Every finding on record at St Andrew's at Francis Place

Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) D, an agency CNA, respected Resident #24's right to remain in bed. On 10/2/25, the CNA transferred the resident out of bed for a shower after the resident told the CNA he/she did not want to get out of bed. The resident said he/she was upset about being made to get up, the transfer was rough and felt like a tussle. During the transfer, the resident sustained a large skin tear, approximately ten centimeters (cm) long, to the left lower leg. The resident was sent to the hospital where five sutures were required to close the skin tear. The facility investigated the incident and in-serviced some nursing staff on transfer training. The facility investigation failed to identify the resident's right to self-determination had been violated, and no interventions regarding resident's rights were implemented. The census was 90. Review of the facility Resident Rights Policy, dated 9/19/24, showed:-Policy Statement: The facility will protect and promote the rights of each resident to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The requirements concerning resident rights are guaranteed to them under Federal and State law;-Procedure:-Information regarding resident rights and facility rules will be posted in a conspicuous location in the facility and copies will be provided to anyone requesting this information;-Staff Competencies in Resident Rights information will include the following: Understanding of abuse, neglect, misappropriation of resident property, and exploitation. Demonstrate respect for residents through actions and interactions. Plan and provide individualized care and services as the resident prefers. Ability to provide residents with quality care and services with respect. Follows resident preferences in care decisions and choices;-Right to a Dignified Existence: Be treated with consideration, respect, and dignity, recognizing each resident's individuality;-Right to Self Determination: Choices of activities, schedules, health care, and providers, including attending physician. Reasonable accommodation of needs and preferences. Request, refuse, and/or discontinue treatment.Review of the facility Resident Handbook, revised 6/22, showed:-Our goal is not to maintain but enrich lives. We respect personal dignity and promote independence;-Our Mission: Empower elders and their caregivers through choices and options that foster a vital life;-We believe that you have the right to make decisions about your medical care, including the right to refuse care;-Resident Responsibilities (includes): Assist in planning your own care;-Nursing Home Residents' Rights (include): -Right to a Dignified Existence: Be treated with consideration, respect, and dignity, recognizing each resident's individuality. Quality of life is maintained or improved;-Right to Self-Determination (includes): Choice of activities, schedules, health care, and providers, including attending physician. Reasonable accommodation of needs and preferences. Request, refuse, and/or discontinue treatment.Review of Resident #24's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 8/11/25, and located in the electronic medical record (EMR), showed:-Hearing: Minimal difficulty;-Speech Clarity: Clear speech - distinct intelligible words;-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Chair/bed-to-chair/transfer: Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort;-Diagnoses of high blood pressure, arthritis, weakness and chronic pain.Review of the resident's care plan, dated 10/2/25, and located in the EMR, showed:-8/11/25, Focus: ADL (activities of daily living) self-care performance deficit. Goal: Resident will maintain current level in ADLs. Interventions: Transfers - partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort;-8/11/25, Focus: Communication problem. Goal: Will be able to make basic needs known on a daily basis. Intervention: Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Ask yes/no questions if appropriate.Review of the resident's physician's order sheet (POS), located in the EMR, showed:-9/8/25: Shower/Bath every Monday and Thursday.Review of the resident's progress note, located in the EMR, showed:-10/2/25 (Thursday) at 9:52 A.M., Licensed Practical Nurse (LPN) B documented: This nurse made aware that the resident had a skin tear to the left leg. Upon assessment, resident was observed with a deep laceration to the lower part of left leg. Pressure was applied. Physician was called and wants resident to go get stitches. Director of Nursing (DON) and Administrator notified.Review of the Executive Director's/Administrator's initial report to the Department of Health and Senior Services (DHSS) on 10/2/25 at 7:35 P.M., showed:-Resident #24 was transferred today from his/her bed to his/her wheelchair. During the transfer, resident hit his/her leg on his/her wheelchair resulting in a skin tear. Resident was sent to the hospital for stitches. Upon return, resident was interviewed. He/She said the CNA who transferred him/her was kind of rough. He/She said the CNA was coming to get him/her up for the day and they were talking about a shower. When asked what he/she meant by rough, he/she said it felt like they were wrestling. Resident did not feel like the CNA was intentionally trying to harm him/her;-The CNA was interviewed. He/She said he/she hugged the resident to transfer him/her and then he/she took a couple of steps to the wheelchair. He/She noticed the resident's leg almost immediately and went to get the nurse for assessment. The CNA said he/she was trying to encourage the resident to get up for the day because in report he/she was told the resident does not get up until later and he/she needs a lot of encouragement, or the resident will stay in bed all day;-The resident is moderate assistance for transfers and can bear weight but needs support to take steps. At this time, the facility does not suspect abuse or neglect. Transfer in-servicing will be completed with staff.Review of the resident's progress note, dated 10/2/25 at 10:30 P.M., showed the resident returned from the hospital with a new order for Keflex (an antibiotic) 500 milligrams three times a day for seven days. Resident has five nylon sutures in his/her left lower extremity.Review of the facility Final Investigation Incident 10/2/25, completed by the DON, showed the following statements:-CNA D: I was getting resident up and told him/her today was his/her shower day. Resident said he/she did not want to have a shower. Nurse told me to get resident up and resident will change his/her mind once out of bed. I got resident on the side of the bed and put the resident's wheelchair at an angle so that when we stood resident could go to the side and sit in the wheelchair. I put my arms around resident's chest, like a bear hug, and together we turned towards the wheelchair, resident was standing up. When almost in the wheelchair, resident kicked with his/her left leg at the same time I was helping him/her sit. He/She hit the left footrest on the wheelchair when he/she kicked and got the skin tear; -Certified Medication Technician (CMT) A: This morning I heard from resident's room an aide (CNA D) getting loud with one of the residents. I informed LPN B he/she might want to check on the situation;-LPN B: At approximately 9:00 A.M. on 10/2/25, CMT (CMT A) made this nurse aware the aide assigned to resident's room seemed to be getting verbally agitated with the resident. This nurse went in room to assess the situation and the aide was observed standing between resident (who was sitting in his/her wheelchair with his/her back toward the door) and the bed. The aide said I am glad you are here because the resident got a skin tear on his/her left shin. This nurse asked what happened and the aide said His/her leg got caught in the wheelchair during the transfer. This nurse pulled the wheelchair back to be able to look and assess the resident's leg, and two lacerations were observed on the left lower front part of the leg;-LPN C: At approximately 9:00 A.M. on 10/2/25, I was walking towards the nurse station when LPN B said to go to the resident's room to help with a skin tear. This nurse walked into the room with the resident's back towards the door and the aide standing in front of him/her. The aide started to get nervous, so this nurse instructed the aide to walk away so the resident does not get scared. LPN B said he/she was going to call the physician. This nurse proceeded to wrap the resident's leg before the paramedics arrived;-DON: Upon returning to the facility, the resident was interviewed by the DON. The resident said his/her aide was trying to get him/her in the wheelchair. They were talking about a shower. The resident said the aide was pulling him/her around to get in the wheelchair and the next thing he/she knew was his/her leg was bleeding. The transfer was rough. When asked what he/she meant by rough, he/she said it felt like they were wrestling. The resident said he/she did not feel like the aide was trying to harm him/her;-DON: The skin tear was approximately 10 cm. In the hospital, the resident received five internal sutures and ten steri-strips (adhesive strips used to hold the skin together). Resident is normally moderate assistance for transfers and can bear weight but needs support to take steps. Due to his/her stitches, he/she has an order for non-weight bearing for two weeks. The resident will utilize a Hoyer lift (a machine used to transfer a resident unable to bear weight) for transfers during this time;-DON: Additional transfer training will be completed by therapy with nursing staff. At this time the community does not suspect abuse. Resident's care plan will be updated to reflect bed baths only. Resident is afraid of the shower room. During an interview on 11/17/25 at 9:21 A.M., the resident said the day his/her leg was injured, CNA D was going to get him/her out of bed to take a shower. He/She did not want to get up and take a shower and told the CNA that, but the CNA got him/her up anyway. He/She tussled with the CNA during the transfer. The resident said tussled meant the CNA was not being very gentle and it felt like a tussle at the time. Since that day, the CNA had not taken care of him/her again. He/She is not afraid of the CNA, but he/she does not want that CNA to take care of him/her anymore.During an interview on 11/18/25 at 10:06 A.M., the resident said when CNA D ignored him/her not wanting to get up it made him/her not feel very good. He/She was mad, and he/she resisted some when the CNA got him/her up. He/She is supposed to have rights, and expects staff do what he/she asks. His/Her leg hurt that day, and it still hurts some times. During a telephone interview on 11/25/25 at 9:18 A.M., CNA D said he/she is employed by a staffing agency and had worked at the facility several times. On 10/2/25, he/she was told by the nurse that the resident needed to get up and take a shower. The resident had family coming for a visit that day. After breakfast, he/she went to get the resident up and the resident said he/she refused to get up. He/She told the nurse the resident said he/she said would not get up. The nurse said the resident always refused but would be fine once he/she was up. He/She went back and sat the resident on the side of the bed. The resident was kicking at him/her and slapping at his/her hands. He/She placed a gait belt (a belt applied around the resident's waist to provide stability during a transfer), lifted the resident up and completed a pivot transfer from the bed to the wheelchair. The resident kicked at him/her during the transfer. Once the resident was in the wheelchair, he/she bent over to pick up the resident's leg and felt something warm on his/her hand. That is when he/she noticed the blood and got the nurse. CNA D felt awful about what happened and cried all day. It still bothers him/her. The nurses told him/her accidents happen, but that did not make him/her feel any better. He/She should have listened to the resident and ignored the nurse. After the incident he/she did not receive transfer training or an inservice on resident's rights. He/She had not worked at the facility since this incident occurred. During an interview on 11/19/25 at 7:28 A.M., CMT A reviewed his/her statement from the facility investigation and confirmed it was accurate. He/She is employed by the facility and administers resident medications. The resident can, for the most part, make