility; -Resident had a history of fall. -Staff did not care plan related to the use of side rails. Observation and interview on 02/05/25, at 1:07 P.M., showed the resident sat up to the edge of bed without the use of grab bars. Two U-shaped grab bars were in an upright position at the head of the bed with a bed controller hanging on the right-side bar. He/she said the side rails were used to hang the bed controller on. Observations on 02/06/25, at 11:47 A.M., and on 02/10/25, at 10:02 A.M., showed two U-shaped grab bars at head of bed in upright position. Review of the resident's February 2025 POS showed staff did not obtain an order for side rails. Review of resident's current medical record showed staff did not document related to the use of possible alternatives prior to use of the side rails, assessing risk versus benefits of side rail use, an informed consent, or of an initial or ongoing assessment to ensure the side rails were appropriate and safe to use. During an interview on 02/06/25 at 2:25 P.M., COTA/L L said the resident used side rails for weakness due to Guillain-Barre syndrome. 4. During an interview on 02/06/25, at 2:25 P.M., the COTA/L L said the following: -Therapy will request grab bars if it would benefit a resident with mobility or positioning; -Physical therapy will evaluate the resident to see if they would benefit from side rail usage; -There is no specific assessment related to side rail use that is filled out by physical therapy; -He/she discussed obtaining side rails for residents during the interdisciplinary plan meeting (IDT); -Maintenance was responsible for installing side rails; -Nursing will put an order for resident side rails in during the IDT meeting; -Maintenance will install the side rails after their use is placed in care plan. During an interview on 02/10/25, at 11:15 A.M., the Maintenance Assistant said the following: -Nursing staff advised maintenance if a resident required side rails; -Side rails required an order, or the resident should request them for mobility help; -Maintenance installed side rails and nursing was responsible for them after that; -Nursing staff will notify maintenance if the resident needed side rails removed or a resident had a room change; -There were no safety checks needed as all the beds come with the exact bars to install the side rails. During an interview on 02/11/25, at 9:40 A.M., RN J said the following: -Maintenance staff install side rails after a physician order is obtained; -Facility should be measuring and assessing side rails; -Side rails should be included in the care plan and there should be a consent on file due to being a type of restraint. During an interview on 02/11/25, at 11:50 A.M., Licensed Practical Nurse (LPN) G said the following: -Side rails should have an informed consent; -Side rails should have an initial assessment and follow up to make sure they are not a restraint. During an interview on 02/13/25, at 12:38 P.M., the MDS Coordinator said the following: -Bed rails should be included on the resident's care plan. The resident should be assessed prior to getting the bed rails put on their bed; -He/she was not sure who completed the assessments. The residents should be reassessed regularly to ensure the side rails have not become a hazard or restraint. During an interview on 02/11/25, at 2:50 P.M., the ADON said side rails should have an order and a consent before use. During an interview on 02/13/25, at 9:05 A.M., the DON said the following: -Therapy evaluates residents for side rails based upon appropriate need for mobility; -Side rails required an order, a consent from the resident or responsible party, and then maintenance staff installed side rails; -Maintenance was responsible for assessment and evaluation of side rails; -Side rails should be included in the care plan. During an interview on 02/13/25, at 12:31 P.M., the Administrator said the following: -If residents need or want a bed rail, nursing staff and the MDS Coordinator should do a risk versus benefits assessment and it should be reassessed annually; -Maintenance staff measure the bed/bed rails and check them regularly; -There should be a completed consent form.

Based on observation, interview, and record review, the facility failed to provide a safe and effective medication system in a manner that met the needs of each resident when staff failed to document administration of multiple doses of scheduled medications for three resident (Resident #1, #3, and #4) with no reason documented. In addition, staff documented administration of medications not available in the facility for administration for two residents (Resident #3 and #4). The facility census was 97. Review of the facility policy titled, Medication Administration-Preparation and General Guidelines, revised August 2014, showed the following: -Medications are administered in accordance with written orders of the prescriber; -A schedule of routine dose administration times is established by the facility and utilized on the administration records; -The individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications; -Current medications, except topicals used for treatments, are listed on the MAR; -The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross referenced to a full signature in the space provided. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis or partial weakness following a stroke), gastro-esophageal reflux disease (GERD-acid reflux), low back pain, contracture (shortening and hardening) of muscle of left shoulder and left hand, and pain in joints of right hand. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 02/06/25, showed the resident was cognitively intact. Review of the resident's current care plan, undated, showed the following: -Resident had an activities of daily living (ADL) self-care performance deficit activity intolerance related to contracture of muscle in left shoulder; -Resident had GERD. Staff are to give medications as ordered and monitor/document side effects and effectiveness. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 11/08/24, for Zanaflex (a muscle relaxant used to treat muscle spasms) oral tablet 4 milligrams (mg), give one table by mouth four times a day for muscle spasm. Review of the resident's March 2025 Medication Administration Record (MAR) showed staff did not document administering the resident's 6:00 A.M. scheduled dose of Zanaflex on 03/27/25, 03/28/25, 03/29/25, 03/30/25, and 03/31/25. The staff did not document why the medication was not administered. Review of the resident's current POS showed an order, dated 12/16/24, for Protonix (a proton-pump inhibitor used in reducing the acid in the stomach) oral tablet delayed release 40 mg, give one tablet by mouth one time a day for GERD. Review of the resident's March 2025 MAR showed staff did not document administering the resident's 6:00 A.M., scheduled dose on 03/27/25, 03/28/25, 03/29/25, and 03/31/25. The staff did not document why the medication was not administered. During an interview on 03/29/25, at 6:32 P.M., the resident said he/she did not always receive early morning medications as physician ordered. 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included insomnia, major depressive disorder, and generalized anxiety disorder. Review of the resident's care plan, created on 02/17/25, showed the following: -Resident had depression, and staff will monitor as needed for and report any signs or symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints and tearfulness; -Resident had a history of pain, and staff should observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease of range of motion, and resistance to care. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident had almost constant pain which effected his/her sleep almost constantly; -Resident was taking a hypnotic. Review of the resident's current POS showed an order, dated 03/24/25, for Zolpidem Tartrate (medication used for treating insomnia) tablet 5 mg, give one tablet by mouth at bedtime for difficulty sleeping. Review of the resident's March 2025 and April 2025 MAR showed the following: -An order, dated 03/24/25, for Zolpidem Tartrate tablet 5 mg, give one tablet by mouth at bedtime for difficulty sleeping; -Staff documented not administering the medication on 03/27/25 and 03/28/25. Staff did not document the reason; -Staff documented administering the medication on 03/29/25, 03/30/25, 03/31/25, 04/01/25, and 04/02/25. Observation and interview on 04/02/25, at 2:03 P.M., with Certified Medication Tech (CMT) F showed the following: -The CMT said the resident had an order for Zolpidem, which staff documented as administered for three to four days when the medication had not been received from the pharmacy; -CMT F showed the surveyor on the MAR where staff had documented administering a dose of Zolpidem on 03/29/25, 03/30/25, 03/31/25, and 04/01/25. CMT F opened the medication cart and showed the surveyor there was no Zolpidem medication available for the resident and no narcotic sheet for the order in the narcotic book. Review of the resident's controlled substance accountability sheet for Zolpidem 5 mg showed the facility received the medication for the resident on 04/02/25 and administered the first does at 8:00 P.M. on 04/02/25. During an interview on 04/02/25, at 3:50 P.M., CMT C said he/she was not paying attention when he/she documented administering Zolpidem to the resident on 03/29/25, 03/30/25, and 03/31/25, when the medication was not available. 3. Review of Resident #4's face sheet showed the following: -admitted [DATE]; -Diagnoses included fracture of unspecified phalanx of right thumb (broken thumb). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Resident received an opioid. Review of the resident's current care plan showed staff did not care plan related to the resident's pain or administration of pain medication. Review of the resident's current POS showed an order, dated 03/31/25, for tramadol HCI (an opioid analgesic used for treating pain) tablet 50 mg, give one tablet by mouth three times a day for moderate to severe pain for three days. Review of the resident's March 2025 and April 2025 MAR showed the following: -An order, dated 03/31/25, for tramadol HCI tablet 50 mg, give one tablet by mouth three times a day for moderate to severe pain for three days; -Staff did not document administration information for the 8:00 A.M., 2:00 P.M. or 8:00 P.M. doses of the medication on 03/31/25. Staff did not document a reason the medication was not administered. -Staff documented administering the 8:00 A.M. dose on 04/01/25; -Staff did not document administration information for the 2:00 P.M. dose on 04/01/25; -Staff documented not administered with no reason given for the 8:00 P.M. dose on 04/01/25; -Staff did not document any administration information for the 8:00 A.M. or 2:00 P.M. dose on 04/02/25; -Staff documented administering the 8:00 P.M. dose on 04/02/25. During observation and interview on 04/02/25, at 2:03 P.M., CMT F said the following: -The resident had an order for tramadol from the previous day and the medication had not been received when staff documented administering a dose; -CMT F showed the surveyor on the MAR where staff had documented administering a dose of tramadol on 04/01/25. CMT F opened the medication cart and showed this surveyor there was no tramadol medication available for the resident and no narcotic sheet for the order in the narcotic book. 4. During an interview on 04/01/25, at 2:37 P.M., Certified Medication Technician (CMT) D said the following: -Staff use the MAR for passing and documenting medication administration; -Staff should not leave blanks on the MAR for scheduled medication administration; -Staff should chart a reason for not administering a scheduled medication such as refused or out of facility. During an interview on 04/01/25, at 2:59 P.M., CMT E said the following: -Staff use the MAR for passing and documenting medication administration; -Staff should not leave blanks on the MAR for scheduled medication administration; -Staff should chart a code reason for not administering a scheduled medication and make a progress note. During an interview on 04/02/25, at 2:03 P.M., CMT F said the following: -Staff use the MAR for passing and documenting medication administration; -Staff should not leave blanks on the MAR for scheduled medication administration; -Staff should chart a code reason for not administering a scheduled medication and make a corresponding progress note. During an interview on 04/02/25, at 3:50 P.M., CMT C said the following: -Staff use the MAR for passing and documenting medication administration; -Staff should not leave blanks on the MAR for scheduled medication administration; -Staff should document a code for the reason a scheduled medication was not administered. -Staff should not document administering medications that were not administered. During an interview on 04/02/25, at 4:13 P.M., License Practical Nurse (LPN) G said the following: -Staff used the MAR for passing and documenting medication administration; -Staff should not leave blanks on the MAR for scheduled medication administration; -Staff should document a code for the reason a scheduled medication was not administered; -Residents have complained about not receiving their morning medications; -Staff should not document administering a medication that was not actually administered. During an interview on 04/10/25, at 9:09 A.M., LPN H said the following: -If a medication is missing, staff should check the cart and the e-kit for it; -If a medication is unavailable, staff notify the charge nurse and the Director of Nursing; -Staff were supposed to document when a medication was not available; -CMTs pass scheduled narcotics and nurses pass as needed narcotics; -He/she was not aware of any issues with running out of medication. During an interview on 04/10/25, at 9:34 A.M., LPN I said the following: -He/she expected the CMT to notify him/her if a medication was not given; -He/she will call the pharmacy to get the medication and notify the DON; -If a medication was not given he/she assessed the resident and notified the physician and family. During an interview on 04/10/25, at 9:12 A.M., the facility Medical Director said the following: -The MAR should reflect if a scheduled medication was administered or why the medication was not administered; -Staff should not document administering a medication if the medication was not administered and if it was not available. During an interview on 04/10/25, at 4:00 P.M., the DON said the following: -Staff use the MAR for passing and documenting medication administration; -Staff should not leave blanks on the MAR for scheduled medication administration; -Staff should document the reason a scheduled medication was not administered; -Staff should not document administering a medication that was not actually administered; -Staff should notify nurse if a medication was not available and should not fail to administer medications for three days; -The DON was responsible for lack of documentation of medication administration and for medications not available for residents. During an interview on 04/10/25, at 4:46 P.M., the Administrator said the following: -Staff use the MAR for passing and documenting medication administration; -Staff should document the administration of scheduled medications in the MAR; -Staff should document reason a scheduled medication was not administered in the MAR; -Staff should not document administering a medication that was not available. MO00251860

Based on record review and interview, the facility failed to protect the residents' right to be free from sexual abuse by staff when one facility staff member (Certified Nurse Aide (CNA) A) had sexual contact with two residents (Resident #1 and Resident #2) and made sexually inappropriate comments at/around one resident (Resident #3). The facility census was 109. On 10/7/2022, at 5:17 P.M.,the Administrator and Director of Nursing were notified of the past noncompliance immediate jeopardy (IJ) which occurred previously. On 10/7/22, the facility notified the Department of Health and Senior Services (DHSS) of the noncompliance, suspended CNA A, started an investigation, immediately began educating the staff about abuse, had the residents seen/assessed by the Nurse practitioner, offered psychiatric care/social services visits, and completed trauma assessments on the residents. The facility updated the residents' care plans and added abuse to their QAPI for continued monitoring. The IJ was corrected on 10/07/22. Record review of the facility policy, titled Abuse Prevention, dated November 8/30/2018, showed the following: -The facility is committed to protecting the residents from abuse by anyone, including, but not necessarily limited to, facility, staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, spongers, friends, visitors, or any other individual; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse may be resident-to-resident, staff-to-resident etc; -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish; -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology; -Sexual abuse is any touching, directly or through clothing, of a resident by an employee for sexual purpose or in a sexual manner. This includes, but is not limited to, kissing, touching of the genitals, buttocks or breast or causing a resident to touch the employee for sexual purposes; -Mental abuse defined as, the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame agitation, or degradation. 1. Record review of the facility's investigation showed the following: -On 10/7/2022, at approximately 8:00 A.M., Resident #3 reported to the Director of Nursing (DON) that he/she heard Resident #1 and a male employee engaging in sexual acts in his/her room. He/she also reported he/she heard there were other residents involved; -The alleged employee, CNA A was not working at the time, but was interviewed and suspended pending the investigation; -Resident #1 approached the DON and said I need to tell the truth, Resident #1 said he/she had sexual interaction, but not sexual intercourse with CNA A. He/She initially reported it happened about a week ago, but then said it may have been around five weeks ago. The physician, administrator, police department and DHSS were made aware of the incident. An investigation was initiated; -Resident #2 initially denied any sexually inappropriate behavior/advances had occurred, but was acting out of character. Upon further interview, Resident #2 admitted to being touched inappropriately during cares. CNA A asked Resident #2 if he/she would like for him/her to, stick his/her finger in it. Resident #2 told him/her to go ahead, and he/she did. Resident #2 told him/her to stop, and he/she did. Resident #2 said the incident happened about a week or so ago; -Resident #3 reported no inappropriate physical contact had occurred, but CNA A commented they could have a three way; -Upon completion of the investigation the facility determined sexual interactions may have occurred with Resident #1 and Resident #2. 2. Record review of Resident #1's face sheet showed the following: -admitted [DATE]; -The resident has a guardian; -Diagnoses included schizoaffective disorder (a condition where symptoms of both psychotic and mood disorders are present together during one episode or within a two week period of each other), cognitive communication deficit (difficulty with thinking and how someone uses language), mild intellectual disabilities (a mild impairment of cognitive skills, adaptive life skills, and social skills), altered mental status, and reduced mobility. Record review of the resident's care plan, dated 5/19/2020 and revised 10/7/2022, showed the following: -The resident has a guardian; -The resident has experienced a traumatic event in the past, that currently affects their mental and psycho-social well-being, Including but not limited to abuse, sexual advances both physically and verbally; -Directed staff to allow the resident to share thoughts and feelings and offer support through listening one on one, include the resident in their plan of care, investigate allegations per facility policy, without bias or judgement; -Refer to social services or counseling as needed and remove/eliminate environmental factors that may trigger. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 8/16/2022, showed the following: -Cognitively intact; -No behaviors exhibited. Record review of the resident's physician's notes, dated 8/10/22, showed the following: -Resident oriented; -Schizoaffective disorder, stable. Record review of the resident's nurses' notes showed no related inappropriate behaviors for the past three months. Record review of the police report showed the following: -On 10/07/22, at approximately 11:43 A.M., the officer was dispatched to the facility for a past sex offense call. The DON said a resident had just reported to her this morning that a staff member had sexually assaulted him/her; -The DON escorted the resident to the DON's office. Resident #1 said an employee (CNA A) had been sexually harassing him/her for weeks now, saying that he/she wanted to, grab his/her breasts, and, have oral sex with him/her, for some time before the assault occurred; -On an unknown date approximately five weeks ago, around 8:00 to 9:00 P.M., CNA A came to the room and pulled the curtain to block Resident #1's roommates view. CNA A started to pull his/her pants down and pulled his/her legs in the air. CNA then started to use his/her mouth on Resident #1's genitals giving him/her oral sex and then started to grope his/her breasts with both of his/her hands. Resident #1 said he/she tried multiple times to pull his/her pants back up, but CNA A kept pulling them back down telling Resident #1 to not, ruin the moment. CNA A then penetrated Resident #1's vagina with what he/she believed to be two fingers from CNA A's right hand. Resident #1 told CNA A to stop and he/she just wanted to go to sleep. CNA A stopped, but sounded upset with him/her and walked out of the room saying, goodnight beautiful ladies. Resident #1 said he/she did not have any bleeding or discomfort after the incident, but felt dirty and wanted to take a shower. Resident #1 believed the incident lasted for approximately five to ten minutes. Resident #1 also had another incident with CNA A approximately two weeks ago. He/she was asleep in his/her room when he/she heard the door open and it woke him/her up. CNA A came in the room and walked up to him/her and grabbed his/her breasts. CNA A said goodnight, and left the room. Resident #1 said he/she heard from his/her roommate that other residents had been assaulted as well by CNA A, but he/she did not know who; -The DON said he/she was notified by Resident #1 this morning about the incident. Resident #1 said he/she did not say anything about it when it occurred due to believing he/she would be kicked out of the facility. The DON said the resident tends to exaggerate at times, but he/she believes that something had happened to Resident #1. The DON said CNA A was interviewed about the incident and said the residents flirt with him/her. Record review of the resident's progress note dated 10/07/2022, at 11:24 A.M., showed the following: -The Nurse Practitioner (NP) said the resident was seen per staff's request due to allegations of a physical encounter with a male staff member. When the resident was interviewed, he/she reports the incident happened a few weeks back, but he/she doesn't remember exactly. The resident said a staff member touched his/her breast and preformed sex on him/her and he/she was uncomfortable and didn't want to tell anyone.; -Assessment of suspected adult physical abuse; -Plan to continue to monitor and report changes. Staff member removed until further investigation. During an interview on 10/7/22, at 1:00 P.M., the resident said the following: -About five weeks ago around 10:00 P.M., CNA A came into his/her room and closed the door and drew the privacy curtain; -CNA A crawled on the bed with him/her and, groped and touched the resident's breasts under his/her shirt; -CNA A then pulled down the resident's pants and put his/her mouth on his/her genitals and gave the resident oral sex; -CNA A pulled down his/her pants and exposed his/her genitals to the resident, he/she told CNA A no and CNA A left; -He/she did not want to get in trouble and did not want CNA A to be mad at him/her, so he/she did not tell anyone until 10/7/22 when his/her roommate told the DON; -He/she did not feel comfortable with it, but was scared he/she would make CNA A mad if he/she did not let him/her or if he/she told anyone about it; -CNA A has also flirted with him/her by commenting on his/her breasts and asked the resident to let him help him/her with a shower, but he/she does not need help in the shower. During an interview on 10/7/22, at 2:20 P.M., Resident #3 said the following: -About two to three weeks ago at 10:00 P.M., CNA A came into the room he/she shares with Resident #1. Resident #3 thought she could hear sex noises, heavy breathing and whispering from Resident #1 and CNA A; -Resident #3 got up to use the bathroom and saw CNA A on the bed with his/her head between Resident #1's legs. It appeared they were doing something sexual; -Resident #1 said CNA A tried to have sex with him/her, but Resident #1 was afraid and told him/her maybe later; -Resident #1 told Resident #3 not to tell anyone. -CNA A told him/her that he/she liked the way Resident #1 breasts bounced and wanted to see under his/her shirt maybe a few weeks ago; -He/she decided to report the incident today because he/she did not feel it was right. 3. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -The resident is his/her own responsible party; -Diagnoses included, acute respiratory failure, encephalopathy (a term for any diffuse disease of the brain that alters brain function or structure), major depressive disorder (causes a persistent feeling of sadness and loss of interest), anxiety disorder, and schizoaffective disorder bi-polar type personality disorder (a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving). Record review of the resident's care plan, dated 5/2/2018 and revised 10/7/2022, showed the following: -The resident has experienced a traumatic event in the past, that currently affects their mental and psycho-social well-being, Including abuse, domestic violence, sexual assault, and violence; -Directed staff to allow the resident to share thoughts and feelings and offer support through listening one on one, include the resident in their plan of care, investigate allegations per facility policy, without bias or judgement. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors exhibited. Record review of resident's psychology notes, dated 3/31/22, showed the following: -The resident is oriented and insight and judgments are reasonable. His/her IQ is average and he/she does not appear psychotic, manic or delusional. His/her memory remains intact. Record review of the resident's physician's notes,dated 9/14/22, showed the following: -Resident oriented; -Schizoaffective disorder, mood stable on current regimen. Record review of the resident's nurses' notes showed no related inappropriate behaviors for the past three months. Record review of the resident's progress notes dated 10/07/22, at 11:20 A.M., showed the following: -On 10/7/22, at 11:20 A.M., the NP said the resident was seen per staff's request due to allegations of a physical encounter with a male staff member. When the resident was interviewed, the resident said he/she asked the staff member to stuck his/her finger in him/her; and the staff member did. -Assessment of suspected adult physical abuse; -Continue to monitor and report changes. Staff member removed until further investigation. During an interview on 10/7/22, at 1:36 P.M., the resident said the following: -About a week ago, CNA A put his/her finger inside his/her vagina during cares because the resident asked him/her to during cares. During an interview on 10/7/22, at 2:20 P.M., Resident #3 said the following: -Resident #2 told him/her that CNA A exposed his genitals to Resident #2 and said he/she could take care of his/her desires. 4. Record review of Resident #3's face sheet showed the following: -admitted [DATE]; -The resident has a guardian; -Diagnoses included schizoaffective disorder, bipolar disorder II, anxiety disorder, and altered mental status. Record review of the resident's care plan, dated 10/15/2019 and revised 7/15/2021, showed the following: -The resident has a guardian; -The resident has a psychosocial well-being problem actual or potential due to schizoaffective disorder bipolar type, mild intellectual disabilities, cognitive communication deficits and other diagnosis. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors exhibited. Record review of the physician's notes, dated 9/26/22, showed the following: -Resident oriented; -Schizoaffective disorder, mood stable. Record review of the resident's progress notes showed no recent documentation related to behaviors for the past three months except for refusing to go to a doctors. During an interview on 10/7/22, at 2:20 P.M., the resident said the following: -CNA A said he/she wanted to have a three some with him/her on 10/5/22 and has also told him/her he/she have sex with him/her. 5. During an interview on 10/11/22, at 8:04 A.M., Certified Medication Technician (CMT) B said the following: -On 10/6/22, at around 10:00 P.M., Resident #3 said he/she wanted to talk to the DON. Resident #3 would not talk about what he/she wanted to discuss and wanted to wait until the next day to talk to her; -He/she called the DON to let him/her know. -He/she would consider any unwanted touching or sexual activity abuse. He/she would report any abuse to the DON/Administrator. During an interview on 10/7/22, at 3:18 P.M., the DON said the following: -On 10/6/22, at around 10:00 P.M., CMT B called him/her and said Resident #3 wanted to speak to him/her in the morning. The resident would not tell CMT B what it was concerning; -He/she spoke to Resident #3 around 7:30 A.M. Resident #3 told him/her that he/she had overheard inappropriate things that sounded like sex happening between CNA A and Resident #1 and had heard that two other residents had also had sexual encounters with CNA A; -Resident #1 initially denied anything happening, but about 40 minutes later came back and told him/her that CNA A had performed oral sex on him/her; -Resident #2 also initially denied anything happening, but then admitted that CNA A had put his/her finger in the resident's vagina. During an interview on 10/7/22, at 1:16 P.M., CNA A said the following: -Sometimes the residents will flirt with him/her a little bit, but he/she ignores it; -He/she would consider any inappropriate touching or sexual acts between a staff member and a resident to be abuse. During an interview on 10/7/22, at 3:35 P.M., Registered Nurse (RN) C said the following: -He/she would consider any sort of sexual interactions with a resident to be abuse and should be reported immediately; -He/she also has never seen any residents flirting with CNA A. During an interview on 10/7/22, at 3:44 P.M. Licensed Practical Nurse (LPN) D said the following: -He/she would consider staff exposing themselves to a resident or engaging in any type of sexual activity to be abuse; -Abuse should be immediately reported to the DON or Administrator and the resident should be kept safe; -He/she has never seen any residents flirting with CNA A. During an interview on 10/7/22, at 3:54 P.M., CNA E said the following: -He/she saw CNA A staring inappropriately at a female staff member and said he/she liked what he/she saw. During an interview on 10/12/22, at 2:31 P.M., CNA F said the following: -He/she would consider any inappropriate touching or sexual acts to be sexual abuse and he/she would report it immediately to the DON/Administrator; -A few months ago CNA A told him/her that CNA F's nipples were hard and that was making him/her hard and that bigger girls were his/her kink. During an interview on 10/11/22, at 7:50 A.M., LPN G said the following: -If sexual activity occurs between a staff member and a resident it would be considered abuse even if it is consensual. During an interview on 10/12/22, at 10:14 A.M., the Medical Director said the following: -He/she would consider staff having oral sex with a resident or exposing themselves to a resident to be abuse; -Sexual activity with a staff member would not be appropriate and would be considered abuse; -Resident #2 is a reliable historian. He/she feels it would be inappropriate and rise to the level of abuse if a staff member put their finger up the resident's vagina just because they asked him/her to do so; -He/she was notified of the sexual abuse allegations and he/she would expect the facility to suspend the employee, report to the police and investigate the allegations. During an interview on 10/12/22, at 1:45 P.M., the interim Administrator, Administrator Trainee, and DON said the following: -When an abuse allegation is made the resident is kept safe and the staff is suspended. An investigation is started immediately. All interviewable residents were interviewed and pertinent staff was interviewed; -They would consider staff having oral sex with a resident, exposing their genitals to a resident, saying inappropriate sexual comments, and putting their finger in a resident's vagina to be unacceptable and would be considered sexual abuse. MO00208036