his/her needs known. On 10/2/25, CNA D was in the resident's room, and he/she heard the CNA's tone being raised, like he/she was aggravated. He/She could not recall any words spoken, and did not hear threats or cursing. He/She did not hear the resident, only the CNA. He/She did not see anything that took place between the resident and CNA. No one else was around at the time. He/She told LPN B he/she may want to go to the resident's room and see what was going on. The LPN went straight to the resident's room. CMT A had not attended the transfer training inservice or any inservices regarding resident's rights since 10/2/25.During an interview on 11/19/25 at 7:38A.M., LPN B reviewed his/her statement from the facility investigation and confirmed it was accurate.LPN B said the resident can make his/her needs known and is capable of making decisions about whether he/she wants to get out of bed and take a shower. On 10/2/25, he/she was walking down the hall when CMT A told him/her he/she needed to go to the resident's room. LPN B had not heard anything unusual himself/herself, but he/she went to the resident's room to check. When he/she entered the resident's room, the resident was in the wheelchair with CNA D bent down like he/she was putting something on the resident's feet. The CNA said he/she was glad he/she came into the room because the resident had a skin tear. The resident seemed normal, no yelling or screaming. It did not seem as there had been any disagreement between the resident and CNA. The resident never said anything at that time about being made to get up out of bed. LPN B was not sure if the resident was even aware of the skin tear. The CNA said the resident's leg got caught in the wheelchair during the transfer. The CNA was upset and crying afterword, because the resident was injured. LPN B called the physician and sent the resident to the hospital. The next day, the resident said he/she did not want to get up on 10/2/25, but the resident never wants to get up. Normally when the resident does not want to get up, you have to try to persuade him/her, but if he/she does not want to get up, then he/she has the right to remain in bed. The resident has a right to refuse. He/She did not tell CNA to get the resident up if the resident refused. LPN B did attend the in-service for transfer training on 10/3/25, but had not attended an in-service on resident rights. During an interview on 11/19/25 at 9:15 A.M., LPN C reviewed his/her statement from the facility investigation and confirmed it was accurate. The resident is able to make his/her needs known. On 10/2/25, LPN B told him/her the resident had a skin tear and asked him/her to go to the resident's room while he/she called the physician. When LPN C entered the room, CNA D seemed scared/nervous, so he/she told the CNA to leave the room because he/she did not want the CNA to scare the resident. The resident did not seem to be in pain and appeared to be confused as to why everyone was coming into the room. The resident did tell him/her he/she did not want to get out of bed, but he/she did not recall if the resident said the CNA made him/her get out of bed against his/her wishes. The resident did not seem upset with the CNA at the time. The resident never wants to get out of bed, so they to try to motivate him/her into getting up. They encourage him/her to get up, but at the end of the day, it is the resident's right to remain in bed. LPN C did not attend the transfer in-service on 10/3/25 and had not attended an in-service on resident's rights since the incident occurred. Review of the resident's POS, showed:-10/2/25: Suture/staple removal on left lower extremity in 14 days. Review of the facility Transfer Training, conducted by the Physical Therapist on 10/3/25, showed twenty nursing staff (a combination of facility staff and agency staff) received transfer training. Review of the resident's POS, showed:-10/6/25: Monitor steri-strips to make sure they remain clean, dry and intact;-10/6/25: Wound Care Company to evaluate and treat for left lower front leg.Review of the wound care company progress note dated 10/7/25, located in the EMR, showed:-Location: Left Distal (situated away from the center of the body or point of attachment), Lower Leg;-Measurements: Length (L): 0.00 cm by Width (W): 12.50 cm by Depth (D): 0.00 cm by Area (A): 0.00 cm;-Etiology: Laceration;-Stage/Severity: Full Thickness;-Wound Status: New;-Wound Edges: Sutured;-Periwound (skin around the wound): No erythema (redness), no fever, no signs of infection;-Exudate (drainage) Amount: None;-Treatment: Leave open to air;-Location: Left Lower, Proximal (situated nearer to the center of the body or point of attachment) Leg;-Measurements: 4.0 cm by 3.50 cm by 0.00 cm by 14.00 cm;-Etiology: Laceration;-Stage/Severity: Full Thickness;-Wound Status: New;-Wound Edges: Surgically glued or bonded. Edges well approximated;-Periwound: Ecchymosis (a discoloration of the skin typically caused by bruising);-Exudate Amount: None;-Treatment: Leave open to air.Review of the resident's POS, showed:-11/7/25: Left distal wound - cleanse with wound cleanser and apply xeroform (occlusive gauze designed to maintain a moist environment for healing wounds) to wound bed and cover every Tuesday and Friday;-11/7/25: Left Proximal Leg: Betadine (an antiseptic solution), daily and leave open to air.Review of the resident's Brief Interview for Mental Status (BIMS, a cognitive assessment) dated 11/7/25 and completed by the Social Service director (SSD), showed a score of 11, indicating moderate cognitive impairment. Review of the wound care company progress note dated 11/11/25, showed:-Location: Left Distal, Lower Leg;-Measurements: 5.80 cm by 2.60 cm by 0.20 cm by 5.08 cm;-Etiology: Laceration;-Stage/Severity: Full Thickness;-Wound Status: Improving;-Wound Edges: Unattached;-Periwound: No erythema, no fever, no signs of infection;-Exudate Amount: Moderate;-Exudate Description: Serosanguineous (thin watery fluid with a pink hue);-Dressing Change Frequency: Tuesday and Friday;-Treatment: Xeroform;-Location: Left Lower, Proximal Leg;-Measurements: 3.90 cm by 3.30 cm by 0.00 cm by 12.87 cm; -Etiology: Laceration;-Stage/Severity: Full Thickness;-Wound Status: Improving;-Wound Edges: Surgically glued or bonded. Edges well approximated;-Periwound: Ecchymosis;-Exudate Amount: None;-Treatment: Betadine daily. Leave open to air.Review of the resident's care plan showed on 11/13/25, the facility added the following intervention/task: Transfer with a Hoyer lift and assistance of two staff until left lower leg laceration is resolved.During an interview on 11/18/25 at 8:13 A.M., CNA E (agency staff) said he/she started coming to the facility about a month ago. He/She had taken care of the resident before. He/She had not been in-serviced on transfer training or resident rights since starting at the facility. If a resident does not want to get up, they should not be forced to get up. They have a right to refuse. If a nurse told him/her to get a resident up that did not want to get up, he/she would not get the resident up and would tell the DON. During an interview on 11/18/25 at 8:35 A.M., CMT F (agency staff) said he/she had been coming to the facility prior to 10/2/25. He/She did not recall taking care of the resident in the past. If a resident does not want to get up, the resident has a right to refuse and stay in bed. He/She would tell the nurse a resident does not want to get up and if the nurse said the resident had to get up, he/she would get the resident up. That has not happened since she has been here. He/She did not attend the transfer training and has not been in-serviced on resident rights since 10/2/25.During an interview on 11/18/25 at 8:58 A.M., CMT G (agency staff) said he/she had been coming to the facility on a steady pace since 7/2/25. He/She has taken care of the resident before. The resident can make his/her needs known. If the resident did not want to get up, he/she would let the nurse know. If the nurse said to get the resident up when the resident did not want to get up, CMT G would refuse to get the resident up and let the Assistant Director of Nurses (ADON) or DON know. He/She did attend the transfer training in-service on 10/3/25 but had not been in-serviced on resident rights since 10/2/25. During an interview on 11/18/25 at 9:33 A.M., LPN H said he/she is facility employed and had worked at the facility for three years. If a resident tells a CNA they don't want to get out of bed or get up to take a shower, he/she would expect the CNA to report that to him/her. He/She would tell the CNA to give the resident more time and reapproach the resident later or ask someone else to ask the resident. If the resident still does not want to get up, the resident would not have to get up. LPN H would not tell a CNA to get a resident up against the resident's will. Residents have rights that should be respected. He/She attended the transfer training in-service on 10/3/25. He/She reviewed the transfer training in-service signature page and said eleven of the twenty staff attending were agency staff. LPN H had not attended an in-service on resident's rights since 10/2/25. During an interview on 11/19/25 at 8:20 A.M., the Director of Rehabilitation said prior to 10/2/25, the resident's transfer status was moderate assistance (50% of the transfer done by staff) of one staff. The resident is able to make his/her own choices. If the resident does not want to get up out of bed, he/she should not have to get up. During an interview on 11/19/25 at 8:56 A.M., the SSD said she completed the resident's BIMS on 11/7/25. For the most part, the resident is able to make his/her needs known. The resident would be able to say whether or not he/she wanted to get out of bed and/or take a shower. Although the resident loves being in bed, staff should not make the resident do something he/she does not wish to do.During an interview on 11/19/25 at 10:22 A.M. with the DON and Administrator, the DON said after she investigated the resident's skin tear, she was focused on the transfer itself rather than a resident's right issue. That is why she had the Physical Therapist give a transfer training in-service on 10/3/25. Not all nursing staff attended the in-service. The day of the incident as well as throughout the week, she told staff in her conversations if a resident does not want to get up, don't get them up. She did not tell all the staff, just the few she had conversations with. The resident can make his/her needs known and staff should respect the resident's wishes. The Administrator said on any given day, a good portion of their staff are agency staff. She expected all staff, facility and agency, to follow the resident rights policy. During a telephone interview on 11/19/25 at 12:14 P.M., the Medical Director said staff are not supposed to force residents to do something against their wishes. He would expect staff to follow their policy for resident's rights. He would have expected the facility to have in-serviced staff on resident's rights as well. Observation on 11/19/25 at 1:05 P.M., showed the resident lay in bed. LPN B unwrapped the resident's dressing on the left lower leg showing two separate skin tears. The left lower proximal leg was scabbed over, and the left lower distal leg remained open with a red floor (wound bed or the base of the wound). 26343682635144