Based on interview and record review, the facility failed to assess, monitor, notify the physician, and provide timely medical intervention for a change in condition for one resident (Resident #1), who received a physician prescribed blood thinning medication, and developed a [MEDICAL CONDITION], that required hospitalization and life sustaining blood products. The facility census was 96. The administrator was notified on 2/26/21, at 2:15 P.M., of an Immediate Jeopardy (IJ) which began on 2/21/21. The IJ was removed on 2/26/21, as confirmed by surveyor onsite verification. Record review of the facility's policy titled, Notification of a Change in a Resident's Condition, dated 11/1/2018, showed the following information: -The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State guidelines; -All licensed nursing personnel are responsible for notifying; -Guidelines for notification of the physician/resident representative include a significant change or unstable vital signs; emesis (vomit)/diarrhea; onset of pressure sores; any accident or incident, symptoms of infectious process; abnormal lab findings; a five percent weight loss or weight gain in 30 days; repeated refusals to take prescription medication for two days; abnormal complaints of pain; ineffective relief of pain from current regimen; change in level of consciousness; unusual behavior; missing resident; or a glucometer (measure the level of glucose (sugar) in the blood) reading below 70 milligrams(mg)/deciliter (dL) or above 200 mg/dL unless specific parameters have been given by physician. This is not an all-inclusive list. -Nursing staff are to document in the interdisciplinary team notes, resident change in condition, physician notification, and notification of the resident representative. Record review of the [MEDICATION NAME] (a platelet aggregation inhibitor (prevents/slows clotting of blood)) package insert, (document included in the package of a medication that provides information about that drug and its use), dated April 2020 showed the following information: -Used to treat people who have chest pain due to heart problems, [MEDICAL CONDITION], or stroke; -Can be used alone or with aspirin to lower chances of having another serious problem with heart or blood vessels such as [MEDICAL CONDITION], stroke, or blood clot that can lead to death; -Blood thinner medicine that lowers the chance of blood clots forming in your body; -Possible side effects include unexpected bleeding or bleeding that lasts a long time; blood in urine (pink, red or brown urine), red or black stools; bruises that happen without a known cause or get larger; cough up blood or blood clots; and vomit blood. -Call the physician right away if there are any of these signs or symptoms of bleeding. Record review of aspirin prescribing information on www.drugs.com, last updated 01/22/21, showed the following information: -A non-steroidal anti-[MEDICAL CONDITION] drug used to reduce pain, decrease fever, prevent blood clots, and decrease inflammation in higher doses; -Can help lower the risk of another [MEDICAL CONDITION] or clot-related stroke; -Side effects can include unusual bleeding or bruising; stomach bleeding; vomiting of blood; bloody or black stools; bloody urine; and stomach pain that does not get better; -Call the physician right away if there are any of these signs or symptoms of bleeding. 1. Record review of Resident #1's current face sheet (basic information sheet) showed the following Diagnoses: [REDACTED].>-Infection and [MEDICAL CONDITION] reaction due to internal right hip prosthesis (infection involving the joint prosthesis (surgically replaced joint) and surrounding tissues); -Need for assistance with personal care; -[MEDICAL CONDITION] (loss of ability to understand or express speech) following cerebral infarction (stroke); -Cognitive communication deficit (disorders as difficulty with any aspect of communication that is affected); -[MEDICAL CONDITION] (common form of dementia caused by an impaired supply of blood to the brain) with behavioral disturbance; -[MEDICAL CONDITION] (a condition in which the heart can't pump enough blood to the body's other organs); -Personal history of venous [MEDICAL CONDITION] (blood clot forms in a deep vein) and embolism (obstruction of an artery, typically by a clot of blood). Record review of the resident's nurses' notes showed the following information: -On 1/27/2021, at 3:19 P.M., the facility sent the resident to the physician's office for an appointment and the physician's office sent the resident to the emergency room (ER); -On 1/27/2021, at 11:09 P.M., the resident remained at the hospital with a [DIAGNOSES REDACTED]. The resident had surgery today (1/27/2021) to clean out the infection from the surgical site and was reported to be doing well; -On 2/1/2021, at 2:42 P.M., the resident arrived back to the facility via ambulance. Staff notified the resident's physician of the resident's return to the facility. The resident had a PICC line (peripherally inserted central catheter) for intravenous (IV - administered into veins) antibiotic treatment. Record review of the resident's provider note, dated 2/2/2021, showed the provider documented readmission evaluation after hospital stay for left hip surgical site infection, wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) in place with IV antibiotic ordered. Record review of the resident's February 2021 physician order [REDACTED]. -[MEDICATION NAME] Bisulfate ([MEDICATION NAME]) 75 milligrams (mg) daily related to embolism and [MEDICAL CONDITION]; -Aspirin 81 mg daily related to cardiovascular disease ([MEDICAL CONDITION]). Record review of the resident's February 2021 functional performance record showed the following information: -Total dependence on staff for incontinent care with one person physical assistance; -Incontinent for bladder function; -Resident had small bowel movement (BM) about every two to three days. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 2/7/2021, showed the following information: -Entered facility on 6/3/2015; -Required extensive physical assistance (one or more staff) when transferring from bed, chair, or wheelchair; -Did not walk in hallway; -Occasionally incontinent of bowel and bladder; -On anticoagulant (medicine that prevents the blood from clotting as quickly as normal) medication. Record review of the resident's care plan, dated 2/10/2021, showed the following information: -At high risk for falls related to the resident's deconditioning (process of physical change, following a period of inactivity or bedrest, that results in a decrease in muscle mass, weakness, functional decline), incontinence, and dementia; -At risk for communication problems related to [MEDICAL CONDITION] and hard of hearing; -Self-care deficit related to dementia; -At risk for abnormal bleeding, hemorrhage (bleeding), and/or increased/easy bruising related to the use of a blood thinner; -Administer anticoagulant as currently prescribed by the physician; -Monitor and report to the nurse and physician any of the following signs and symptoms of bleeding: Bleeding gums, nose bleeds, unusual bruising, tarry black stools, pink or discolored urine. During an interview on 2/26/2021, at 8:50 A.M., Certified Nursing Assistant (CNA) D said he/she worked on the 500 hall and the back half of the 400 hall. The residents on the back of 400 hall were fairly independent except for Resident #1 and #2. The CNA that worked the 600 hall would let him/her know when the call light was on for Resident #2, which was about every two hours. CNA D went to help Resident #2 on 2/21/2021, at about 5:00 A.M. After he/she helped the resident up to the bathroom, he/she went to adjust Resident #1 and re-situate the resident in the bed. CNA D turned Resident #1 on his/her side and opened his/her incontinent brief to check for soiling. CNA D found blood in the brief with a small amount of BM under the blood. While trying to locate the source of the bleeding, blood starting gushing from the resident's rectum. CNA D went to get Registered Nurse (RN) G. RN G came to the room and completed an evaluation of the resident and both staff then cleaned up the resident. The aide and the nurse did not take any vital signs. He/she had been told that vital signs are not completed during the night unless a resident had a fall. The 400 hall has so many residents that it is split up and the schedule will say that the resident was technically RN G's resident, but Licensed Practical Nurse (LPN) F was the charge nurse for Resident #1 and #2 that shift. He/she did not notify LPN F of the incident as the aide had told RN G because he/she was closer. He/she did not notify anyone at shift change. CNA D said he/she did not check on Resident #1 after completing personal cares and getting the resident re-situated in bed, shift change occurred within that hour. During an interview on 2/25/2021, at 3:03 P.M., RN G said the following: -He/she worked the overnight shift on 2/20/2021, but was not responsible for Resident #1; -On 2/21/2021, between 4:00 A.M. and 5:00 A.M., CNA D reported to him/her that Resident #1 had bleeding from his/her genital area; -He/she checked on the resident and saw that the blood was coming from the resident's rectum. There was a moderate amount of blood. There was enough blood for him/her to be concerned about. He/she cleaned up the blood; -He/she told the resident's nurse, LPN F, about the resident bleeding and change in condition around 5:00 A.M. He/she also told LPN F that he/she should pass on the change in condition in report and monitor the situation just in case the physician wanted to send Resident #1 to the hospital; -He/she thought LPN F would contact the physician and further assess the resident since it was his/her resident; -He/she did not check the resident's vital signs; -He/she informed LPN E and LPN H when they came in for their shift around 6:00 A.M.; -He/she thought LPN F had contacted the physician; -He/she did not monitor or check on the resident again after telling LPN F about the resident and then shift change occurred within the hour. During an interview on 2/25/2021, at 1:24 P.M., LPN F said the following: -He/she was responsible for taking care of Resident #1 on the night of 2/20/2021 from 6:00 P.M. to 2/21/2021 at 6:00 A.M.; -He/she checked on Resident #1 at around 10:00 P.M., and did not notice anything out of the ordinary; -On 2/21/2021, at 5:30 A.M., RN G informed LPN F that Resident #1 had bleeding from his/her rectum and he/she cleaned the resident up; -He/she thought RN G called the resident's physician twice about the resident's change in condition; -The day shift arrived about 10 minutes later and LPN E was informed of the resident's change in condition; -He/she did not assess Resident #1 or check the resident's vital signs after being informed about the resident's change in condition; -He/she thought RN G had made the phone call to the physician; -He/she did not check on the resident before notifying the next shift of the resident bleeding. During an interview on 3/1/2021, at 9:40 A.M., LPN H said he/she arrived to work on 2/21/2021, at about 5:30 A.M., RN G told him/her about Resident #1 and said he/she had put a call out to the resident's physician. LPN F came through and RN G told him/her about Resident #1. It was LPN F's resident. LPN H thought LPN E came through also and was told about Resident #1. LPN H said, if (he/she) had been my patient, I would have contacted the doctor again, since there had not been a call back. During an interview on 2/25/2021, at 12:07 P.M., CNA C said the following: -On 2/21/2021, he/she did not get report from the overnight CNA because there was one CNA for four halls; -At around 7:00 A.M. to 8:00 A.M., he/she went to Resident #1's room to assist the resident with breakfast. He/she noticed Resident #1 was uncovered. Resident #1 had blood up the back and front of his/her body. There was coagulated blood the size of a fist that fell out of the bed. The soaker pad was soaked with blood. He/she immediately went to get LPN E; -LPN E assessed Resident #1 and called the resident's physician; -LPN E said he/she had heard from the overnight staff that the resident had a little blood from his/her rectum overnight. There were a couple of little blood clots and he/she thought there was nothing to worry about. LPN F was supposed to call the physician when the blood was first found; -CNA C checked vital signs and reported them to the nurse and wrote them on a brown napkin. He/she remembered the resident's oxygen saturation being in the 70's. The resident did not have on oxygen. He/she cleaned up the resident with the assistance of CNA N. During interviews on 2/25/2021, at 4:10 P.M. and 2/26/2021, at 9:35 A.M., LPN E said he/she did not receive any information at shift change report about the resident having blood in his/her brief. CNA C notified the LPN at approximately 7:30 A.M. or 8:00 A.M. of the resident having a large amount of blood in his/her brief. He/she went to look at the resident and completed a head to toe evaluation. As he/she left the room, he/she asked CNA C to get the resident's vital signs. He/she went to call 911 immediately. After calling 911, he/she went back to the room and the aide was cleaning the resident. He/she clearly remembers CNA C bringing the vital signs on a brown paper towel, and remembers the only thing out of the normal range was the resident's oxygen saturation level. It registered at 88%. The resident's blood pressure and pulse were within normal limits. The brief was completely full with large clots and overflowing through the legs of the brief. The resident was normally confused and difficult to understand but he/she said, I'm ready, let's go. The resident grimaced and had his/her fists clenched. The resident did not appear relaxed. During an interview on 2/26/2021, at 8:45 A.M., CNA N said the following: -On 2/21/2021, when he/she arrived to the facility in the morning, at around 7:00 A.M., the residents had not been cleaned up because the facility was understaffed on the overnight shift; -At around 8:30 A.M., CNA C asked for help to clean up Resident #1. Resident #1 was covered with blood and it was all over the bed and floor around the bed; -Resident #1 was hard to arouse. CNA C checked the resident's vital signs and documented it on a napkin; but he/she did not know what they were; -LPN E was in and out of the room and called the physician; -Facility staff sent the resident to the hospital around 8:30 A.M. Record review of the resident's nurses' progress notes showed the following information: -On 2/21/2021, at 9:15 A.M., staff documented the observation of the resident in bed laying in dark red clotting blood. Staff secured the resident in bed. Staff checked the resident's vital signs and completed a head to toe assessment. The resident bled from the rectum. The aide provided peri-care (cleaning of private area). The nurse called 911. Staff transported the resident to the hospital. Staff attempted to contact any family member, but was unsuccessful. Staff notified the physician on call of the transfer to the hospital. Staff notified the Director of Nursing (DON). (Staff did not document any other nurses' progress notes regarding the resident's condition that morning or the discovery of bleeding earlier in the morning.) Record review of the resident's emergency department notes, dated 2/21/2021, showed the following information: -Patient was evaluated in the emergency department room at 9:05 A.M.; -Resident arrived for evaluation of rectal bleeding; -Currently took [MEDICATION NAME] and aspirin; -Emergency Medical Staff (EMS) reported rectal bleeding that began earlier today; -EMS saw a very large clot on the floor near the patient; -Patient oxygen saturation at 84% on room air; -EMS placed him/her on 4 liters (L) of supplemental oxygen with improvement; -Review of symptoms showed large blood clot coming from the rectum, appeared to have pain around the rectum, no obvious hemorrhoids or fissure, no palpable masses in the rectum, large stool ball of brown non-bloody stool, which staff removed most of with no visible vaginal bleeding. Record review of the resident's pelvis CT scan (an x-ray image made using a form of tomography in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces the image) without contrast (substance used to increase the contrast of structures or fluids within the body in medical imaging), dated 2/21/2021, showed the following information: -Moderate volume of stool and liquid in the rectum; -No abnormally distended small bowel loops. Record review of the resident's [MEDICATION NAME] hospital note, dated 2/22/2021, showed the following information: -Hemoglobin (protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body and carries carbon [MEDICATION NAME] back to the lungs), was noted to be 6.8 (normal range for women 12.0 to 15.5 grams per deciliter) on arrival; -Patient's baseline hemoglobin trended around 9-11; -Resident received two units of packed red blood cells (PRBC), with improvement of hemoglobin to 9.9. Record review of the resident's hospital medicine progress note, dated 2/23/2021, showed the following information: -Resident brought to the emergency room for evaluation of rectal bleeding; -Per EMS, staff checked on the patient this morning and found him/her to have rectal bleeding with numerous clots; -Upon EMS arrival, they saw a very large blood clot on the floor near the patient; -EMS reported the patient's oxygen saturation at 84% on room air, they placed him/her on 4 L of supplemental oxygen with improvement; -Patient currently had a PICC line in place for IV antibiotics secondary to recent surgical wound infection. Record review of the resident's nurses' notes showed the staff documented the following information: -On 2/24/2021, at 6:00 P.M., the resident returned from the hospital via ambulance and three attendants. The resident returned on comfort care (plan of care that is focused on symptom control, pain relief, and quality of life, typically administered to those hospitalized several times, with further medical treatment unlikely to change matters). During an interview on 2/26/2021, at 2:10 P.M. and 3:54 P.M., the DON said the following: -He/she was not made aware of Resident #1's change in condition on 2/21/2021, around 5:00 A.M., when CNA D found the resident bleeding rectally; -He/she was only aware of the resident being found on 2/21/2021, around 8:00 A.M. and sent to the hospital; -Resident #1 should have been assessed by the nurse, the resident's vital signs should have been taken and the physician should have been notified as soon as the change in condition was noticed. During an interview on 2/26/2021, at 2:10 P.M. and 3:03 P.M., the administrator said the following: -She would have expected that the nurse that found Resident #1 laying in blood would have told the nurse responsible for that resident about the situation, but then should have monitored the situation; -He/she would expect staff to notify the charge nurse immediately of a change in condition. -She would have expected the nurse to contact the physician and DON/administrator about the resident's change in condition; -She would have expected the nurse to assess the resident, including taking vital signs. -She did not know about the resident's change of condition until after the resident was being transported to the hospital. During an interview on 2/26/2021, at 3:45 P.M., the corporate nurse said the following: -The CNA should let the charge nurse know if they notice a change in a resident's condition; -The nurse is responsible for assessing the resident and notifying the physician and DON of the resident's change in condition; -The CNA should feel empowered to call the DON if they notice bleeding or something out of the ordinary for the resident. During an interview on 2/26/2021, at 9:19 A.M., the medical director (and Resident #1's primary physician) said the following: -The facility staff did not contact him about Resident #1's change in condition until after they had already called 911; -He/she was not contacted prior to 8:00 A.M. on 2/21/2021; -He/she would expect to be contacted with any significant change with a resident, including a moderate amount of blood coming from the rectum; -He/she would expect the facility staff to assess a resident that has had a change in condition, including getting vital signs. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 808

Based on interview and record review, the facility staff failed to provide adequate supervision and monitoring for three residents (Resident #1, #2 and #3), when facility staff did not conduct resident checks as per facility expectation. The three residents eloped from the facility and staff were not aware the residents were gone for an extended amount of time. The facility census was 96 residents. The administrator was notified on 10/28/20 at 6:30 P.M. of an Immediate Jeopardy (IJ) which began on 10/22/20. The IJ was removed on 10/29/20, as confirmed by surveyor onsite verification. Record review of the facility's policy titled, Missing Resident/ Elopement dated 11/1/18, showed the following: -The unit charge nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc., the staff in these programs will be responsible for the location of their participants; -It is the responsibility of all personnel to report any residents attempting to leave the premises, or suspected of being missing to the charge nurse as soon as practical; -Should an employee discover that a resident is missing from the facility he/she should, determine if the resident is authorized to leave the facility, make a thorough search of the building and premises; -Notify the Administrator and the Director of Nursing (DON), resident's legal representative, physician, and law enforcement; -Provide search teams with resident identification information and make an extensive search of the surrounding area; -Determine time and location when the resident was last seen; -Once the resident is located the resident will be evaluated thoroughly; -The charge nurse will document the incident in the resident's medical record including times, an accident/ incident report, implement interventions and update care plan; -The Administrator/ DON will notify the Department of Health per state regulations. Record review of the facility's in-service titled, Elopement and Recovery in-service, dated 9/4/2020, showed the following: -Elopement is defined as, An act or instance of leaving a safe area or safe premises; -In the facility residents may occasionally attempt to leave the building; -The residents should be visualized by facility staff once every other hour. Staff should see a face at any time of day or night; -If a resident is missing the facility staff should notify the on-call phone; -The facility staff should immediately check all rooms, verify there are no other residents missing, note the time for documentation, call 911 if staff believes the resident has left the building, and begin an outside search. 1. Record review of Resident #1's face sheet showed the following: -admission date of [DATE]; -The resident had an appointed guardian; -[DIAGNOSES REDACTED]., and physical symptoms that can occur after you go through a stressful life event), anxiety disorder, unspecified mood disorder, psychoactive substance abuse, [MEDICAL CONDITION] (sleep disorder in which you have trouble falling and/or staying asleep), and [MEDICAL CONDITION]. Record review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 9/4/20, showed the following information: -A Brief Interview for Mental Status (BIMS) (required screening tool used in skilled nursing facilities to assess cognition) score of 15 indicating the resident was cognitively intact; -No behaviors exhibited; -Independent with activities of daily living (ADLs), transfers and ambulation; -Antipsychotic medication received on a routine basis. Record review of the resident's care plan, dated 1/3/20, revised 3/5/20, showed the following: -Resident #1 has a potential or actual behavior problem due to [MEDICAL CONDITIONS] disorder, anxiety disorder, adjustment disorder, ADHD and other diagnosis; -The facility staff to administer medications as ordered and monitor/document for side effects and effectiveness, anticipate the resident's needs, discuss the resident's behavior and explain/reinforce why behavior is inappropriate, intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause; -Resident #1 uses [MEDICAL CONDITION] medications due to [MEDICAL CONDITIONS] disorder, anxiety disorder, ADHD and other diagnosis; -The facility staff to administer medications as ordered and monitor/document for side effects and effectiveness, monitor and record occurrence of/for target behavior symptoms; pacing, wandering, disrobing, inappropriate response verbal communications, violence/aggression towards staff and others. Record review of the resident's psychiatrist's notes, dated 5/28/20, showed the following: -The resident had no chance of going back to independent living if he/she stopped his/her medications as he/she had done previously; -The resident's insight and judgement is at best poor to fair. Record review of the resident's October 2020 physician order [REDACTED]. -Behavior monitoring for the following: restlessness (agitation), increase in complaints, elopement, delusions, hallucinations, [MEDICAL CONDITION], aggression refusing care and refusing directions from staff, dated 8/8/20; -Facility staff to document observations once per shift, dated 8/8/20. Record review of the resident's Elopement-Wandering Risk Scale, dated 8/28/20, showed the following: -A score of four, indicating a low risk of Elopement-Wandering. Record review of the resident's nurse's notes showed the following: -On 10/21/20 at 6:23 P.M., Licensed Practical Nurse (LPN) A documented the resident was defiant and refusing to follow staff's instruction when told to wear a mask while in the hallway and wash food off of his/her face; -On 10/23/20 at 8:55 A.M., the Assistant Director of Nursing (ADON), documented on 10/22/20 at approximately 8:45 A.M., LPN B notified him/her that Resident #1 could not be located. The ADON documented the resident was not observed in the building or on the grounds; -On 10/23/20 at 10:52 A.M., the Administrator documented on 10/22/20 it was reported to him/her by the ADON that Resident #1 could not be located in house or on the facility grounds. The department heads went on a drive search in a ten mile radius. The resident had used a butter knife to remove the [MEDICATION NAME] from the window and laid the window neatly against the bed, removed the screens and placed them beside the building. The resident's belongings were left in the room. The resident did take his/her cell phone. He/she tried calling the resident's phone, but was unable to reach him/her. The Administrator documented some residents reported they knew Resident #1 was leaving the building, but did not know where. The Administrator documented contact with the police department again at 9:00 P.M., on 10/22/20 and 10/23/20 at 8:20 A.M., with no new updates; -On 10/26/20 at 2:11 A.M., LPN A documented, the resident called the building and said he/she was staying in a trailer in the backyard of his/her family member's house. The trailer had no heat. He/she was staying there until he/she could figure out how to get his/her guardianship ended. Record review of a letter from the resident's public administrator, dated 10/29/20, showed the following: -On 1/27/20 the facility was given permission for the resident to have five day passes from the facility during day time hours and to leave the facility by himself/herself to walk to the store and to walk to his/her mother's house for visits. If he/she plans to be gone overnight, the resident will have to get consent from the public Administrator; -The resident's ability to leave the facility changed solely due to the COVID-19 pandemic and the tightened restrictions of the Health Department and the Centers of Disease Control to reduce the spread of [MEDICAL CONDITION] through nursing homes; -On 3/13/20 the facility received an email to cease of all out of facility activity for every individual that they had residing at the facility, including Resident #1; -Under normal circumstances, Resident #1 would still have had access to the five day passes per week as long as his/her behaviors remained well-managed. Resident #1's behaviors prior to elopement were consistent with behaviors that would have permitted him/her to retain his/her passes; -He/she feels that Resident #1's elopement was due to the COVID-19 lockdown and if he/she had routine passes to visit his/her family, he/she does not believe the incident would have occurred. Record review of www.googlemaps.com showed the following -The resident's family member's house was approximately 1.7 miles from the facility. Record review of www.weather.com for the immediate area of the facility showed the following: -The temperature outside on 10/21/20 was a high of 79 degrees and a low of 55 degrees; -The temperature outside on 10/22/20 was a high of 84 degrees and a low of 65 degrees; -The temperature outside on 10/23/20 was a high of 66 degrees and a low of 40 degrees; -The temperature outside on 10/24/20 was a high of 46 degrees and a low of 38 degrees; -The temperature outside on 10/25/20 was a high of 47 degrees and a low of 41 degrees; -The temperature outside on 10/26/20 was a high of 43 degrees and a low of 33 degrees. Record review of Resident #2's face sheet showed the following: -admission date of [DATE]; -The resident had an appointed public administrator; -[DIAGNOSES REDACTED]. Record review of the resident's Quarterly MDS showed the following information: -A BIMS score of four indicating severe cognitive impairment; -No behaviors exhibited; -Independent with activities of daily living (ADLs) and walking, but requires supervision with locomotion off of the unit. Record review of the resident's care plan, dated 8/28/20 showed the following: -The resident is at risk of elopement as evidenced by a [DIAGNOSES REDACTED]. -The resident will not leave the facility unattended through the next review date; -The facility staff is to identify patterns of elopement: Is exit seeking purposeful, aimless, or escapist? Is the resident looking for someone or something?; -If the resident exits the building, do not leave unattended, staff expected to walk with him/her and/or keep in line of sight; -Notify the supervisor, DON and Administrator immediately of any successful exits from the building. Follow the facility elopement protocol; -Provide structured activities; walking inside and outside, reorientation strategies including signs, pictures and memory boxes; -The resident is unable to make safe decisions without assistance/prompting and does rely on staff assistance with daily decision making. Record review of the resident's Elopement-Wandering Risk Scale, dated 8/28/20, showed the following: -A score of nine, indicating the resident is at risk to wander. Record review of the resident's October 2020 POS showed the following: -The resident may go out on leave of absence with responsible party, dated 5/14/20. Record review of the resident's nurse's notes showed the following: -On 10/23/20 at 8:57 A.M., on 10/22/20 at 8:45 A.M. the ADON documented LPN B notified him/her that Resident #2 could not be located. The resident was not observed in the building or on the grounds; -On 10/23/20 at 11:44 A.M., the Administrator said he/she received notification of the resident not being in the building. A facility and ground search was completed. He/she was making a police report when he/she received a call from the resident's family member that a community employee recognized the resident from previous interactions and had called the family member. The community employee agreed to bring the resident back to the facility and the resident was willing to return. The resident arrived safely back to the facility and was placed on the memory care unit for continued monitoring. The resident's public administrator was notified. Department of Health and Senior services (DHSS) was notified (on 10/23/20) at 4:55 P.M., of the event with Resident #1. Record review of the facility's investigation, dated 10/26/20, showed the following: -On 10/22/20 at approximately 8:00 A.M., facility staff reported the window in Resident #1 and #2's room had been removed and neither resident was in the room. The Administrator was notified and a facility and grounds search was initiated. The resident's physician, public administrator, local police department and DHSS were made aware of the incident. An investigation was initiated; -Upon completion of the investigation it was determined by the staff that Resident #1 and #2 removed the window and screen and exited the facility. Resident #2 was located at a local gas station and escorted back to the facility without difficulty; -Resident #2 was unable to recall why he/she left the facility; -On 10/22/20, the charge nurse reported that both residents were sleeping in their beds at midnight and the window was intact; - On 10/26/20 at 2:30 A.M., Resident #1 called the facility and said he/she had been at his/her family member's house. The charge nurse notified the police department regarding the resident's call. The police located Resident #1, at a gas station near his/her family member's house. The police attempted to take the resident to the hospital, the resident refused. The resident's on-call Public Administrator was contacted by the police. Record review of www.googlemaps.com showed the following -The gas station where the resident was found was approximately 4.8 miles away from the facility. During an interview on 10/23/20 at 11:52 A.M., Resident #2 said the following: -He/she had not left the building recently; -The residents are not allowed to leave the building; -He/she had no plans to leave the facility and could not remember why he/she would have left the building with Resident #1; -He/she did not know where Resident #1 was and could not remember the last time he/she had seen him/her. During an interview on 10/23/20 at 10:50 A.M., the Administrator said the following: -On 10/22/20 at 8:45 A.M., he/she was notified that Resident #1 and #2 were missing and a full search of the grounds was initiated; -Resident #1 and #2 eloped from the facility sometime during the night on 10/21/20. They were last seen by staff at 12:00 A.M.; -Resident #2 was found at a gas station by an old case worker who happened to recognize him/her; -Resident #2 was put on the locked unit for closer monitoring; -Resident #1 has not been found at this time; -Resident #1 had never tried to elope from the facility; -Resident #1 removed the bracket that keeps the window from fully opening with a butter knife and went out the window; -The facility contacted the police, hospitals and homeless shelters in attempts to find the resident. During an interview on 10/23/20 at 11:55 A.M., CNA J said the following: -On 10/22/20 he/she took trays to Resident #1 and #2 around 8:00 A.M., and noticed that the residents were not in their rooms; -He/she left the trays there and went to tell the charge nurse; -He/she generally keeps a closer eye on these two residents due to confusion and behaviors; -The residents were not on any increased monitoring more than the usual checks every two hours. During an interview on 10/23/20 at 12:10, RN K said the following: -Resident #1 was on behavior monitoring that was documented once per shift; -Resident #1 often talked about wanting to get out of the facility and eventually leaving the facility. He/she was not specifically being monitored for elopement. During an interview on 10/26/20 at 10:47 A.M., the Administrator said the following: -He/she had spoken with Resident #1 who had been staying at his/her dad's house in a trailer behind the house that had no electricity or heat; -He/she had not contacted the resident's father because the facility did not have any contact information; -The police were notified because the resident called the facility from a gas station on 10/26/20 around 2:30 A.M Resident #1 refused to go to the hospital and the police took the resident back to his/her