Based on observation, interview and record review, the facility failed to ensure residents designated to receive walk to dine restorative services (staff assist residents to walk to and/or from the dining room daily at breakfast, lunch or dinner) received that restorative service. The facility identified 22 residents on the walk to dine program. Of those 22, five were interviewable and all five said staff did not walk them to and/or from the dining room for any of the three meals (Residents #18, #9, #21, #2 and #19). The census was 101.Review of the facility's Restorative Nursing Care policy dated 2021, showed:Policy: It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the resident's comprehensive assessment, to achieve and maintain the highest practicable outcome;Procedure:-Restorative Nursing programs include nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible;-A resident may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy. Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy;-Nursing personnel are trained in restorative nursing care, and our facility has an active program of restorative nursing care which is developed and coordinated through the resident's care plan;-The comprehensive assessment will identify the resident's baseline functional and cognitive status in order to determine appropriate interventions;-Based on the comprehensive assessment, the care plan will be individualized and the resident/representative will be included in the development of the restorative/rehabilitative care plan and provided the risks and benefits of the treatments;-The facility's restorative nursing care program is designed to assist each resident to achieve and maintain optimal physical, mental and psychosocial functioning;-Restorative nursing care is performed daily for those residents who require such services. Such a program includes, but is not limited to: Assisting residents with mobility. Assisting residents with all activities of daily living including walking and transferring. Assisting residents to carry out prescribed therapy exercises;-Through the resident care plan, the goals of restorative nursing care are reinforced in the restorative services;-Restorative nursing techniques are included in the orientation program and the ongoing staff development program. Review of the facility's Restorative Nursing Assistant (RNA) job description, dated 8/2022, showed:-Assists residents in restorative functions with the intent of facilitating optimal capability and quality of life;-Provide restorative nursing care as directed by the physical therapist;-Provide restorative nursing care as outlined by the physician's orders and the resident care plan;-Document progress notes outlining the resident's response or lack of response to treatment provided;-Review care plan before providing restorative functions to residents;-Document in the restorative notes each treatment provided as ordered;-Make recommendations for the discontinuation of restorative services as needed.Review of the facility Certified Nursing Assistant (CNA) job description dated 8/1/22, showed Duties and Responsibilities: Perform restorative nursing as outlined in each resident's plan of care. Includes ambulation, range of motion (repetitive exercise/movement of the major joints).1. Review of Resident #18's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/4/25, showed:-Adequate hearing;-Speech Clarity: Clear Speech, distinct intelligible words;-Makes Self Understood: Understood;-Ability To Understand Others: Understands, clear comprehension;-Cognitively intact;-Walk 10 feet: Supervision or touching assistance;-Walk 50 feet or 150 feet: Not attempted due to medical conditions or safety concerns;-Diagnoses: High blood pressure, diabetes mellitus (high/low blood sugar), arthritis, and depression;-Number of Falls Since admission or Prior Assessment: Two;-Number of days each of the following restorative program was performed (for at least 15 minutes a day) in the last 7 calendar days: Walking: 0. During an interview on 8/29/25 at 11:41 A.M., the resident sat in a wheelchair in the dining room. The resident said he/she wheeled himself/herself to/from the dining room. Staff had never offered to walk him/her to/from the dining room. If staff asked him/her to walk to/from the dining room, he/she would walk with them. He/She did not walk by himself/herself because he/she did not want to fall.During an interview on 8/29/25 at 2:00 P.M., the RNA said he/she walked the resident 235 feet after lunch. 2. Review of Resident #9's quarterly MDS dated [DATE], showed: -Adequate hearing;-Speech Clarity: Clear Speech, distinct intelligible words;-Makes Self Understood: Understood;-Ability To Understand Others: Understands, clear comprehension;-Cognitively intact;-Moderately impaired cognition;-Walk 10 feet, 50 feet and 150 feet: Not applicable;-Diagnoses: High blood pressure and depression;-No falls since admission or prior assessment;-Number of days each of the following restorative program was performed (for at least 15 minutes a day) in the last 7 calendar days: Walking: 0.During an interview on 8/29/25 at 10:24 A.M., the resident sat in his/her wheelchair in his/her room. He/She said physical therapy told him/her the CNAs were supposed to walk him/her, but when he/she asked the CNAs who said it was not their responsibility. He/She could not recall the last time a CNA walked him/her anywhere, let alone to/from the dining room. This had been going on for months now. He/She wanted to walk, but the CNAs wouldn't do it. During an interview on 8/29/25 at 2:00 P.M., the RNA said he/she walked the resident 175 feet after lunch. 3. Review of Resident #21's admission MDS dated [DATE], showed:-Adequate hearing;-Speech Clarity: Clear Speech, distinct intelligible words;-Makes Self Understood: Understood;-Ability To Understand Others: Understands, clear comprehension;-Cognitively intact;-Walk 10 feet and 50 feet: Partial/moderate assistance;-Walk 150 feet: Dependent;-Diagnoses: High blood pressure and asthma (a condition that makes the airways to narrow and swell making breathing difficult);-Any Falls Since admission or Prior Assessment: No;-Number of days each of the following restorative program was performed (for at least 15 minutes a day) in the last 7 calendar days: Walking: 0. During an interview on 8/29/25 at 10:47 A.M., the resident sat in his/her wheelchair in his/her room. The resident was informed he/she was on the facility walk to dine program. The resident laughed and said that was news to him/her. No one ever walked him/her to/from the dining room, and no one ever asked. He/She would love to have someone walk with him/her. He/She would love to get out of his/her wheelchair and walk. Observation on 8/29/25 at 10:52 A.M., showed the resident wheeled himself/herself into the dining room. 4. Review of Resident #2's quarterly MDS dated [DATE], showed:-Adequate hearing;-Speech Clarity: Clear Speech, distinct intelligible words;-Makes Self Understood: Understood;-Ability To Understand Others: Understands, clear comprehension;-Cognitively intact;-Walk 10 feet: Independent;-Walk 50 feet and 150 feet: Not attempted due to medical condition or safety concerns;-Diagnoses of high blood pressure, diabetes mellitus, seizure disorder, anxiety and depression;-No falls since admission or prior assessment;-Number of days each of the following restorative program was performed (for at least 15 minutes a day) in the last 7 calendar days: Walking: 0. During an interview on 8/29/25 at 11:30 A.M., the resident lay in bed. The resident was told heshe was on the walk to dine program and the resident said staff weren't going to do that. The resident said They're not going to walk me. All they do is wheel me to/from the dining room. He/She said if staff asked him/her to walk to/from the dining room, he/she would walk. He/She had seizures and was afraid to walk alone. 5. Review of Resident #19's quarterly MDS dated [DATE], showed:-Minimal difficulty hearing;-Speech Clarity: Clear speech, distinct intelligible words;-Makes Self Understood: Understood;-Ability To understand Others: Understands, clear comprehension;-Moderately impaired cognition;-Walking 10 feet, 50 feet and 150 feet: Supervision or touching assistance;-Diagnoses: High blood pressure, dementia and anxiety;-No falls since admission or prior assessment;-Number of days each of the following restorative program was performed (for at least 15 minutes a day) in the last 7 calendar days: Walking: 0. During an interview on 8/29/25 at 11:50 A.M., the resident sat in the dining room in a chair with his/her walker next to his/her chair. He/She said no one asked to walk with him/her at all. He/She had been walking by himself/herself with his/her walker. If staff wanted to walk with him/her that would be fine, but he/she was not going to wait around on them to ask. 6. During an interview on 8/29/25 at 9:21 A.M., the RNA said he/she could not walk all the residents on the walk to dine program. At best he/she might be able to walk them to/from the dining room for one meal once or twice a week. The residents should be asked if they wanted to walk to and/or from the dining room for every meal, or at least one meal a day. The CNAs were supposed to be helping, but they were not good about it. If the CNAs didn't help, there was no way he/she could do it alone because he/she also had to do the residents' range of motion exercises and apply splints and braces. During an interview on 8/29/25 at 2:35 P.M., the RNA said after lunch, she walked Resident #18, and he/she walked 235 feet. Resident #9 walked 175 feet. Resident #21 walked 80 feet. 7. During an interview on 8/29/25 at 10:10 A.M., Certified Medication Technician (CMT) G, an agency CMT, said he/she had worked at the facility several times. There was only one resident that he/she knew was on the walk to dine program. He/She did not know of any other residents on the walk to dine program and did not know where to find out which residents were on the walk to dine program. 8. During an interview on 8/29/25 at 10:20 A.M. CNA D, an agency CNA, said he/she had worked at the facility before. He/She thought one resident was on the walk to dine program and gave the resident's name. The resident was not one of the 22 listed by the facility. He/She did not know of any other residents on the walk to dine program and did not know if the facility had a list available where he/she could find out. He/She said Resident #2 was on his/her assignment today, but he/she was not aware the resident was on the walk to dine program. 9. During an interview on 8/29/25 at 10:41 A.M., CNA H, an agency CNA, said he/she had worked at the facility before. He/She had seen a walk to dine list in the past, but after looking at the nurse's station he/she could not find it. He/She did not walk any residents to/from the dining room because therapy did that. He/She had not been told by management to walk with any residents. 10. During an interview on 8/29/25 at 11:06 A.M. Licensed Practical Nurse (LPN) B said the CNAs were supposed to ask residents on the walk to dine program if they want to walk to/from the dining room for each meal. The facility just made out new Kardex's (a document that gives a brief overview of a resident's care needs) for each resident and if a resident was on the walk to dine program it should be on the resident's Kardex at the nurse's station. He/She looked at Resident #18's Kardex and it showed he/she was on the walk to dine program. He/She looked at Resident #19's Kardex and it did not show the resident was on the walk to dine program. The nurses were responsible to make sure the CNAs walked with residents on the walk to dine program. 11. During an interview on 8/29/25 at 12:00 P.M., the Therapy Director said Resident #21wais currently on hospice, but he/she was still supposed to receive walk to dine services. Residents #2, #18 and #19 were currently receiving skilled therapy but they should also receive walk to dine services. Resident #2 needed supervision while walking because his/her rollator (walker) got away from him/her and he/she had a history of seizures. Resident #9 needed contact guard assistance (physical support or steadying is required to walk) while walking because he/she could not feel the bottom of his/her feet due to neuropathy (damage or disease affecting the nerves that can cause pain or numbness). Resident #18 needed supervision to walk because his/her feet get away from him/her and he/she fell a couple of months ago. Resident #19 had a history of falls and needed supervision while walking. Resident #21 needed contact guard assistance to walk because his/her knee could buckle on him/her. The walk to dine program benefited residents by keeping them mobile, increasing functional mobility and decreased their fall risk. 12. During an interview on 8/29/25 at 2:17 P.M., LPN I said the facility put out new Kardex's for each resident a few days ago. They got a list of residents on walk to dine on 8/25/25. It was not the first time they had a list, but they were not consistent with updating them. Sometimes he/she knew who was on the walk to dine program, but if the list was not available or updated, he/she did not know. CNAs were responsible to walk with residents to/from the dining room. 13. During an Interview on 8/29/25 at 2:15 P.M., the Administrator said she expected staff to follow the facility's policies. CNAs should know who was on the walk to dine program and they should offer walk to dine services to the residents at every meal. The walk to dine program was important to maintain functional ability and could potentially assist in preventing falls.