dad's house per the guardian's request; -He/she would have expected staff to check on residents throughout the night, however Resident #1 had requested not to be disturbed and Resident #2 does not like to be disturbed, however staff still should have checked on them; -He/she would have expected LPN A to do a head and bed check of all residents at midnight. During an interview on 10/26/20 at 11:07 A.M., CNA L said the following: -The nursing staff is supposed to do rounds every two hours to check on all residents; -The CNAs have to at least visualize the resident's every two hours. During an interview on 10/26/20 at 1:45 P.M., Certified Nurse Aide (CNA) D said the following: -He/she worked the night of 10/21/20 and morning of 10/22/20; -He/she did not check or visualize Resident #1 during the night or morning hours of 10/21/20 to 10/22/20; -He/she is expected to check on residents every two hours during rounds; -He/she found out about the residents eloping the next day after it was discovered; -He/she saw Resident #2 around 10:00 P.M. on a different hall; -He/she was not aware of a reason why staff would not check on residents during the night. The residents have never voiced any complaints about being checked on at night to him/her. During an interview on 10/26/20 at 2:05 P.M., Registered Nurse (RN) F said the following: -LPN A was responsible for the 400 hall which was the hall that Resident #1 and #2's room was on 10/21/20; -He/she saw the residents around 7:00 P.M. on 10/21/20; -The CNAs are supposed to check on the residents every two hours and the nurses check on residents every two to three hours; -The nursing staff is still expected to do bed checks if the resident has closed their door; -Resident #1 had a history of [REDACTED]. -Resident #1 and Resident #2 had not tried to elope from the facility that he/she was aware of; -The nurses have to complete census around midnight each night and that includes laying eyes on all residents in the building. On 10/26/20 at 4:40 P.M., LPN B said the following: -On 10/22/20 between 8:30 and 9:00 A.M., CNA G told her that he/she was concerned because Resident #1 and #2 had not touched their breakfast tray that had been left in their room; -Resident #1 and #2 generally go to the courtyard to smoke around 8:00 A.M., but they were not there; -CNA G did not work on that hall, but was concerned because nobody else seemed to notice they were not in their normal spot. He/she reported that the residents were missing to the ADON. -Resident #1 has behaviors such as anger and depression and is monitored every shift. The facility staff was not really monitoring for elopement; -The CNAs are supposed to check on residents every two hours depending on behaviors and the resident's specific needs; -The staff should look in the resident's rooms at night every two hours to make sure they are okay; -He/she was not aware that Resident #2 was care planned as being at risk for elopement. He/She did have confusion at times; -After the facility began the house-wide search they noticed that the screen had been removed from the window and it was assumed that the residents went out the window; -Resident #2 was more confused when he/she came to the facility and has become more oriented since he/she has been here. -If a resident is at risk of elopement they are put on the locked unit or given a Wander guard that is checked every shift. During an interview on 10/26/20 at 4:54 P.M., CNA H said the following: -He/she worked the night of 10/21/20 until 6:00 A.M., 10/22/20; -He/she was made aware of the elopement on 10/22/20 evening; -He/she did not work on Resident #1 and #2's hall and did not see them during his/her shift; -CNA I was responsible for Resident #1 and #2's hall and should have been checking on the residents; -Resident #1 and #2 should have been checked on every two hours; -Resident #1 had talked about leaving the facility recently and was on suicide watch with 15 minute checks a few weeks ago. He/she should have been being monitored regularly due to behaviors. During an interview on 10/27/20 at 7:25 A.M., LPN A said the following: -He/she worked at the facility the night of 10/21/20 from 6:00 P.M. to 6:00 A.M. and was responsible for Resident #1 and #2; -He/she last saw Resident #1 and #2 on 10/21/20 at around 10:00 P.M. laying in their beds, the door was closed after that; -Resident #1 was on behavior monitoring each shift. The facility staff watched for changes in behavior to see if the resident's medications were effective. He/she was not aware that elopement was included in the items listed to monitor for; -Resident #1 was having behaviors that evening, such as, refusing to wear a mask and was being defiant:' Resident #1 could be non-compliant and would refuse to pull his/her pants up; -He/she did not think the resident's increase in behaviors warranted any increased monitoring; -Resident #1 took his/her evening medications and then he/she did not see him/her again; -Resident #1 was not an elopement risk due to not being exit seeking; -He/she felt there was no reason to check on Resident #1 or #2 during the night; -He/she does not monitor or check these residents over night; -He/she was not aware of Resident #2 being at risk of elopement; -Resident #2 was confused and had memory deficits, but did not have exit seeking behaviors; -Facility staff check on residents every one to two hours during the day. If they have not seen them, they will look for them; -The CNAs round on residents every two hours to make sure their needs are met during the day; -The facility staff do not check on residents at night so they will not disturb them, unless they require incontinence care; -He/she is responsible for the census at midnight but, he/she did not remember if he/she saw the residents at midnight; -CNA I was responsible for doing rounds; -He/she received a call at the facility from Resident #1 on 10/26/20 at around 2:30 A.M. Resident #1 said he/she left to prove that he/she could be independent. He/she agreed to come back to the facility; -Resident #1 was allowed to leave the facility during the day prior to COVID-19. It was a difficult adjustment for him/her to adjust to being at the facility all the time. During an interview on 10/27/20 at 11:48 A.M., LPN M said the following: -On 10/21/20 at around 9:00 P.M., Resident #1 came up to the nurse's desk and said he/she was tired of living here and he/she didn't want to be here anymore; -LPN A ignored the resident and did not respond to him/her; -He/she tried to talk him/her down, because he/she appeared to be upset; -CNA I told the resident, nobody cares. He/she felt it was not appropriate to say that to the resident; -The nurses are supposed to lay eyes on the residents they are responsible for every two hours; -He/she did not think Resident #1 would elope, but he/she should have been being monitored for behaviors; -He/she had never been told not to check on Resident #1 or #2. The nurses should lay eyes on their face to make sure they are breathing. During an interview on 10/27/20 CNA I, said the following: -He/she worked from 2:00 P.M. to 6:00 A.M., on 10/21/20; -He/she thinks he/she saw Resident #1 and Resident #2 in their room at around midnight on 10/21/20. After that he/she did not check on them again, because their door was shut; -He/she did not see the residents prior to leaving the facility at the end of his/her shift; -He/she was not aware that Resident #2 was care planned for being an elopement risk, because he/she does not have access to the resident's care plans. He/she was aware Resident #2 is confused sometimes; -He/she did not see LPN A check on any of the residents; -He/she does not monitor the hall that Resident #1 and Resident# 2 live on as much, because the residents tend to be more independent; -There is not enough staff at the facility to monitor the residents the way they should be monitored; -He/she did not remember telling Resident #1 that, nobody cared, on 10/21/20, but he/she has told him/her that before because Resident #1 is really persistent and won't leave him/her alone. -Resident #1 was monitored for behaviors due to refusing to wear a mask and exposing his/her buttocks to staff. Resident #1 had those types of behaviors on 10/21/20; -Resident #1 and Resident #2 did not come to the last smoke break at 8:00 P.M., because they were in bed; -On 10/22/20 at around 2:00 A.M., he/she heard a loud banging sound coming from somewhere close to Resident #1 and #2's room. He/she did not check to see what it was, because he/she thought it could be the staff on the other hall around the corner getting trash. In hindsight he/she thinks it was the residents removing the window and eloping from the facility. During an interview on 10/26/20 at 11:25 A.M., the ADON said the following: -CNA I reported that he/she had seen Resident #1 and #2 at their last smoke break and then again in their room around midnight; -He/she is assuming they did not check on the residents after that; -The nurse should be laying eyes on the residents every two hours even if the door is closed; -The midnight census should be completed by the nurse that laid eyes on the residents during rounds; -Resident #1 has talked about not wanting to be at the facility; -LPN M said on 10/21/20 Resident #1 came up to the nurse's station and said he/she was tired of being at the facility, did not want to stay here and wanted to leave. Resident #1 was really upset. LPN A did not respond to him/her. LPN M had to try to calm him/her down. CNA I told Resident #1, nobody cares. He/she did not treat the resident with respect and it was not appropriate in the situation with a resident being upset even if he/she was joking. -He/she felt that Resident #1 should have been put on 15 minute checks due to his mental state and behaviors; -The facility staff reported the residents were missing on 10/22/20 at around 8:45 A.M.; -The residents could have been gone eight hours or more; -The residents' window had been dismantled. During an interview on 10/27/20 at 9:28 A.M., the interim DON said the following: -The nurses should be monitoring all residents every two hours by at least visualizing them; -The nurses are supposed to go room to room at midnight and check to make sure all the residents are where they are supposed to be for the census; -Resident #1 was on behavior monitoring that is standard for all residents that take [MEDICAL CONDITION] drugs to make sure they are effective; -Resident #1 was being monitored for behaviors such as agitation and it was documented once a shift by the nurse; -Resident #2 was considered at risk for elopement due to confusion and orientation. He/she was not exit seeking and had not tried to elope before, however he/she should have been checked on every two hours. During interviews on 10/26/20 at 11:32 A.M. and 10/28/20 at 10:25 A.M., Resident #1 and #2's public administrator said the following: -Resident #1 was allowed to leave the facility by himself/herself to walk to the gas station or places nearby, during day time hours prior to the lockdown in March caused by COVID-19; -Resident #1 had to have prior permission to leave the facility at night; -At this time, Resident #1 was not allowed to leave the facility except for medically necessary appointments for his/her safety due to COVID-19; -Resident #2 is more confused and is not allowed to leave the facility by himself/herself; -Resident #2 is not safe to be out of the facility by himself/herself due to confusion and poor memory; -He/she was made aware of the residents elopement on 10/22/20 by the Administrator; -He/she was contacted by Resident #1 on 10/26/20 and said he/she had been staying in a trailer behind his/her dad's house without electricity or heat; -Resident #1 said he/she left the building around 8:00 P.M., shortly after he/she got his/her evening medications; -Resident #1 said he/she left Resident #2 at the gas station, because he/she was talking about wanting alcohol. -The police called the over-night phone for the guardian's office due to Resident #1 being found at a gas station. The resident refused to go to the hospital to be medically cleared and the facility would not readmit until he/she got checked out. The on-call person gave the okay for Resident #1 to return to his/her dad's house due to it being the only option available. This was not an ideal situation due to a concerning past history with the resident's dad, but at least he/she had shelter; -He/she was worried for Resident #1's safety due to him/her not making good choices; -On 10/26/20 at 9:30 A.M., Resident #1 called him/her and agreed to go to the hospital to be assessed; -Resident #1 said he/she did marijuana and other drugs while he/she was out of the facility. During an interview on 10/28/20 at 5:45 P.M., Resident #1 said the following: -He/she left the facility around 8:00 P.M., after he/she took his medication; -He/she took the bracket out of the window and then climbed out. Resident #2 followed him/her out the window, but he/she left him/her at the gas station; -He/she did not tell anyone before leaving, but had told staff earlier in the night that he/she did not want to be there anymore and he/she was thinking about leaving. He/she then walked to his/her dad's house and stayed in a trailer behind the house. The trailer did not have electricity or heat; -He/she wanted to prove he/she could be independent and did not like living at the facility, because he/she did not like the other residents and sometimes the staff are not very understanding; -The staff do not check on him/her at night usually, so he/she left at that time; -He/she plans to leave again because he/she wants to be independent, but may stay for a little while because it is cold outside. During an interview on 10/28/20 at 6:57 P.M., the Administrator said the following: -LPN A said he/she did rounds on the resident's every two hours, however he/she could tell LPN A did not complete rounds from watching the facility's camera; -It was LPN A's responsibility to round on the resident's every two hours to ensure their safety. During an interview on 10/30/20 at 9:35 A.M., the Facility's Medical Director said the following: -He/she was made aware by the facility that two residents had eloped from the facility; -Resident #1 had started talking about wanting to leave the facility about two weeks ago in order to be more independent; -The resident was told when things calmed down with COVID-19 then he/she could move to a more indep

Based on interview and record review, the facility failed to send one resident (Resident #1) to the hospital for evaluation immediately following a change in condition, including reduced blood oxygen levels, altered skin color, and singed hair, related to the resident attempting to smoke in his/her room while wearing oxygen causing combustion. The facility census was 102. Record review of the facility's policy titled, Notification of a Change in a Residents Condition, last reviewed 11/1/2018, showed the attending physician and resident representative will be notified of a change in a residents condition, per standards of practice and Federal and/or State regulations. (The policy did not identify guidance for assessing and treating a residents change in condition.) Record review of an undated facility policy titled, Smoking Contract, showed the following: -Residents will be assessed upon admission to measure their cognitive and functional ability to smoke safely and independently; -All assessments will be reviewed and signed off by the resident's physician and the Director of Nursing (DON); -If a resident has been determined to meet all criteria they will be allowed to maintain their smoking materials (except for items that ignite) and smoke as desired in the designated areas where they can be supervised; -Smoking status will become part of their care plan and will be reviewed and reassessed quarterly; -Residents not meeting criteria based on assessment will be allowed to smoke in designated areas at designated times set by the facility with direct supervision from staff. The resident will be required to turn in all smoking materials at the nurses station and they will be dispensed at the smoking times. 