42247 45083 Based on interview and record review, the facility failed to ensure a consistent and updated code status (a medical directive that specifies the type of resuscitation and medical interventions a resident wishes to receive in the event of a cardiac or respiratory arrest) in the residents' medical records for four out of 18 sampled residents (Residents #18, # 14, #17 and #62). The census was 73. Review of the facility's Therapeutic Support Level/Resuscitation Plan Policy, dated revised ,d+[DATE], showed: -In order to facilitate timely intervention in those situations which require immediate action, and to support the resident's wishes related to health care directives, the resident or their legally appointed representative or healthcare agent, upon admission to the facility, will be asked to complete a therapeutic support level/resuscitation plan. The therapeutic support level (TSL)/resuscitation plan will assist the facility staff in obtaining physician orders supporting the resident's wishes related to the level of intervention to be initiated in the event of a life threatening emergency; -In the event of a medical emergency, facility staff will provide care based on documented physician orders and supported by the resident's advanced directive and/or TSL/resuscitation plan. Care will be provided in accordance with the level of training of facility staff and following basic principles of first aid and under the direction of a licensed nurse; -In the event of a cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing, and consciousness), when vital signs (pulse and respiration) are not present, facility staff will provide care based on documented physician orders and supported by the resident's advanced directive and/or therapeutic support level/resuscitation plan. Cardiopulmonary resuscitation (CPR, a lifesaving technique useful in which someone's breathing or heartbeat has stopped) will be provided by licensed nursing staff. (Note: CPR will be provided only for residents with TSL 1 (Provide aggressive medical management, this includes all treatments to reduce advancement of disease and/or death. Including Resuscitation/CPR)); -The resident's advanced directive and/or resident's TSL/ resuscitation plan will be reviewed annually; -If a resident brings an Outside the hospital Do Not Resuscitate (DNR, instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating) form (OHDNR) to the facility, the resident's wishes will be honored and the information will be transferred, to the TSL/resuscitation plan which will be approved and signed by the resident and/or resident's designee and the physician. 1. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated [DATE], showed: -Severe cognitive impairment; -No hallucinations and delusions behaviors -Diagnoses included anemia, heart failure, high blood pressure, multidrug-resistant organism (MDRO), pneumonia, diabetes, high cholesterol, Alzheimer's disease, stroke, hemiplegia or hemiparesis (weakness or paralysis on one side of the body), anxiety and depression. Review of the resident's care plan, in use at the time of survey, showed: Need: The resident is at the end stage of life and is utilizing hospice care services; Goals: Resident will receive palliative care directed by hospice interdisciplinary team and provided by nursing facility and hospice staff through next review period; Interventions/Tasks: Facility staff and hospice staff will coordinate care, supplies, and equipment to meet the resident's needs. Review of the resident's electronic medical records (EMR) showed: -admitted on [DATE]; -A scanned DNR form, with hospital letterhead, signed by representative and physician on [DATE]; -A scanned TSL/Resuscitation Plan sheet, TSL 1 was checked (signed by representative and physician) on [DATE], and by the physician on [DATE]. Review of the resident's hospice binder showed an original purple OHDNR form signed by the resident and spouse on [DATE]. The physician signed on [DATE]. During an interview on [DATE] at 3:25 P.M., Licensed Practical Nurse (LPN) M said residents' code statuses were found in the EMR, and in the nurse's report sheet. LPN M showed the current nurses' report sheet which contained daily columns for a full week. The first column of the sheets contained the resident's information which included their name, their physician and their code status. Review of the Nurse's Report Sheet, showed the resident's code status as TSL 1 Full Code. 2. Review of Resident #14's MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: heart failure, high blood pressure, diabetes, dementia, anxiety, depression, and psychotic disease (a mental illness that causes a person to lose touch with reality). Review of the resident's care plan, in use at the time of survey, showed: -Need: Resident had an advance directive; -Goal: The resident's advance directive will be honored through next review date; -Interventions/Tasks: Code status will be reviewed quarterly and as needed; has a signed full code TSL form; has a TSL 1 form. Review of the resident's EMR, showed: -An order summary report, with an order dated [DATE], for TSL 1; -The Advanced Directive tab, showed the resident had a DNR, with an effective date of [DATE]. During an interview on [DATE] at 3:00 P.M., the Administrator said the resident wanted to remain a full code and a new TSL form was completed today. Residents' code status should be reviewed annually, after a year the code status expired. A new form should be completed each year. 3. Review of Resident #17's quarterly MDS, dated [DATE], showed: -admitted to the facility on [DATE]; -readmitted to the facility on [DATE]; -Severe cognitive impairment; -Diagnoses included: heart disease, high blood pressure, high cholesterol, dementia, Alzheimer's disease, dementia, anemia, and psychotic disorder. Review of the care plan, in use at the time of survey, showed: -Need: Resident had an advance directive; -Goal: Resident's advance directive will be honored; -Interventions/Tasks: Code status will be reviewed quarterly and as needed. Resident is a TSL 3 (Provide non-aggressive individualized or comfort care. All care will be directed toward providing comfort measures only throughout the advancement of disease and/or dying process. No Resuscitation/No CPR). Resident had a signed DNR ordered. Review of the TSL/resuscitate plan, showed, the form was last updated on [DATE]. 4. Review of Resident #62's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: high blood pressure, diabetes, dementia, anxiety, and depression. Review of the care plan, in use at the time of survey, showed: -Need: Resident had an advanced directive; -Goal: Resident's advanced directive will be honored; -Interventions/Tasks: Code status will be reviewed quarterly and as needed. Resident had a signed DNR ordered; A signed TSL 3. Review of the TSL/resuscitate plan, showed, the form was last updated on [DATE]. 5. During an interview on [DATE] at 4:43 P.M., the Director of Nursing (DON) said the residents' code status information should be obtained and should be part of the admission process. The nurses and the clinical support nurse were responsible for obtaining the code status information. During the resident's arrival or admission to the facility, the charge nurse should obtain the current code status information. If there was no documentation, the nurse should verify with the resident or responsible party then notify the physician to receive an order. Physician's orders should be documented in the EMR. The DON said all residents should have a code status order. The nurses had a reference shift report that they used daily or every shift. The charge nurses were responsible for updating the shift report sheets. The DON said Resident #18's code status will be updated to DNR immediately. 6. During an interview on [DATE] at 5:06 P.M., the Administrator said she expected the staff to obtain the residents' code statuses during admission. They are to be updated annually at the expiration date. If the resident or the responsible party requested a change in code status, a new form should be filled out and a physician's order should be obtained.

Based on observation, interview and record review, the facility failed to ensure resident's needs and preferences were accommodated when staff rearranged two resident's rooms which prevented one resident access to some of his/her personal belongings (Resident #64) and hindered one resident from freely maneuvering his/her wheelchair in between his/her side of the bed and the other bed in the room (Resident #46). In addition, after removing all side rails in the facility, the facility failed to provide alternative options for four residents who requested the use of siderails for mobility and repositioning (Residents #13, #46, #12 and #14). The sample was 18. The census was 73. Review of the facility's Resident Rights policy, dated 9/19/24, showed: -Procedure: staff competencies in resident rights information will include the following: -Plan and provide individualized care and services as the resident prefers; -Follow resident preferences in care decisions and choices; -Right to self-determination: -Reasonable accommodation of needs and preferences; -Personal and cultural preferences. Review of the facility's Adaptative/Assistive Device and Potential Restraints Policy, revised 11/30/24, showed: -Policy statement: to ensure that physical restraints and adaptive/assistive devices will be used only when it has been determined through an evaluation process that it is necessary to treat a resident's medical condition or as a therapeutic intervention to enhance the resident's functional abilities to promote the resident's highest level of wellbeing and after evaluation of risks; -Procedure: - Other adaptive/assistive devices such as Geri-chairs (large padded chair), Broda chairs (tilt chair), siderails and assist bars, low air loss mattresses (air mattress), lap buddys (device used to support upper body), canoe/scoop mattresses (mattress with raised edges or contoured sides), alarms and other devices and/or combination of devices that are not assessed as a restraint will be evaluated for necessity and risk prior to being placed, quarterly, upon significant change of condition, and when a mattress is changed; -Siderail(s) and assist bars will be evaluated in combination with the mattress prior to placement of a mattress or siderail(s) upon admission, quarterly, upon significant change of condition, and each time the mattress is changed; -Consent will be obtained from the resident (where appropriate) or responsible family member/legal guardian/Durable Power of Attorney (DPOA) for adaptive devices such as Geri-chairs, broad chairs, siderails and assist bars, low air loss mattresses, lap buddy, canoe/scoop mattresses, alarms and other devices and/or combination of devices placed near, next to, or in contact with the resident's body prior to placement if the device assesses to be a restraint. Phone consent/verbal consent will suffice until written consent can be obtained provided that the evaluation is read to the consenting party. A copy of the evaluation will be presented with the consent for signature as soon as practicable. 1. During a group interview on 2/5/25 at approximately 10:30 A.M., six residents, whom the facility identified as alert and oriented, attended the meeting. Residents #46, #12, #64 and #14 were among the residents who voiced concerns during the meeting. Residents #46 and #64 said they wanted their beds to be placed against the wall. Resident #64 said he/she could not reach his/her things from the nightstand which was placed in the far corner of the room because his/her wheelchair could not go around the bed. He/She said the bed used to be placed against the wall and the nightstand was on the other side of bed, but staff had rearranged the furniture. He/She had informed the staff, but nobody fixed the issue. Resident #46 said he/she was in the same situation and was told staff had to move the bed away from the wall with at least a three foot gap due to state regulations. He/She said the siderails were also removed for the same reason. He/She said having the bed against the wall and siderails helped him/her with repositioning and made him/her feel safer. The bed against the wall, also provided extra space in between the two residents. Especially when moving around with a wide wheelchair when the roommate used a stand lift. The roommate (Resident #12) agreed with Resident #46 and added that he/she also preferred to have siderails on his/her bed to assist with repositioning. Resident #14 said he/she needed the siderails for repositioning as well. Both residents said the siderails helped them turn side to side instead of being fully dependent to the staff. They felt safer having the siderails in place. They said staff removed their siderails due to regulations. All four residents said the facility did not provide any siderail and bed positioning assessments. 2. Review of Resident #64's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/2/25, showed: -Cognitively intact; -No behaviors; -No impairment in functional range of motion (ROM); -Used a manual wheelchair/scooter; -Once seated in wheelchair/scooter, the ability to wheel at least 50 feet make two turns: Independent; -Diagnoses included: heart failure, anxiety disorder, depression, and chronic lung disease. Review of the care plan, in use at the time of survey, showed: -Need: The resident has an Activities of Daily Living (ADL) self-care performance deficit; -Goal: Resident will show an improvement in ADL performance; -Interventions included: transfer: the resident required moderate assistance by one staff to move between surfaces; -Need: The resident had limited physical mobility; -Goal: The resident will demonstrate the appropriate use of wheelchair to increase mobility; -Interventions: locomotion: the resident can self-propel in wheelchair for locomotion. Observation and interview on 2/3/25 at 6:59 A.M. showed the resident sat in his/her wheelchair in his/her room. On the right side of the bed, there was a nightstand against the wall. A two foot isle was between the wall and the bed. There was approximately 12 inches from the head of the bed to the wall. On the left side of the bed, there was a three drawer container with a telephone on top of it. Approximately six inches from the container was a recliner chair in the corner. The resident said he/she could not reach the items on his/her nightstand. State came in and told the facility they had to have 20 inches between the bed and the wall. The facility moved his/her bed away from wall, and now he/she could not reach his/her items. Observation and interview on 2/7/25 at 10:05 A.M., showed the resident in his/her wheelchair, in his/her room. The resident tried to propel from the foot of the bed and turn to go down the aisle between the bed and the wall where the nightstand was. The resident's wheelchair got caught on the foot of the bed and he/she was unable to make the turn. The resident said he/she preferred the bed against the wall and the nightstand on the other side of the bed, so he/she could reach his/her items and the telephone. The way the room was arranged now, when the phone rang, whomever called had hung up by the time he/she could get to the telephone. The resident said he/she had talked to staff about this, and they had a care plan meeting, but he/she was told they could not grant his/her request. During an interview on 2/7/25 at 10:05 A.M., Certified Nurse Aide (CNA) O said today was the first time he/she was made aware of the situation with the room arrangement. It had been some time since he/she worked with the resident, but the last time he/she worked with the resident, the nightstand was on the other side of the room. During an interview on 2/7/25 at 11:46 A.M., Physical Therapist (PT) L said therapy could do an evaluation for residents who had concerns with reaching items in their rooms. Therapy could assess the resident's mobility and the way the rooms were set up to ensure residents were able to move around safely. The resident was seen by PT and Occupational Therapy (OT) for several months. Documentation on 1/17/25, showed the resident required contact guard to minimum assist for bed mobility and minimum assistance with wheelchair mobility. During an interview on 2/7/25 at 1:15 P.M., Licensed Practical Nurse (LPN) K said residents should be able to decide how their rooms were arranged. The beds must be three feet from the wall. LPN K was not aware the resident could not reach items in his/her room. During an interview on 2/7/25 at 2:55 P.M. CNA E said, the resident had voiced concerns about his/her bed not being against the wall. CNA E reported the resident's concerns to the nurse. During an interview on 2/7/25 at 5:06 P.M., the Administrator said she was not aware the resident could not reach items in his/her room. She would check on the resident to make sure he/she was able to reach his/her nightstand and telephone. They had to move the resident's bed to comply to the regulation. 3. Review of Resident #46's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Used wheelchair as mobility device; -Independent with mobility and self-care, and supervision with shower or bath; -Occasional urinary incontinence; -Diagnoses included cancer, heart disease, high blood pressure, and high cholesterol. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has an ADL self-care performance deficit; -Goal: Resident will maintain current level in ADL performance; -Interventions/Tasks: Bed Mobility, the resident is independent for repositioning and turning in bed, chooses to keep his/her bed next to the wall; -Need: The resident has limited physical mobility; -Goal: The resident will maintain current level of mobility, such as able to propel self; -Interventions/Tasks: The resident is independent to walk, usually will only walk short distances in room, related to pain in left hip. The resident used a wheeled walker for walking. The resident is independent of locomotion. Used a wheelchair for long distances, may ask for assistance when tired. Observation and interview on 2/7/25 at 9:55 A.M., showed the resident's bed was positioned approximately two feet from the wall. There were boxes of personal belongings in between the bed and wall. There were no siderails observed attached to the bed. The resident said he/she used to have U-shaped rails that he/she could grab onto when he/she turned/repositioned. Now, he/she reaches down under the side of bed to reposition. He/She preferred to have the bed against the wall because he/she relied on the wall for repositioning independently and his/her wide wheelchair made it difficult to get in and out with the tighter space in between the two residents' beds. He/She was very upset when the facility moved the bed and removed the siderails. The resident said there was no proper education or explanation of the reasons why these changes were made. The resident was informed today, that therapy will do an evaluation for bed mobility and safety next week. During an interview on 2/7/25 at 11:46 A.M., Physical Therapist (PT) L said the facility entered a physician order for an OT evaluation for bed safety and bed positioning, which would be completed on 2/10/25. The resident had no previous therapy records. During an interview on 2/7/25 at 1:15 P.M., LPN K said the resident never had siderails but he/she wanted siderails. The resident talked to the old DON about how this would benefit his/her mobility, but the corporation said no. 4. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -No rejection of care; -No functional limitation in ROM; -Roll left to right: partial/moderate assistance (helper does less than half the effort); -Diagnoses included: high blood pressure, diabetes, depression, chronic lung disease; -Moisture Associated Skin Damage (MASD, skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat or wound drainage). Review of the care plan, in use at the time of survey, showed: -Need: impaired physical mobility; -Goal: resident will be able to perform activity within physical limits: -Interventions: encourage use of prescribed assistive devices; had tried trapeze on his/her bed to aid in bed mobility but decided to have it removed; monitor for environmental barriers to mobility; needs staff assistance to turn and reposition in bed. Use pillows and wedges to aid in positioning; occupational therapy to treat to assist with bed mobility; -Need: the resident has an ADL self-care performance deficit; -Goal: resident will maintain current level in ADL performance; -Interventions included: bed mobility: the resident is able to turn in bed with maximum assistance; resident to be turned side to side while in bed; -Need: Is at risk for MASD and yeast infection related to moisture to mid back, skin folds and groin 1/29/25- mid back to mid-thigh MASD resolved, still has MASD to groin, abdominal folds and under breasts; -Goal: the resident will have intact skin, free of redness, blisters, or discoloration by/through review date; -Intervention included: two staff assist for care when in the bed for incontinence care and turning and repositioning. Review of the OT treatment encounter notes, dated completed on 11/11/24, showed: Summary of skill: patient continues to have right shoulder issues (chronic from old rotator cuff injury); patient continues to use bed rails for assist with positioning and for hygiene purposes. Review of the annual MDS dated [DATE], showed: -Cognitively intact; -No behaviors; -No rejection of care; -No functional limitation in Range of Motion (ROM) in upper extremities; impairment of lower extremities on both sides; -Roll left to right: substantial/maximal assistance (helper does more than half the effort); -MASD. Observation and interview on 2/2/25 at approximately 11:30 A.M. and on 2/7/25 at 9:30 A.M., showed the resident lay in bed on an air loss mattress, with no siderails up. The resident said he/she had a U shaped siderails on his/her bed after fighting for them. He/She could not stand up but could pull himself/herself over with the rails. Also, he/she tended to lean to the right while sitting up and with the siderails up he/she was able to readjust himself/herself. A few weeks ago, the siderails were removed from the bed. He/She was told, once state came in, the facility would put the siderails back on the bed. A couple of weeks ago the Director of Nursing (DON) and the Nurse Practitioner (NP) came in and told the resident not to ask for the siderails anymore. The corporation had decided this building would not use siderails because they were a restraint, and it would not matter if he/she had a doctor's order. During an interview on 2/7/25 at 11:46 A.M., PT L said the resident was evaluated upon admission and was noted to be appropriate for an air mattress and bedrails. During an interview on 2/7/25 at 1:15 P.M., LPN K said, the facility used to use U shaped siderails. They were removed from the residents' beds sometime between September 1st and December 30th, 2024. He/She was not given a clear reason why the siderails were removed from the beds. The old DON fought to get the residents siderails. The siderails really helped the resident turn and reposition his/herself. Last week the new DON and NP went in to talk with the resident. Later the resident told LPN K the corporation said he/she could not have the siderails. The resident's bed mobility had declined since he/she did not have the siderails because he/she was unable turn and reposition himself/herself. During an interview on 2/7/25 at 2:55 P.M. CNA E said the resident had siderails when he/she first came to the facility and he/she was able to reposition him/herself. After the siderails were removed, the resident was not able to do that anymore. This was not an improvement for him/her. No residents in the facility currently used siderails. Some residents used siderails in the past. He/She did not know why the siderails were removed from the beds. 5. Review of Resident #12's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No hallucinations and delusions behaviors; -Used wheelchair as mobility device; -Impairment on one side of the upper extremities, and impairment on both sides of lower extremities; -Frequent urinary incontinence, and occasional bowel incontinence; -Diagnoses included anemia, heart failure, high blood pressure, kidney disease, high cholesterol, anxiety, asthma, and respiratory failure. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has an ADL self-care performance deficit due to history of CVA (cardiovascular accident, or stroke), with left hemiplegia (weakness), impaired balance, difficulty using his/her hands, especially right hand; -Goal: Resident will maintain current level in ADL performance; -Interventions/Tasks: Bed Mobility, the resident required maximum assistance by one staff to turn and reposition in bed, requires maximum assistance by one staff to dress upper body, and dependent on staff for lower body. During an interview on 2/7/25 at 10:21 A.M., the resident said his/her U-shaped siderails were removed a couple of weeks ago and he/she was unhappy about the facility's decision. He/She was informed the siderails had to be removed because there was no approval from the state. The siderails helped him/her turn side to side during care and he/she felt more comfortable and safer with the siderails up. The facility did not provide the resident a siderail assessment. During an interview on 2/7/25 at 11:46 A.M., PT L said the resident had been on the PT and OT caseload since 1/28/25, due to a decline in mobility. PT L said the documentation showed the resident required moderate assist for rolling side to side. There was no documentation showing the resident required bed adaptive equipment. However, the resident could potentially have bed adaptive equipment following an assessment. During an interview on 2/7/25 at 1:15 P.M., LPN K said the resident used to have siderails and they were taken away. He/She did not know why the siderails were removed. 