1. Record review of Resident #1's face sheet (basic resident information) showed the following: -An admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's assessment titled, Smoking Safety Screening, dated 2/26/2020 showed the resident indicated as a supervised smoker and the facility needed to store the resident's smoking supplies. Record review of the resident's current care plan showed the following: -The resident went on hospice services for [CONDITION(S)] on 2/17/2020; -On 2/26/2020, the facility indicated the resident as a supervised smoker related to poor safety awareness; -Staff indicated to remind the resident to remove oxygen prior to smoking and assist putting oxygen on when finished smoking; -Nursing staff to maintain and monitor all smoking materials in the designated smoking area; -Complete periodic smoking evaluations and assessments per policy and for change in condition. Record review of the resident's active physicians' orders, as of 3/11/2020, showed the following orders: -Oxygen at 2 to 4 liters via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) as needed for [CONDITION(S)]. Record review of the resident's nurses' notes showed the following: -On 3/10/2020, at 7:27 A.M., a nurse documented that around 4:00 A.M. to 4:15 A.M., the resident lit a cigarette with his/her nasal cannula and oxygen on. The resident stated, I tried to put it out. The residents face was black and ashy with his/her facial hair singed. The resident was alert, breathing, and sitting on the side of his/her bed. Staff replaced the resident nasal cannula and the resident's oxygen saturation (percentage of hemoglobin binding sites in the bloodstream occupied by oxygen) level was at 54 percent (normal level is 90 percent or greater). The physician was contacted (no time noted or directive from physician noted) and the resident's oxygen was turned up to six to seven liters and his/her oxygen saturation was at 69 percent. Staff attempted to wipe the black ash off the resident's face and the resident stated his/her face was sore. The resident swallowing was assessed by giving the resident water. The resident had no coughing or complaints of discomfort or pain. Hospice arrived around 6:00 A.M. Staff completed 15-minute checks and attempted to have resident on one-on-one care, but staff was limited. Staff asked hospice to provide a one-on-one sitter; -On 3/10/2020, at 9:17 A.M., a nurse documented the resident was alert and responded with a nod or shake of his/her head. The resident's respirations were labored at rest. The resident stood in a tri-pod stance while sitting in his/her chair. The resident's oxygen was at 4 liters via nasal cannula. The resident's nose had thick yellow phlegm making inside of nose unable to be visualized. The resident had blisters on his/her upper lip and right eye. The residents face was blackened and scorched in appearance. Hospice was contacted and a message was left. The resident's oxygen saturation was at 46 percent at four liters of oxygen. Record review of the resident's skin observation dated 3/10/2020, at 9:17 A.M., showed the resident had a scorched face, blisters on his/her upper lip and right eye area, chapped lips, and abdominal bruising. Record review of the resident's pain assessment dated [DATE], at 9:17 A.M., showed the resident initially indicated pain at four out of a possible ten in pain (one indicating mild pain to ten indicating worst pain possible). A second indicator of pain showed the resident indicated a pain score of six out of ten in pain. A third indicator of pain showed the resident indicated a pain score of eight out of a possible ten. The pain evaluation indicated the pain related to the incident earlier in the morning (approximately 4:00 A.M.) when the resident lit a cigarette while wearing a nasal cannula hooked up to oxygen. During an interview on 3/11/2020, at 9:08 A.M., the Administrator said she received a call from Registered Nurse (RN) A on 3/10/2020, at 4:19 A.M The Administrator said RN A reported that the resident tried to light a cigarette in his/her room with his/her oxygen on. The resident is a supervised smoker and should not have been in possession of smoking supplies. The staff found one unlit cigarette and two lighters in the resident's room. The RN did not know how the resident got smoking supplies. The RN reported the resident's face was singed and his/her oxygen levels were low, but did not elaborate on the condition of the resident. The RN reported he/she left a voice message with the physician and contacted hospice. The Administrator said she called the Regional Nursing Consultant (RNC) on 3/10/2020, around 8:00 A.M. to 8:15 A.M., regarding the incident. The Administrator said she arrived at the facility on 3/10/2020 at approximately 8:00 A.M. The Administrator observed the resident on 3/10/2020, at approximately 8:40 A.M. The resident was sitting in his/her recliner with his/her oxygen on and his/her face looked black and ashy. She immediately went to the nurses' station. The resident did not appear how RN A described the resident. RN B said he/she was worried about the resident and had placed a call to the physician. RN B said hospice came and assessed the resident and did not seem concerned. RN B said the resident's face was singed and was developing blisters on his/her top lip. RN B said he/she needed to speak with the physician because he/she did not believe the physician was aware of the severity of the residents condition. Hospice evaluated the resident around 6:30 A.M. to 7:00 A.M. Emergency Medical Services (EMS) was called and took the resident to the hospital. The Administrator received a call from the hospital on 3/10/2020, at 11:58 A.M., reporting the resident had passed away. The resident should have been sent out for evaluation immediately. During an interview on 3/11/2020, at 9:46 A.M., the RNC said she received a call from the Administrator on 3/10/2020 around 8:00 A.M. to 8:15 A.M. The Administrator reported the resident attempted to light a cigarette with his/her oxygen on and was singed. The RNC said she arrived at the facility on 3/10/2020 around 9:00 A.M., and immediately went to assess the resident. The resident said he/she was okay. The resident's face looked dark-gray in color with no blistering initially observed. The resident showed no signs of distress. She called the physician at 9:14 A.M. and requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident began forming blisters on his/her upper lip, but denied any difficulty breathing. The RNC said RN A should have called 911 immediately and sent the resident out for evaluation. During an interview on 3/11/2020, at 10:40 A.M., Certified Nursing Assistant (CNA) C said during rounds with CNA D on 3/10/2020, at 4:00 A.M., the CNA's smelled fire and began searching residents' rooms. The CNA's checked Resident #1's room and observed the resident sitting in his/her chair. The resident's face was black and looked like he/she had smoke on his/her face. The resident's nasal cannula was melted. The resident's room smelt like smoke. The CNA notified RN A. The CNA replaced the nasal cannula for the resident because the resident said he/she was out of breath. The resident reported to staff the inside of his/her nose hurt. The CNA said two lighters and an unlit cigarette were found in the resident's room. During an interview on 3/10/2020, at 11:27 A.M., RN B said he/she arrived at the facility on 3/10/2020, around 7:00 A.M., for orientation. The RN said he/she overheard RN A telling another staff about Resident #1. RN A reported the resident's oxygen saturation level was in the 30 percent range when RN A first assessed the resident. RN A told RN B the resident's oxygen saturation was in the 50 percent range now and his normal oxygen saturation was in the 60 percent range. RN B said the resident was on hospice services and hospice assessed the resident around 6:30 A.M. RN A reported the resident blew his/her nasal cannula off his/her face. RN B said he/she assessed the resident on 3/10/2020, around 8:05 A.M., in his/her room. The resident's face was black and scorched and he/she had blisters around his/her upper lip. The resident could no open his/her mouth fully and the resident shook his/her head 'yes' when asked if it hurt to swallow and if the inside of his/her nose hurt. The resident had potential for smoke inhalation. The RN said he/she called the physician at 8:25 A.M. He/she reported to the physician the resident needed to be sent for evaluation for smoke inhalation and the resident's oxygen saturation level was 40 percent with a pulse of 46. EMS arrived at the facility, around 9:10 A.M. RN B said he/she felt the resident should have been sent for evaluation immediately. During an interview on 3/12/2020, at 8:58 A.M., CNA D said during rounds with CNA C on 3/10/2020, at 4:00 A.M., the CNA's smelled smoke on the 200 hall of the facility. The CNA said he/she heard the resident calling out for help from his/her room. The resident was sitting on his/her bed when the CNA entered the room around 4:00 A.M. The resident's face was black and the CNA immediately went to get RN A. The resident kept saying, I tried to put it out, but the resident could no specify what he/she was trying to put out. The resident's oxygen tubing was melted and broken in half. The resident's face looked burnt, singed, and black. The resident appeared confused and was not making sense. The staff could not get the resident's oxygen saturation above 50 percent. RN A notified hospice and the CNA's checked on the resident regularly until hospice arrived around 6:00 A.M. The CNA said two lighters and one unlit cigarette were found in the resident's room. During an interview on 3/12/2020, at 10:45 A.M., RN A said CNA C and CNA D were completing rounds on 3/10/2020, around 4:00 A.M., and they came to the nurse and reported smelling something burning. The RN said he/she could smell something on the 200 hall had been burning and as he/she got closer to Resident #1's room the smell became stronger. He/she arrived to the resident's room around 4:00 A.M. to 4:15 A.M. and observed the resident sitting on his bed. The resident told him/her that he/she, tried to put it out. He/she asked the resident what he/she tried to put out and the resident said, I just wanted to smoke. The RN told the resident he/she cant smoke in his/her room especially with his/her oxygen on. The resident has been told in the past to not smoke with his/her oxygen on. The RN said the resident was a supervised smoker and should not have had any smoking supplies due to the resident past history of attempting to smoke in his/her room. The resident had a little wheezing and shortness of breath which was normal for the resident. The resident had singed hair and a slightly swollen nose. The RN said no open areas or blisters were noted during the assessment. He/she turned the residents oxygen up to 6 to 7 liters and the resident's oxygen saturation went to 69 percent. The RN said he/she checked on the resident periodically until hospice arrived. The RN said hospice arrived on 3/10/2020, around 6:15 A.M. The resident was on hospice services and he/she was waiting to hear from physician or hospice before sending out for evaluation. The RN said he/she felt the resident should have sent out for evaluation immediately because of concerns of smoke inhalation and the resident's throat possibly closing from swelling. During an interview on 3/12/2020, at 11:41 A.M., the resident's physician said he/she was called on 3/10/2020, around 6:30 A.M., and informed the resident was smoking in his/her room with his/her oxygen on. The physician said the facility staff reported the resident was stable with no respiratory distress or visible [CONDITION(S)]. The physician did not know if the facility staff contacted him/her prior to 6:30 A.M. During an interview on 3/16/2020, at 9:07 A.M., the Emergency Medical Technician (EMT) said he/she was called to the facility on [DATE], around 9:30 A.M. to 10:00 A.M. The EMT said upon arrival to the resident's room he/she observed the resident sitting in his/her chair leaning forward in a tripod position. The resident's face was black with blistering on his/her nose and mouth. The resident's hair on his/her face was singed. The resident had his/her nasal cannula on at 4 liters. Facility staff reported the resident's oxygen saturation was at 46 percent. The EMT said the resident's oxygen saturation was in the 30 to low 40 percent saturation range. The resident complained he/she couldn't breath. The resident burned his/her airway. During an interview on 3/16/2020, at 9:17 A.M., the hospice nurse said he/she received a phone call on 3/10/2020, around 4:30 A.M., from RN A who reported he/she smelled something burning and Resident #1's face was black. The RN reported the resident attempted to smoke in his/her room while wearing oxygen. He/she arrived at the facility around 5:45 A.M. and assessed the resident. The resident's eyebrows and hair was singed and it appeared someone had attempted to wipe away the black material off the resident's face. The nurse said resident reported no concerns with breathing or swelling. The resident had no signs of redness or blistering. The resident's oxygen saturation level was around 68 percent. MO 758

Based on interview and record review, the facility failed to prevent a significant medication error when staff failed to ensure medications to treat [MEDICAL CONDITION] were available and administered to one resident (Resident # 2). The resident experienced a [MEDICAL CONDITION] and was subsequently sent to the hospital emergently after not receiving multiple doses of [MEDICAL CONDITION] medication. The facility census was 112. Record review of the facility's Medication Administration Policy, dated 2007, showed the following: -Medications are administered as prescribed; -If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the Medication Administration Record [REDACTED]. An explanatory note is entered on the reverse side of the record provided for as needed (PRN) documentation. If two consecutive doses are withheld or refused, the physician is notified; -The resident's MAR indicated [REDACTED] -The nursing care center maintains supplies necessary for the administration of medications to residents; -The nurse or authorized staff member is notified if supplies are inadequate. The nurse reports supply deficiencies to the Director of Nursing (DON). Record review of the facility's Medication Error Reporting and Adverse Reaction Prevention and Detection Policy, dated 2007, showed the following: -Medication errors are considered significant if they: -Require hospitalization ; -Result in disability; -Require treatment with a prescription medication; -Result in cognitive deterioration or impairment; -Are life-threatening; -In the event of a significant medication error, immediate action is taken, as necessary, to protect the resident's safety and welfare; -The physician is notified promptly of any significant medication error. 1. Record review of Resident # 2's face sheet (general resident information) showed the following: -admission date of [DATE]; -Most recent discharge date of [DATE]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool completed by facility staff, dated 6/6/18, showed [DIAGNOSES REDACTED]. Record review of the resident's care plan, dated 10/12/17, showed the following: -The resident has [MEDICAL CONDITION]; -The resident will remain free from injury related to [MEDICAL CONDITION] activity; -Give [MEDICAL CONDITION] medication as ordered by the doctor. Monitor side effects and effectiveness. Record review of the resident's nurse's note dated 08/02/18, at 11:17 P.M.,showed at 2:00 (did not not specify A.M. or P.M.), the resident had a tonic/conic (involves sudden muscle stiffening and contraction, and rhythmic twitching or jerking) [MEDICAL CONDITION] that continued for three minutes after first observed. The resident was lying across the bed when discovered. When the [MEDICAL CONDITION] subsided, the resident was unable to follow instructions or speak to staff. During the period following the [MEDICAL CONDITION], the resident followed staff with his/her eyes, and occasionally moaned. This period lasted approximately one hour. Staff notified the physician and he/she ordered [MEDICATION NAME] (antianxiety medication sometimes used to treat acute [MEDICAL CONDITION]) 10 milligrams (mg) to be given now and stat labs. The laboratory company called and said the labs could not be drawn until 4:00 A.M. The physician was notified of the stat lab delay. Record review of the resident's (MONTH) (YEAR) physician's orders [REDACTED]. -An order dated 8/2/18, for stat (immediate) order for [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) and [MEDICATION NAME] acid ( [MEDICATION NAME] medication to treat [MEDICAL CONDITION]) lab levels one time only. Record review of the resident's laboratory results showed the following: -On 8/3/18, collected at 5:09 A.M., the laboratory level for [MEDICATION NAME] acid was 50 micrograms (mcg) per milliliter (ml) with the normal reference range of 50-100 mcg/ml (normal level); -On 8/3/18, collected at 5:09 A.M., and reported on 8/7/18, the lacosamide (lab value used to detect therapeutic levels of [MEDICATION NAME] in the bloodstream) was 2.6 micrograms (ug)/ml (low) with the therapeutic reference suggested range (not well established) of 5-10 ug/ml. Record review of the resident's (MONTH) (YEAR) POS showed the following: -An order dated 8/8/18 and discontinued on 8/27/18, for [MEDICATION NAME] 100 milligrams (two tablets to equal 200 mg) by mouth at bedtime and give one tablet (100 mg) in the morning related to [MEDICAL CONDITION]; -An order dated 8/27/18 for [MEDICATION NAME] 150 mg by mouth in the morning. Record review of the resident's laboratory results showed the following: -On 8/22/18, the [MEDICATION NAME] acid level was 53.1 which was normal; -On 8/22/18 and reported on 8/25/18, the lacosamide level was 4.3 ug/ml (low). Record review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Record review of the resident's nurse's progress note dated 8/25/18, at 7:28 P.M., showed waiting on pharmacy for [MEDICATION NAME]. Record review of the resident's (MONTH) (YEAR) POS showed the following: -An order dated 10/21/17, for [MEDICATION NAME] sodium ([MEDICATION NAME] - medication to treat [MEDICAL CONDITION]) tablet delayed release 500 mg, give two tablets by mouth two times a day related to [MEDICAL CONDITION]; -An order dated 8/27/18, for [MEDICATION NAME] 150 mg by mouth in the morning related to [MEDICAL CONDITION] (increase in dosage from previous order); -An order dated 8/27/18, for [MEDICATION NAME] 200 mg by mouth, give