6. Review of Resident #14's MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Mobility devices: wheelchair (manual or electrical); -Roll left to right: independent; -Chair/bed-to-chair transfer-the ability to transfer to and from a bed to chair (or wheelchair): Supervision or touching assistance (helper provides verbal cues or touching/steadying and/or contact guard assistance as resident completes activity); -Diagnoses included: heart failure, high blood pressure, diabetes, dementia, anxiety, depression, and psychotic disease (a mental illness that causes a person to lose touch with reality). Review of the care plan in use at the time of survey, showed: -Need: has an ADL self-care performance deficit; -Goal: Resident will show an improvement in ADL performance; -Interventions included: bed mobility: the resident is needing touching assist/supervision to turn and reposition herself in bed; transfer: can self-transfer in/out of bed to her wheelchair. During an interview on 2/03/25 at 7:49 A.M. the resident said about a year ago the facility took his/her siderails off the bed. He/She wished the siderails were back on because they helped him/her reposition while in bed and it gave him/her something to hang on to when he/she transferred in/out of the bed. During an interview on 2/7/25 at 2:55 P.M. CNA E said the resident used to have siderails. Since his/her siderails were removed the resident had not had a decline in his/her mobility. He/She just did better with the siderails. 7. During an interview on 2/7/25 at 11:46 A.M., PT L said the therapy department assessed residents who had mobility concerns including getting in and out of bed. Currently no residents required any adaptive bed equipment. Typically, if therapy recommended side rails for a resident therapy would work with the resident in therapy and simulate the bed with siderails to assess for safety. If the therapy department determined a resident needed adaptive equipment, therapy would bring it up to the Interdisciplinary Team (IDT), but it would depend on the facility's decisions. PT L did not know who was responsible for completing the siderail assessments. 8. During an interview on 2/7/25 at 5:06 P.M., the Administrator said the facility did not use siderails. The facility was in the process of evaluating the usage of siderails, and their policy and procedures. During this process, the facility has removed all siderails. While in the process of developing their new policy and procedures, the residents' care plans were updated to reflect their needs and provide appropriate care to assure residents' safety without the use of siderails. The Administrator expected the staff to follow the residents' updated care plan. She said the beds were moved to have three feet clearance according to state regulation. 45083

Based on interview and record review the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 12 CNAs who worked for the facility for at least one year. Six CNAs (CNA #B, #D, #E, #G, #H, and #I) and Four Certified Medication Technician (CMT)s (CMT #A, #C, #F and #J) were sampled. The facility failed to document the length of time the training was provided for all sampled staff . The census was 73. 1. Review of CNA B's employee file showed: -Date of hire: 10/17/22; -Three in-services were completed; -The in-services failed to show the length of time the training was provided. 2. Review of CNA D's employee file, showed: -Date of hire: 10/10/22; -10 in-services were completed; -The in-services failed to show the length of time the training was provided. 3. Review of CNA E's employee file showed: -Date of hire: 7/25/18; -11 in-services were completed; -The in-services failed to show the length of time the training was provided. 4. Review of CNA G's employee file showed: -Date of hire: 4/15/2010; -Eight in-services were completed; -The in-services failed to show the length of time the training was provided. 5. Review of CNA H's employee file showed: -Date of hire: 7/1/15; -Nine in-services were completed; - The in-services failed to show the length of time the training was provided. 6. Review of CNA I's employee file showed: -Date of hire: 3/9/16; -One in-service was completed; -The in-services failed to show the length of time the training was provided. 7. Review of CMT A's employee file, showed: -Date of hire: 5/18/11; -12 in-services were completed; -The in-services failed to show the length of time the training was provided. 8. Review of CMT C's employee file showed: -Date of hire: 8/1/22; -13 in-services were completed; -The in-services failed to show the length of time the training was provided. 9. Review of CMT F's employee file showed: -Date of hire: 9/2/22; -16 in-services were completed; - The in-services failed to show the length of time the training was provided. 10. Review of CMT J's employee file showed: -Date of hire: 4/22/15; -20 in-services were completed; -The in-services failed to show the length of time the training was provided. During an interview on 2/4/25 at 2:35 P.M., the Administrator said the facility did not track the time for the in-services and they would not be able to tell if the CNAs or CMTs had received the required 12 hours of education or not. She would expect for staff to have the required education and for the hours to be tracked.

Based on observation, interview and record review, the facility failed to ensure that kitchen equipment was kept clean during five of six days of observation. In addition, the facility failed to ensure expired thickened milk was discarded. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 73. Review of the kitchen's cleaning schedules, showed: -[DATE]'s schedule: -Steamer cleaned: [DATE]; -Stove (trays) cleaned: [DATE], [DATE] and [DATE]; -Flat grill cleaned: Not listed on cleaning schedule; -Deep fryer cleaned: [DATE], [DATE] and [DATE]; -[DATE]'s schedule: -Steamer cleaned: no days initialed; -Stove (trays) cleaned: [DATE] and [DATE]; -Flat grill cleaned: Not listed on cleaning schedule; -Deep fryer cleaned: [DATE] and [DATE]; -No cleaning schedule for [DATE]. 1. Observation on [DATE] at 9:35 A.M., [DATE] at 10:35 A.M., [DATE] at 12:09 P.M., [DATE] at approximately 3:00 P.M., and [DATE] at approximately 3:15 P.M., of the kitchen, showed the following: -The stove: heavy caked-on stains along the front and sides of the of the stove; -Steamer: Heavy caked-on stains along the front; -Flat grill: heavy caked-on stains along the front and sides; 2. Observation on [DATE] at 9:35 A.M., [DATE] at 10:35 A.M., [DATE] at 12:09 P.M., [DATE] at approximately 3:00 P.M., of the the deep fryer inside the kitchen, showed: -Heavy caked-on stains along the front and sides of the fryer; -Old grease in the fryer. -Heavy caked on grease and batter along the inside of the fryer. 3. Observation on [DATE] at 12:09 P.M., [DATE] at approximately 3:00 P.M. and on [DATE] at approximately 3:15 P.M., in the cooler inside the kitchen, showed a box that contained several cartons of 2% milk, expired on [DATE]. Observation on [DATE] at 12:09 P.M. and on [DATE] at approximately 3:00 P.M., in the cooler inside the kitchen showed an opened full box that contained cartons of 2% milk, expired on [DATE]. 4. During an interview on [DATE] at approximately 3:15 P.M., with the Dietary Manager (DM) and the Kitchen Manager (KM), the DM said the expired milk should have been discarded. He expected for all items to be properly labeled, dated, stored and for any expired items to be discarded. The KM said everyone is responsible for properly labeling, dating, storing, and discarding expired food. The DM said the general cleaning is done daily. They have some items that are cleaned every Tuesday, then other items are cleaned the other Tuesday. This process is rotated. He has a staff person who is responsible for cleaning the hood.

42247 Based on interview and record review, the facility failed to ensure resident records were complete and accurately documented when staff failed to document one resident's treatments (Residents #26). In addition, the facility failed to have the certification of terminal illness for one resident (resident #56) who was receiving hospice services. The sample was 18. The census was 73. Review of the facility's Administration Procedures for all Medications policy, dated May 2018, showed: -After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the Medication Administration Record (MAR) or the Treatment Administration Record (TAR); -If resident refuses medication, document refusal on MAR or TAR; -Notification of physician/prescriber for persistent refusals. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/10/25, showed: -Moderately impaired cognition; -No behaviors; -No rejection of care; -Number of stage four pressure ulcers (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling): One; -Number of stage four pressure ulcers that were present on admission: 0; -Received pressure ulcer care: applications of ointments/medications other than to feet; -Diagnoses included: cancer, heart failure, neurogenic bladder (the bladder does not empty properly due to a neurological condition), diabetes and paraplegia (impairment in motor or sensory function of the lower extremities). Review of the care plan in use at the time of survey, showed: -Need: The resident has pressure ulcers, is at risk for impaired skin Integrity related to incontinence of stool and decreased mobility. Was admitted with a Deep Tissue Injury (DTI, damage to the soft tissue beneath the skin caused by pressure or shear forces) to his/her sacrum (triangular bone located above the coccyx (tailbone), is now a stage four. On 1/21/25, continues with stage four pressure injury to sacrum; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions included: resident was being seen by the wound team, see the TAR for treatment. Review of the TAR, dated 12/5/24 through 12/31/24, showed: -An order for coccyx: cleanse wound bed for mechanical debridement (physical force to remove dead or damaged tissue) and cleanse Peri-wound (area around the wound) with normal saline and gauze. Apply Santyl (sterile enzymatic debriding ointment) and gentamicin ointment (antibiotic) to the wound bed, and cover with superabsorber adhesive dressing. Change daily or as needed (PRN) based on saturation every day shift for wound management, start date: 12/11/2024; -Documentation showed five out of 20 opportunities left blank; -An order for: gentamicin sulfate ointment 0.1 %, apply to coccyx every day shift for unstageable tissue loss (UTD, wounds where the depth is obscured by tissue breakdown, such as slough, eschar, or necrosis.), start date: 12/11/2024; -Documentation showed five out of 20 opportunities were blank; -An order for: Santyl ointment 250 unit/gram (GM) apply to coccyx every day shift for wound care; -Documentation showed six out of 26 opportunities left blank. Review of the resident's progress notes dated 12/5/24 through 12/31/24 showed: -No documentation the resident refused his/her treatment, the treatment was placed on hold or the treatment should not have been completed per physician orders; -No documentation the physician was notified. Review of the TAR dated 1/1/25 through 1/31/25, showed: -An order for coccyx: cleanse wound bed for mechanical debridement and cleanse peri-wound with normal saline and gauze. Apply Santyl and gentamicin ointment to the wound bed, and cover with superabsorber adhesive dressing. Change daily shift OR PRN based on saturation every day shift for wound management. The order was discontinued on 1/8/25; -Documentation showed three out of eight opportunities left blank; -An order for coccyx: cleanse wound bed for mechanical debridement and cleanse peri-wound with normal saline and gauze. Apply Santyl, pack with aquacel (Wound drainage absorbent product) and cover surrounding area with aquacel, cover with sacral foam dressing. Change three times weekly or PRN based on saturation every day shift every three days for wound management, start date 1/9/25 and discontinue date 1/16/25; -Documentation showed: one out of three opportunities left blank; -An order for coccyx: cleanse wound bed for mechanical debridement and cleanse peri-wound with Dakin's 1/4 strength (antiseptic) and gauze. Apply Santyl, pack with calcium alginate (provides a moist environment for wound healing) and cover surrounding area with calcium alginate, cover with sacral foam dressing. Change daily or PRN based on saturation every day shift for wound management, start date 1/17/25; -Documentation showed: six out of 15 opportunities left blank; -An order for: gentamicin ointment 0.1 % apply to coccyx every day shift for UTD; -Documentation showed: 10 out of 31 opportunities left blank; -An order for Santyl Ointment 250 unit/GM, apply to coccyx every day shift for wound care; -Documentation showed 11 out of 31 opportunities left blank. Review of the progress notes dated 1/1/25 to 1/31/25, showed: there was no documentation showing the resident refused his/her treatment or the treatment was placed on hold, or the treatment should not be completed per physician orders and no documentation showing the physician was notified. Review of the TAR dated 2/1/25 through 2/5/25, showed: -An order for coccyx: cleanse wound bed for mechanical debridement and cleanse peri-wound with Dakin's 1/4 strength and gauze. Apply Santyl, pack with calcium alginate and cover surrounding area with calcium alginate, cover with sacral foam dressing. Change daily or PRN based on saturation every day shift for wound management; -Documentation showed two out of five opportunities were blank; -An order for: gentamicin ointment 0.1 % apply to coccyx topically every day shift for UTD; -Documentation showed two out of five opportunities were blank; -An order for: Santyl ointment 250 unit/GM apply to coccyx every day shift for wound care; -Documentation showed two out of five opportunities were blank; Review of the progress notes dated 2/1/25 through 2/5/25, showed: -No documentation the resident refused his/her treatment, the treatment was placed on hold or the treatment should not have been completed per physician orders; -No documentation the physician was notified. During an interview on 2/7/25 at 1:15 P.M., Licensed Practical Nurse (LPN) K said the facility's clinical support nurse completed the treatments when she was in the building. When she was off or if she could not complete the treatment, the charge nurse on the floor would be responsible for completing the treatments. The treatment should be documented on the TAR after they were completed. If a treatment was not documented, it would be assumed it was not done. One possible consequence of a treatments not being completed as ordered would be the wound could decline. During an interview on 2/7/24 at 5:06 P.M., the Administrator said she expected for staff to follow the physician orders and document after the treatment was completed. 2. Review of Resident #56's significant change MDS, dated [DATE], showed the following: -admitted to the facility: 5/20/24; -Moderate impaired cognition; -Prognosis: Condition or chronic disease that may result in a life expectancy of less than 6 months: Yes; -Special treatments and programs; Hospice care while a resident; -Diagnoses included atrial fibrillation (A-Fib, irregular heart rhythm), heart failure, diabetes mellitus (DM, metabolic disease), hypertension (high blood pressure), hyperlipidemia (high cholesterol), dementia, depression, chronic obstruction pulmonary disease (COPD, lung disease), and respiratory disease. Review of the resident's physician's order sheet dated 2/6/25 showed an order dated: 1/29/25, for hospice consult to evaluate and treat senile degeneration of the brain (dementia), congestive heart failure, and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues). Review of the resident's medical record and hospice binder, showed no documentation of the resident's certification of terminal illness form. During interviews on 2/5/25 at 5:28 P.M. and 2/7/25 at 5:07 P.M., the Administrator said the resident's certification of terminal illness form was not in the building at the time. The hospice provider was sending it over. The resident had just signed started hospice about a week ago on 1/30/25 or 1/31/25. She expected for the certification of terminal illness form to have been in the facility with the resident's medical records and/or hospice binder.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were followed up on for the final accounting within 30 days for a resident who expired. This affected one of five residents who expired and had money in their resident trust account (Residents #240). The census was 73. Review of Resident #240's resident fund account, showed the following: -Resident expired on [DATE]; -A balance of $481.39; -TPL completed [DATE]; -As of [DATE], the resident's account remained open with a balance of $481.39. During an interview on [DATE] at 11:10 A.M., the Corporate Business Office Manager (BOM) said the resident expired on [DATE]. The balance report was submitted on [DATE]. The balance was $481.39. She was still awaiting a letter to close account. She would contact someone at the TPL unit today to see when they would send the letter to advise how much of the resident's funds needed to be submitted. Normally, if she hadn't heard from anyone in the TPL unit, within 30 days she would have followed up before now. She should have followed up before now. During an interview on [DATE] at 5:06 P.M., the Administrator said when a resident expired and had money left in their account, she expected for the BOM to complete a TPL form and submit it within 30 days. It was her expectation that follow up would be made on the TPL forms for the final accounting for expired residents to ensure that there would be a zero balance in the resident's account.

Based on interview and record review, the facility failed to revise care plans to address a recent fall and hospice status for two of 18 sampled residents (Residents #26 and #56). The census was 73. Review of the facility's Care Plan policy dated January 2011 and reviewed January 2023 showed: -Policy: It is the policy of the facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, nutritional, emotional, spiritual, and psychological needs. -Procedures: -An interdisciplinary team, in coordination with the resident and his/her responsible party, develops and maintains a comprehensive care plan for each resident; -The comprehensive care plan has been designed to: -Incorporate identified problem's areas; -Incorporate risk factors associated with identified problems; -Build on the resident's strengths; -Reflect treatment goals and objectives in measurable outcomes; -Identify the professional services that are responsible for each element of care; -Ensure that all relevant areas of the federal and state guidelines, outlined in the facility corporate compliance program manual, are upheld with respect to resident care; -Prevent declines in the resident's functional status and/or functional levels; and; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program. Review of the facility's Fall Risk Reduction policy, dated revised 11/2024, showed: -Purpose: To identify residents at risk for falls and implement interventions to reduce risks; -Actions steps following a fall: Update a new fall risk assessment, immediately update the care plan, and implement interventions to further reduce the risk of reoccurrence. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/10/25, showed: -Moderately impaired cognition; -Diagnoses included: cancer, heart failure, neurogenic bladder (the bladder does not empty properly due to a neurological condition), diabetes and paraplegia (impairment in motor or sensory function of the lower extremities). Review of the progress notes dated 11/22/2024 at 7:24 AM, showed a fall was not witnessed. Fall occurred in the resident's room. Review of the care plan in use at the time of survey, showed staff did not include the resident was at risk for falling and what interventions were put into place to prevent the resident from falling. 2. Review of Resident #56's significant change MDS, dated [DATE], showed the following: -admitted to the facility: 5/20/24; -Moderate impaired cognition; -Prognosis: Condition or chronic disease that may result in a life expectancy of less than 6 months: Yes; -Special treatments and programs: Hospice care while a resident; -Diagnoses included atrial fibrillation (A-Fib, irregular heart rhythm), heart failure, diabetes mellitus (DM, metabolic disease), hypertension (high blood pressure), hyperlipidemia (high cholesterol), dementia, depression, chronic obstruction pulmonary disease (COPD, lung disease), and respiratory disease. Review of the resident's physician orders, showed an order dated 1/29/25, for hospice consult to evaluate and treat. Review of the resident's care plan, used during the survey showed the care plan not revised to reflect his/her hospice diagnosis, goals, and/or interventions. 3. During an interview on 2/7/25 at 4:37 P.M., the MDS Coordinator said care plans should be updated when there had been a change in the resident's condition or after a resident fell . Care plans could be updated by the nurse or by the MDS Coordinator. The MDS Coordinator was made aware of changes in a resident's condition during the facility's clinical meetings. She expected for the care plans to be updated and accurate so the Certified Nurse Aide (CNA) could follow the care plan to know what care to provide to the resident. 4. During an interview on 2/7/25 at 5:06 P.M., the Administrator said care plans should be updated as needed. If anything needed to be changed both the nurse and the MDS Coordinator could update them. If a resident fell , the care plan should be updated, as needed. She would expect for the care plan to be complete and accurate because they are individualized for each resident to show what care the resident needed. 42247

45083 Based on interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice by not following the physician orders for daily and weekly weights for one resident (Resident #78), and not obtaining physician's order for hospice care for one resident (Resident #18). The sample was 18. The census was 73. Review of the facility's Physicians' Orders policy, dated ,d+[DATE], showed: -Policy: All treatments and medications must be ordered by the resident's attending physician; -Procedure: All physicians' orders shall be recorded on the Physician's Order Form for each resident and must be signed or initialed by the attending/prescribing physician as per state and/or federal regulations and as outlined in the facility's Management Services Corporate Compliance Manual; -Physician orders include all medications, treatments, diets, restorative measures (long-term and short-term), special medical procedures required for the safety and well-being of the resident, limitation of activities, others as necessary and appropriate; -The original physician orders must remain in the resident's chart at all times; -Physicians' orders are rewritten every thirty days; -Medications, diets, therapy, or any treatment may not be administered to the resident without a written order from the attending physician; -The policy did not provide instructions for procedures in following the physicians' orders. Review of the facility's undated Hospice Policy and Procedure, showed: -Policy: The facility staff will provide and arrange for hospice services for all patients deemed eligible and interested in hospice services. When a resident has elected hospice services, the nursing home must communicate, establish, and agree upon a coordinated plan of care for both providers. The coordinated plan of care must identify the care and services which the nursing home and hospice will provide to be responsive to the unique needs of the resident. Nursing home and hospice are responsible for performing each of their perspective functions that have been agreed upon and will be included in the plan of care. Hospice retains overall professional management for directing the implementation of the plan of care related to the terminal illness and related conditions; -Procedure: The facility staff will discuss the availability of hospice services for all residents deemed by his/her physician to have a condition where the resident is given a terminal diagnosis and who may meet hospice criteria, with patients and/or family. Social Services or designee will notify nursing of need for physician's order for hospice. 1. Review of Resident #78's medical record, showed: -admitted on [DATE]; -Expired on [DATE]; -Intact Cognition; -Understood/Understand; -Clear speech distinct intelligible words; -Diagnoses included anemia (low levels of healthy red blood cells to carry oxygen throughout the body), malnutrition, hypertension (high blood pressure), heart disease and heart failure. Review of the resident's Physician Order Sheet (POS), showed: -Order dated [DATE], start date: [DATE], to take weights every day shift every Tuesday; -Order dated [DATE], start date: [DATE], to take weights for three days; admission/weekly weights times three, then monthly. Review of the resident's baseline care plan, undated, showed: -Dietary Nutritional Status: -Resident's dietary goal: -Maintain weight; -Prevent weight loss. Review of the resident's weight report, showed his/her weight of 204.5 pounds (lbs) on [DATE]. No other weights were recorded. During an interview on [DATE] at 5:06 P.M., the Administrator and Director of Nursing (DON) said they expected staff to follow the physician's order. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated [DATE], showed: -readmitted on [DATE]; -Severe cognitive impairment; -Diagnoses included anemia, heart failure, high blood pressure, multidrug-resistant organism (MDRO), pneumonia, diabetes, high cholesterol, Alzheimer's disease, stroke, dementia, hemiplegia or hemiparesis (weakness or paralysis on one side of the body), anxiety and depression; -On hospice care. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident is at the end stage of life and is utilizing hospice care services; -Goal: Resident will receive palliative care directed by hospice interdisciplinary team and provided by nursing facility and hospice staff; -Interventions/Tasks: Facility staff and hospice staff will coordinate care, supplies, and equipment to meet the resident's needs. Review of the resident's medical records, showed no order for hospice care was documented. During an interview on [DATE] at 4:43 P.M., the DON said there should be a physician's order for hospice care.