one tablet at bedtime related to [MEDICAL CONDITION]; Record review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED].M. Record review of the resident's nurse's progress note dated 8/27/18, at 8:36 A.M. showed [MEDICATION NAME] not available. Record review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the resident's nurse's progress note dated 8/27/18, at 8:30 P.M. showed [MEDICATION NAME] not available. Record review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED].M. on 8/28/18. Record review of the resident's nurses' progress notes, dated 8/28/18, showed staff did not document why the medication was not administered. Record review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the resident's nurse's progress note dated 8/29/18, at 7:50 P.M., showed waiting on pharmacy to deliver [MEDICATION NAME]. Record review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the resident's nurses' notes', dated 8/29/18, showed staff did not document why the [MEDICATION NAME] was not administered. Record review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED].M. Record review of the resident's nurse's progress note dated 8/29/18, at 7:49 P.M., showed waiting on pharmacy to deliver [MEDICATION NAME]. Record review of the resident's nursing progress note dated 8/30/18, at 1:23 P.M., showed the resident was found on the floor in his/her room having a [MEDICAL CONDITION]. The nurse was called to the room for assessment. The resident continued to have a [MEDICAL CONDITION] for 11 minutes. A call was placed to the physician, and an order was received to administer [MEDICATION NAME], two mg intramuscularly (IM). Staff unable to follow order as [MEDICATION NAME] unavailable. The physician was called again and an order was received for [MEDICATION NAME] (antianxiety medication sometimes used to treat acute [MEDICAL CONDITION]), two mg IM. The resident stopped having a [MEDICAL CONDITION]. The resident was unable to move extremities on the right side and pupils were unequal in size. The resident began having a [MEDICAL CONDITION] again. An order was received to send the resident to the emergency room for evaluation. The paramedics were called and arrived per emergency response. The resident had a [MEDICAL CONDITION] for 18 minutes. Record review of the resident's (MONTH) (YEAR) and (MONTH) (YEAR) nurses' notes showed staff did not document contacting the physician regarding the missed doses of anti-[MEDICAL CONDITION] medications. Record review of the resident's hospital records dated 8/30/18, at 1:07 P.M., showed the following: -Resident presents via emergency medical system (EMS) for evaluation of [MEDICAL CONDITION]. The resident has a history of [MEDICAL CONDITION] and is on [MEDICATION NAME] and [MEDICATION NAME], however, it is noted that the resident ran out of [MEDICATION NAME] one week ago; unsure if the resident is still on [MEDICATION NAME]; -The nursing home went to check on the resident approximately one hour ago when the resident was found on the floor with [MEDICAL CONDITION] activity and called for an ambulance. In route by EMS, the resident had no [MEDICAL CONDITION] activity. No medications were administered prior to arrival by EMS or nursing home; -The resident has been non-verbal with some movement of his/her extremities and follows some commands. The resident is noted to normally be pleasantly confused with movement of all extremities. Today, the resident is not using his right upper extremity; -The nursing home had not been able to give the resident his/her medication for the last several days because the nursing home could not obtain it; -Laboratory value of [MEDICATION NAME] acid level showed level was abnormal at 3.3 (normal value 50-100 ug (milligrams)/milliliters; -No laboratory value shown for [MEDICATION NAME]. Record review of the resident's physician's note dated 09/01/18, at 12:05 A.M., showed the following: -The resident was found to be critically ill requiring bedside monitoring and organization of care. The resident had a sudden and life threatening neurological event that is accompanied with great risk for disability and death; -This is likely a stroke mimic-most likely [MEDICAL CONDITION] and now the resident is postictal (altered state of consciousness after an epileptic [MEDICAL CONDITION]); -Principal problem is acute [MEDICAL CONDITION] ([MEDICAL CONDITION] is a broad term used to describe abnormal brain function or brain structure. The abnormality may be transient, recurrent, or permanent. The loss of brain function may be reversible, static and stable, or progressive with increasing loss of brain activity over time). During an interview on 9/10/18, at 1:02 P.M., Registered Nurse (RN) A said the facility had been having trouble getting medications from the pharmacy. Residents had been going without medications. The facility staff order medications online to the pharmacy. The physician has to sign the orders. Most of the time the physician gets them signed, but occasionally one slips through. Some medications are pulled from the emergency supply kit (E-Kit). RN A reported to the supervisor if he/she couldn't obtain a medication. Nurses should chart if a medication is unavailable. During an interview on 9/10/18, at 1:15 P.M., RN B said if a certified medication technician (CMT) ran out of medications, they would let the nurse know. Sometimes the resident would run out of medications before the CMT let the nurse know. The pharmacy does not always fill the E-Kit. It sometimes takes a week or longer to get medications. Nurses should chart if the medication cannot be given. The facility had been out of [MEDICAL CONDITION] medications for the resident for a week recently. The resident had been out of the medication [MEDICATION NAME] when the CMT notified nursing. The resident's laboratory levels for the [MEDICAL CONDITION] medications, which had been drawn on a Thursday and reported on a Friday, had been low. RN B had told a nurse to tell the physician they needed the prescription. The medication came in the day the resident went to the hospital. The resident had a [MEDICAL CONDITION]. The resident had ran out of the medication before Labor Day, on a Wednesday or Thursday, and was still out of it on Labor Day (9/3/18). During an interview on 9/11/18, at 12:35 P.M., CMT C said the facility had been running out of medications a lot since he/she began since last January. Sometimes the facility waits on a physician's orders [REDACTED]. He/she thought the issue was mostly due to waiting on the physician's responses. Sometimes the E-Kit ran low on medications. The facility has ran out of medications for five to six days at times. The past holiday was particularly bad, along with the last three to four days. During an interview on 9/11/18, at 2:00 P.M., Licensed Practical Nurse (LPN) D said there had been a problem with the facility running out of all kinds of medications lately. The situation had gotten worse during the last few weeks. The problem had been due the pharmacy not sending them or the physician not signing the prescriptions. The E-kit had been running out of medications as well. LPN D saw the resident have a [MEDICAL CONDITION] a couple of weeks ago. LPN D heard a rumor the resident had ran out of [MEDICAL CONDITION] medications. The resident had ran out of [MEDICATION NAME] for four to five days. When LPN D assessed the resident after the [MEDICAL CONDITION], he/she assumed the resident could have had a stroke with the [MEDICAL CONDITION]. The resident could not squeeze with his/her right hand or move his/her right leg. The resident's right arm would flop down. This was a change for the resident. During an interview on 9/11/18, at 2:53 P.M., the physician said the issue of the facility not receiving medications timely had been due to the pharmacy being negligent. The pharmacy would say they filled the medications, but they hadn't. The issue had been occurring for two to three months. The E-Kits had been wiped out as well. He had to provide a lot of substitute medication prescriptions a lot due to the issue. The pharmacy had kept promising to get the medications to the facility. He didn't know why the facility hadn't used the local pharmacy before. If a resident had not received [MEDICAL CONDITION] medications as prescribed, the resident could experience a [MEDICAL CONDITION]. During an interview on 9/11/18, at 5:50 P.M., the DON said the facility tried to get the resident's [MEDICATION NAME] from the pharmacy. The pharmacy would say they were waiting on the physician's orders [REDACTED]. The physician signs the prescriptions electronically. The E-kit had been running out of medications constantly. During an interview on 9/11/18, at 5:50 P.M., the administrator said the resident had been out of [MEDICATION NAME] three days, and went to the hospital on the fourth day. The resident went to the hospital on [DATE]. The [MEDICAL CONDITION] cold have caused a stroke, or the stroke could have caused the [MEDICAL CONDITION]. There are only certain medications staff can get from the local pharmacy. The DON tried to get the [MEDICATION NAME] from the pharmacy, and the physician had been notified of the situation. The pharmacy has always said they would look into things. The E-kit had been running out of medications constantly. This had been an issue for several months, but had gotten more severe for the past four to six months. MO 000

Based on interview, and record review, facility staff failed to ensure adequate supervision to prevent one resident with confusion and poor safety awareness (Resident #1) from eloping from the facility when a staff member allowed another resident (Resident #2) to escort Resident #1 to the secured unit after a facility outing. Resident #2 left Resident #1 alone outside the doors to the secured unit and Resident #1 walked away from the facility and hitchhiked to a family member's house in a city approximately 23 miles from the facility. The resident was missing with his/her whereabouts unknown until the resident's guardian returned the resident to the facility two days later. The facility census was 116. 1. Record review of the facility's "Walk Away/Missing Resident" policy, revised on 6/11/09, showed the following: -Residents prone to wandering will be identified through the Minimum Data Set (MDS- a federally mandated assessment instrument) review and interventions will be planned to ensure their safety. -Residents at risk for elopement will be identified on the care plan. -Upon notification that a resident is missing, the charge nurse for the Skilled One nurses' station will be responsible for initiating procedures; -The charge nurse is to check the facility locations that the resident most often frequents; -If not located, the charge nurse must organize and conduct a room to room search of the entire facility; -If not located and if after normal business hours, contact the Director of Nursing (DON), the Residential Care Facility Director, and the administrator; -The charge nurse should organize and conduct a search of the facility grounds and areas within a two block radius of the facility; -If not located, the charge nurse should contact the next of kin and frequent visitors to ascertain possible areas the missing resident may have wandered to; -The charge nurse should notify the police and provide specific resident information and request assistance; -The charge nurse should recall off-duty personnel as needed; -Assist the police with an expanded search as needed; -Once the resident is located, contact anyone previously called and inform them the resident has been found; -The policy did not direct staff to escort secured unit residents back to the secured unit following an outing or activity. 2. Record review of Resident #1's history and physical from a recent hospital admission, dated 5/23/14, showed the following: -The resident is a [AGE] year-old that is psychotic, a poor historian and cannot explain what lead to the hospitalization ; -The police found the resident walking down the middle of the highway barefoot and the police had to use a Taser (an electroshock weapon) on him/her; -The resident laughed inappropriately and admitted to hearing voices but did not know what they were saying. The resident appeared to be hallucinating at times; -The resident was alert and awake and oriented to self. The resident did not know the month, date, year, the town he/she was in, or the name of the hospital; -The resident's attention span, concentration, and memory function were impaired; -The resident had poor insight and judgment; -The resident had a [DIAGNOSES REDACTED]. Record review of the Pre-Admission Screening/Resident Review (PASRR), used to determine if a resident has a severe mental illness and/or mental retardation, showed an independent agency completed the assessment on 6/11/14 and mailed it to the facility on [DATE]. The assessment showed the following: -[DIAGNOSES REDACTED]. -The resident was found walking barefoot and his/her hair was matted; -The resident's mother said the resident has never been able to care for him/herself; -The resident had a history of [REDACTED]. -The resident communicates with difficulty and speaks in little/short answers. -The resident had an unsteady gait. -The resident was oriented to person, confused at times of day and night, and forgetful at times. The resident had poor concentration, poor judgment, irrelevant, loose associations, short term memory and long term memory deficits, problems with abstraction, blocking, impoverished, disorganized thinking, and poor insight. -The resident did not make good decisions, could not follow simple directions, and could not stay on task or complete assignments. -The resident had below-average intellectual functioning, was easily distracted, guarded, suspicious and nervous or restless. -The resident was able to answer one of thirteen questions correctly in the cognitive capacity questions. -The resident had poor hygiene and appeared careless, disheveled, or sloppy. -The resident had mild depression, moderate anxiety, and was confused. The resident's affect was flat or blunted. The resident had auditory hallucinations, visual hallucinations, and mild paranoid delusions. -The resident's limitations included difficulty interacting appropriately and communicating effectively, history of altercations, fear of strangers, avoidance of interpersonal relationships, social isolation, difficulty concentrating, difficulty sustaining focused attention to complete tasks, inability to complete tasks within established time, made frequent errors or required assistance, difficulty in adapting to typical changes associated with work, family and social interactions, manifested agitations, exacerbated signs and symptoms associated with illness, withdrew from situations, and required interventions from mental health or judicial systems. -The resident required the maximum minute safety checks due to being a fall risk and wandering. Record review of the face sheet showed the facility admitted the resident on 6/14/14 with paranoid schizophrenia with acute exacerbation, generalized pain, and nondependent tobacco use disorder. Record review of the resident's undated initial care plan showed staff documented the resident had memory problems and was confused and anxious at times. The care plan did not address the resident's prior history of wandering and poor safety awareness. Record review of the initial activity assessment, dated 6/17/14, showed the resident's favorite color was purple and the resident spoke clear in English. Record review of the physician's progress note, dated 6/23/14, showed documentation that the resident was recently hospitalized for [REDACTED]. Record review of the activity progress note, dated 6/24/14, showed the resident enjoyed coloring and attended social activities in the Grand Hall (secured unit). Record review of the resident's comprehensive MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Did not display hallucinations, delusions, behaviors or wandering during the assessment period; -Very important to have family or close friends involved in discussions about his/her care; -Independent with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing, toileting and personal hygiene; -No range of motion limitations; -[DIAGNOSES REDACTED]. -Received antipsychotic and antidepressant medications on seven of the past seven days of the assessment period. Record review of the care plan, dated 7/3/14, showed staff documented the resident had a deficit in the self-performance of activities of daily living (ADLs) related to change. Additionally, the care plan had handwritten and undated information added that said the resident had frequent delusional beliefs and the resident was not to leave the facility at any time with anyone except facility staff per the resident's guardian. The care plan did not specifically address the resident's history of wandering and poor safety awareness. Record review of the nurses' notes showed the following: -On 7/12/14 at 9:30 A.M., the resident attended an activity outing with staff and other residents to the nature center. The group, including the resident, returned to the facility at 10:40 A.M. A resident that resides on the non-secured skilled area of the facility walked the resident back to the secured unit. The staff on the secured unit reported they did not see the resident return to the secured unit following the activity outing. At 11:00 A.M., the certified nurse aides (CNAs) said the resident had not returned from the outing yet. The charge nurse notified the administrator. The charge nurse had staff search the facility for the resident, and the activity staff searched the facility grounds from 11:00 A.M. through 12:00 P.M. The staff did not find the resident in the facility or around the facility grounds. At 12:10 P.M., the charge nurse notified the resident's guardian that staff were unable to locate the resident, and the guardian requested the facility notify the police with a missing person's report. At 12:25 P.M., the charge nurse notified the police department. The police department said they would send a police officer to the facility for a report. At 1:10 P.M., the charge nurse notified the resident's physician of the elopement. At 3:30 P.M., the police officer arrived at the facility and took report on the resident's elopement; -On 7/13/14 at 4:00 P.M., the resident's guardian called the facility for an update on the missing resident. The charge nurse documented there were no updates available. The charge nurse told the guardian he/she would call local and surrounding hospitals to see if the resident had been admitted . At 5:10 P.M., the charge nurse documented he/she called local hospitals, other hospitals outside the area, and the police department with no new findings. The charge nurse notified the administrator and the resident's guardian; -On 7/14/14 at 4:50 P.M., the guardian returned the resident to the facility. The staff placed a WanderGuard bracelet on the resident for safety. Record review of the care plan showed a handwritten entry, added on 7/14/14, for the placement of the WanderGuard bracelet (protection system is a device used to protect people when they are at risk for wandering) on the resident for safety. Record review of the facility form titled, "Elopement Risk Assessment", signed and dated by Registered Nurse (RN) A on 7/14/14, showed the following information: -The resident had cognitive impairment with poor decision making skills; -The resident had a [DIAGNOSES REDACTED]. -The resident ambulated independently; -The resident did not have any visual or auditory deficits; -The resident did not express a desire to go home; -The resident did not have a history of elopement at home; -The resident did not have a history of leaving the facility without needed supervision or informing staff; -The resident did not wander aimlessly; -The resident was a new admission, received medication that would increase restlessness or agitation, had new behavior or medication changes, pain, personal tragedy or upsetting information, and wandering to find spouse or family; -RN A did not plan or initiate any interventions to prevent elopement and did not document whether any interventions would be included on the care plan; -In the summary area of the form, RN A documented the resident seemed to be settling onto the secured unit, but the resident wanted to move out of the secured area and onto the regular floor. The resident did not display any exit-seeking behaviors. During an interview on 7/16/14 at 12:45 P.M., RN A said he/she did not know a lot about the resident except that he/she eloped last weekend. The RN said the elopement assessment is completed upon admission based on the information that is available to the nurse at that time. RN A said he/she did not fill out Resident #1's Elopement Assessment that was completed on 7/14/14, but only reviewed, signed, and dated the assessment. The assessment was filled out by the charge nurse who worked the day of the resident's admission to the facility on [DATE]. RN A said he/she reviewed and signed the form on 7/14/14. After reviewing the assessment, RN A said the assessment was not appropriate and he/she should have reviewed it better before signing and dating the form. RN A said he/she would have checked "yes" on the resident's verbal expressions (of wanting to go home) and his/her history of elopement at home. RN A said he/she would have then written a detailed message in the lines below. RN A said he/she would reassess the resident that day (7/16/14). During an interview on 7/15/14 at 10:35 A.M., CNA B said he/she primarily worked on the secured unit as a shower aide. On 7/12/14, he/she worked on the floor with the residents. The residents left for the outing at 10:00 A.M. Resident #1 was the only resident from the secured unit to go on the facility outing. The CNA said he/she was unsure at the time about the resident going on the outing because the resident had been verbally exit-seeking and had wanted to see his/her mom prior to the outing. The CNA said before a resident from the unit is allowed to participate in an out-of-facility activity, the charge nurse must first approve the resident's attendance of the activity. If the nurse is not available to approve the resident to go on the activity, the resident does not get to go. CNA B said charge nurse D said Resident #1 could go on the outing. At 11:00 A.M., the staff looked for Resident #1 to serve his/her lunch tray. The aides asked Activity Assistant (AA) H if the group had returned from the outing. AA H said they returned to the facility at 10:40 A.M. and he/she directed Resident #2 to assist Resident #1 back to the unit. The aides then started looking for Resident #1 in the facility. During an interview on 7/15/14 at 11:15 A.M., Resident #2 said he/she had been at the facility for one year. On Saturday 7/12/14, he/she went on the facility outing. After returning to the facility, AA H asked him/her to take Resident #1 back to the secured unit. He/she took Resident #1 back to the secured unit doors by the nurse's desk. He/she did not remember if a staff member was at the desk. Resident #2 said he/she did not know the code to the secured unit doors to let Resident #1 back into the unit so he/she knocked on the secured unit doors. Resident #2 said Resident #1 said he/she would just stand there until the staff opened the doors and let him/her in the unit. Resident #2 said he/she left Resident #1 at the secured unit doors and went to the computers by the other nurse's station. Resident #2 said he/she assists residents back to the secured unit following activities on a regular basis, but he/she wished the staff would take some of the residents back themselves. During an interview on 7/15/14 at 11:25 A.M., CNA C said Resident #1 wanders restlessly throughout the secured unit and looks out the windows of the unit doors. CNA C said he/she has seen residents from the outside of the secured unit assist residents back to the secured unit following activities. During an interview on 7/15/14 at 11:48 A.M., the Activity Director (AD) said AA H had been with the activity department for one year. AA H notified the AD on 7/12/14 of the resident's elopement. After the residents returned to the facility from the outing, AA H directed Resident #2 to assist Resident #1 back to the secured unit because AA H had to use the restroom. The AD said it was not facility practice for residents to assist residents back to the secured unit after outings/activities, and AA H was trained not to do this. Prior to this incident, Resident #1 only participated in activities on the secured unit. No one told the activities department that Resident #1 was an elopement risk. During an interview on 7/15/14 at 1:30 P.M., the office assistant for the resident's guardian said prior to the resident's admission to the facility in June 2014, the Highway Patrol found the resident walking barefoot down the middle of the highway. The resident told the Highway Patrol that he/she lived in a bank. The guardian placed the resident at the facility on the secured unit to keep him/her safe. During interviews on 7/15/14 at 10:12 A.M. and 2:09 P.M., Resident #1 said he/she was not sure how to get back onto the secured unit after he/she returned to the facility from the outing. The resident said he/she sat in a chair inside the main doors of the facility after the outing. The resident said AA H walked another resident down the hall and did not tell Resident #1 to go back to the secured unit. The resident said no one assisted him/her back to the secured unit so he/she got up and walked out the main door of the facility. The resident said he/she walked for approximately 45 minutes to a grocery store at a busy intersection and then got in a truck with an unknown young man and his daughter. The resident said he/she gave the driver directions to his/her parent's house in a nearby city. Resident #1 said he/she did not know the address, but was able to give directions to the man. The resident said he/she arrived at his/her parent's house at approximately 3:00 P.M. The resident said he/she was scared after thinking about what could have happened to him/her while hitchhiking with the unknown male. During an interview on 7/15/14 at 3:40 P.M., LPN D said he/she is usually the charge nurse at the nurses' desk by the secured unit, but he/she only works weekends and the occasional night shift. LPN D said Resident #1 went on the outing on 7/12/14 with three to four other residents who did not reside on the secured unit. LPN D told the CNA who took Resident #1 to the van to inform AA H that staff should escort the resident at all times. At 11:00 A.M., LPN D questioned the aides on the secured unit whether or not the resident had returned. The aides denied seeing the resident, so LPN D found AA H. LPN D learned from AA H that they returned from the outing around 10:40 A.M. LPN D then initiated elopement procedures because they did not know where the resident was. Resident #2 told LPN D that he/she initially took Resident #1 to the double doors on the 400 hall, but Resident #1 requested to go around to the doors by the other nurse's desk. LPN D said Resident #1 would constantly question when he/she could go home, but had not eloped or actively sought an exit. LPN D said residents who reside off of the secured unit should not assist residents who live on the secured unit back to the unit following an activity. LPN D has observed AA H allow residents who reside off of the secured unit to assist residents back to the secured unit prior to this occasion. LPN D said AA H knew this was Resident #1's first outing with the facility. During an interview on 7/15/14 at 4:20 P.M., CNA E said he/she has seen residents who reside off of the secured unit escort residents back to the secured unit following activities. During an interview on 7/15/14 at 4:25 P.M., CNA F said Resident #1 had verbally expressed the desire to leave and go home. The DON and administrator told him/her not to allow the resident to go out of the secured unit for activities prior to the elopement. CNA F said the weekend shift allowed the resident out of the secured unit and out of the building for an outing. The CNA said Resident #1 is smart and alert but has poor safety awareness and periods of confusion. CNA F said the staff should have escorted the resident to and from the activity and not allowed another resident to assist. During an interview on 7/16/14 at 11:50 A.M., the Director of Nursing (DON) said the floor nurse supervisor (RN A) completed all elopement assessments on new admissions unless it was after hours. In that case, the floor nurse supervisor would review the assessment and sign off on it. During an interview on 7/16/14 at 12:32 P.M., LPN G said Resident #1 had not been in the facility long and had always been on the secured unit due to poor safety awareness. The resident had not gone to doors and tried to get out, but had expressed the desire to be out of the secured unit. The resident had asked when he/she could move to a room outside of the secured unit. The resident was not supposed to be out of the secured unit for activities, but if the resident was allowed out for a special reason, the staff should remain with the resident during the entire period of time. LPN G said he/she has seen other residents escort secured unit residents back to the secured unit following activities on occasion, but this should not occur. After reviewing the resident's Elopement Assessment, dated 7/14/14, the LPN said the assessment was not accurate for the resident. Record review of the resident's Elopement Risk Assessment, signed and dated by RN A on 7/16/14, showed the following information: -The resident is cognitively impaired with poor decision making skills; -The resident has a [DIAGNOSES REDACTED]. -The resident ambulates independently; -The resident verbally expresses a desire to go home; -The resident has a history of elopement at home. RN A further documented the resident was found walking down the middle of the highway barefoot; -The resident has history of leaving the facility without supervision and the resident left the faciity on e time without informing staff for four days; -The resident was a new admission within the last 30 days and was not accepting of the new situation. The resident wanted to go home and see his/her parent; -The resident experienced generalized pain; -The resident sustained [REDACTED]. RN A documented the resident was unhappy with living at the facility; -The resident exhibited wandering/seeking to find spouse or family. RN A further documented the resident left the building to find his/her parent; -The interventions for the resident included the resident had been placed in the secured unit since admission and the new placement of a WanderGuard bracelet on the resident on 7/14/14; -In the summary area RN A documented the resident came back to the facility on his/her own with the guardian. The resident lives in the secured unit and has a WanderGuard on his/her ankle. The staff members are aware of his/her elopement risk and frequently check on the resident. During an interview on 7/16/14 at 2:08 P.M., the DON said they placed the resident on the secured unit upon admission because a bed outside of the secured unit was not available. This also gave the staff time to assess the resident. At the time of the care plan meeting, the guardian felt the resident should remain on the secured unit. The DON said the charge nurse might not have had the history and physical or notes from the hospital when he/she completed the initial Elopement Assessment for Resident #1. If the documentation from the hospital indicated an elopement risk, the staff should have reassessed the resident at that time. During an interview on 7/17/14 at 12:50 P.M., AA H said he/she normally does the activities for the Residential Care Facility, but on Saturdays he/she takes the skilled residents on outings. He/she took the residents on an outing for about an hour on 7/12/14. An aide brought Resident #1 to the van as the residents were loading. This was the first time he/she had ever seen or been around Resident #1. Resident #1 was not signed up to go on the list originally. He/she assumed the resident was from the secured unit, but the resident did not have a WanderGuard on. Staff did not tell AA H that the resident was an elopement risk or to stay with the resident at all times. Upon returning to the facility, he/she had to use the restroom and asked Resident #2 to escort Resident #1 back to the secured unit. AA H said Resident #2 had always been a helper and that day he/she needed to use the restroom and used poor judgment. AA H said residents who reside off of the secured unit usually walk with AA H to take residents back to the secured unit. He/she had never allowed residents to escort residents back to the secured unit before the date of the incident. During an interview on 7/15/14 at 3:01 P.M., the DON said the facility admitted Resident #1 to the secured unit for his/her security. The DON said she attempted to place a WanderGuard on the resident on admission but the resident resisted, so she did not apply the WanderGuard. The resident would often say "when can I go home" or would express the desire to go home but did not actively seek an exit. The resident's guardian attended the care plan meeting on 7/2/14 when the team and the guardian decided to keep the resident on the secured unit. The staff assesses all new residents for elopement risk. Then they reassess the residents at least quarterly or if there is a change in behavior or mood. The DON said the staff should have assisted the resident back to the secured unit following the outing. Staff should not ask a resident to assist any resident back to the secured unit. During an interview on 7/15/14 at 9:45 A.M., the administrator said on 7/12/14, Resident #1 went on a facility outing with AA H. Upon return to the facility, AA H allowed a resident to escort Resident #1 back to the secured unit. Resident #1 has some cognitive issues but had obeyed rules up to this point. It was not uncommon for the resident to say he/she wanted to go to his/her parent's house. The administrator said he did not expect staff to allow residents to assist residents to the secured unit. The resident's guardian brought the resident back to the facility on the evening of 7/14/14. MO 632 Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed and implemented a new process to more timely assess and monitor residents for possible elopement risk and prevention. The facility returned Resident #1 to the secured unit and trained all staff on proper supervision of the resident. The facility will continue to reassess all residents in the facility for elopement risk and train staff on elopement risk. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.