Based on interview and record review, the facility failed to implement a 14-day stop date for the PRN (as needed) use of psychotropic medications or provide a rationale for the continued use of the medication for two residents (Residents #18 and #15). The facility census was 73. Review of the facility's undated Psychotropic Medication Use policy, showed: -Policy: Based upon each resident's comprehensive assessment, the facility will ensure that residents who have not used psychotropic drugs are not given them unless the medication is necessary to treat a specific condition that is diagnosed and documented in the clinical record. Residents will not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals; -The facility will monitor psychotropic medications for proper dose, including duplicate therapy, duration, evidence of adequate monitoring for efficacy and adverse consequences and to prevent, identify and respond to adverse consequences. Residents who receive psychotropic medications will receive gradual dose reductions and behavioral interventions unless clinically contraindicated with the intention to decrease or discontinue the use of the psychotropic medication whenever safe and possible; -PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN anti-psychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. When selecting medications and non-pharmacological approaches, members of the interdisciplinary team and the resident and resident representative, if applicable, will participate in the care process to identify, assess, advocate for, monitor and communicate the resident's needs and changes of condition. 1. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/19/24, showed: -readmitted on [DATE]; -Severe cognitive impairment; -No hallucinations and delusions behaviors; -Diagnoses included Alzheimer's disease, stroke, anxiety and depression. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident uses antidepressant medication; -Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy; -Interventions/Tasks: Administer antidepressant medications as ordered by physician, monitor and document side effects and effectiveness every shift; monitor/document/report PRN adverse reactions to antidepressant therapy; -The resident uses anti-anxiety medications; -Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy; -Interventions/Tasks: Administer anti-anxiety medications as ordered by physician, monitor and document side effects and effectiveness every shift; monitor/document/report PRN adverse reactions to anti-anxiety therapy. Review of the resident's physician order, dated 11/13/24, showed an order of Lorazepam Intensol Oral Concentrate (medication used to treat anxiety) 2 milligrams per milliliter (mg/ml), give 0.25 ml by mouth every 4 hours as needed for pain. No stop date documented. 2. Review of Resident #15's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Severe cognitive impairment; -No hallucinations and delusions behaviors; -Diagnoses included dementia and depression. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits; -Goal: The resident will maintain involvement in cognitive stimulation, social activities as desired; -Interventions/Tasks: Invite the resident to scheduled activities; the resident needs assistance/escort to activity functions; -No mentioned of resident using psychotropic medication. Review of the resident's physician order, dated 11/13/24, showed an order of Quetiapine Fumarate Tablet (an atypical antipsychotic used to treat schizophrenia (a chronic mental illness characterized by disruptions in thought processes, perceptions, emotions, and social interactions), bipolar disorder (a chronic mental health condition characterized by extreme shifts in mood, energy, and activity levels) and depression), give 25 mg by mouth at bedtime as needed for agitation. No stop date documented. 3. During an interview on 2/7/25 at 3:57 P.M., Licensed Practical Nurse (LPN) K said all PRN psychotropic medications required a consent signed by the resident or their responsible party. These medications should have an order for 14 days. The pharmacy reviewed and sent a recommendation to the physician to review and renew the order for another 14 days if needed or have an indefinite stop date ordered. 4. During an interview 2/7/25 at 5:06 P.M., the Administrator and the Director of Nursing (DON) said they expected all PRN psychotropic medications to have a 14-day stop date, and a new order should be obtained if needed.

42247 Based on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to wear appropriate Personal Protective Equipment (PPE) for two residents (Resident #26 and #20) and failed to post signage for one resident (Resident #18) who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS). In addition, the facility failed to position the urinary catheter (a sterile tube inserted into the bladder to drain urine) release valve (tap-like feature on the bag that is manually open to allow urine to flow out) drain from touching the floor and failed to clean the release valve drain prior to placing it back in the drain holder (holds the tip of the release valve drain) for one resident (Resident #26). The sample was 18. The census was 73. Review of the Enhanced Barrier Precautions Policy, dated 4/24, showed: - Enhanced Barrier Precautions are to be implemented in addition to Standard Precautions when other Transmission-Based precautions do not apply, when facility identifies any resident with: wounds or skin openings that require dressings; -Any indwelling medical device, regardless of MDRO colonization status, for example: urinary catheter; -Post clear signage on the door/wall outside resident room: -Personal Protective Equipment is required for all staff providing high-contact resident care activities to include gown and gloves with: - Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: urinary catheter. Review of the facility's Catheter Care policy dated reviewed 2/2019, showed: -Emptying drainage bag (collects urine): -Wipe release valve on drain bag with alcohol prep; -Re-clasp release valve; -Policy failed to show what staff should do if the release valve drain was touching the floor. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/10/25, showed: -Moderately impaired cognition; -Diagnoses included: Cancer, heart failure, neurogenic bladder (the bladder does not empty properly due to a neurological condition), diabetes and paraplegia (impairment in motor or sensory function of the lower extremities); -Number of stage four pressure ulcers (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling): One; -Indwelling catheter. Review of the care plan in use at the time of survey, showed: -Need: Risk for infection; -Goal: Resident will show no signs/symptoms of infection; -Interventions included: manage indwelling catheters to minimize risk of infection; -Need: The resident has a urinary catheter, is on EBP; -Goal: The resident will be/remain free from catheter-related trauma through review date; -Interventions: Staff to follow EBP during catheter care and close personal care. Observation on 2/4/25 at 6:00 P.M., there was an EBP sign posted on the resident's door. The resident was lying in bed. The catheter drainage bag was attached to the bed frame and was draining to gravity. The release valve drain tube was clamped closed, but the tip of the drain was touching the floor. Certified Nurse Aide (CNA) O brought the resident's dinner tray into the room and sat it on the over the bed table. The resident asked the CNA to straighten his/her legs out. The CNA left the room to get help. CNA O returned with Certified Medication Technician (CMT) N. CMT N placed the drain tube into the drain holder without cleaning it. CNA O and CMT N repositioned the resident in bed by rolling him/her from side to side and pulling him/her up in bed. Neither staff member wore a gown. After the resident was repositioned, CMT N emptied 500 milliliters of yellow urine from the drainage bag without wearing a gown. During an interview on 2/6/25 at 3:01 P.M., CNA S said if a piece of the catheter drain was on the floor, it would need to be sanitized. He/She would let the nurse know. The nurse would change it, but that piece of the catheter should never be on the floor. During an interview on 2/6/25 at approximately 3:13 P.M., CMT T said if a piece of the catheter drain was on the floor, it would need to be sanitized. He/She would let the nurse know because that would be a hazard for infection. The nurse would change it, but that piece of the catheter should never be on the floor. During an interview on 2/6/25 at 2:34 P.M., Registered Nurse (RN) P said if the catheter drain touched the floor staff should change the appliance. During an interview on 2/6/25 at approximately 3:35 P.M., Licensed Practical Nurse (LPN) U said if there was a piece of the catheter on the floor, he/she would just change it because of contamination. During an interview on 2/7/25 at 1:15 P.M. LPN K, said if a catheter drain touched the floor it would be considered contaminated and it would need to be changed because there would be a risk for infection. During an interview on 2/7/25 at 5:06 P.M., the Director of Nursing (DON) said if the catheter drain touched the floor, staff should sanitize the drain before placing it in the drain holder. The DON did not know what staff should sanitize the drain with, but she would expect for staff to follow the facility's policy. Changing the appliance may be a good option if it was in the policy. 2. Review of Resident #20's admission MDS, dated [DATE], showed the following: -admitted to the facility: 10/9/24; -readmitted to the facility: 11/1/24 -Moderately impaired cognition; -Section K- Nutrition Approach; tube feeding while a resident; -Diagnoses included cancer, anemia, benign prostatic hyperplasia (enlarged prostate), diabetes, high blood pressure, dementia, depression, and malnutrition. Review of the resident's care plan, used during the survey showed: -Problem: The resident has a G-tube (tube feeding for nutrition), he/she had been getting intermittent feedings, now only flushing the G-tube to keep patent. He/She has a swallowing problem related to esophageal cancer. He/she is on hospice; -Goal: The resident's insertion site will be free of signs and symptoms (s/sx) of infection through the review date. He/She will maintain adequate nutrition and hydration status as evidenced by (aeb) weight stable, no s/sx of malnutrition or dehydration through review date. -Interventions included: The resident needs total assist with tube feeding and water flushes. See physician orders for current orders. Check for tube placement and gastric contents/residual volume per facility protocol and record. Monitor/document/report as needed (PRN) any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site. Provide local care to G-tube site as ordered and monitor for s/sx of infection. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. Review of the resident's physician's order sheet dated 2/6/25 showed: -An order dated 11/1/24, for EBP during high contact care activities; -An order dated 11/27/24, to cleanse G-tube site with wound cleanser, apply dressing daily and as needed, every day shift for G-tube care. Observations of the resident's room on 2/5/25 showed: -At 2:37 P.M., CNA Q came out of the resident's bathroom with the resident. CNA Q did not have on gloves or a gown. He/She asked the Surveyor if he/she needed Resident #20 and said the resident was in the bathroom, and then CNA Q exited out the room; -At approximately 2:38 P.M., CNA Q returned to the resident's room. He/she opened the bathroom door. CMT R was in the bathroom with the resident. CMT R did not have on gloves or a gown. -At 2:40 P.M., the resident, CNA Q and CMT R came out the bathroom and exited out of the resident's room. During an interview on 2/5/25 at 2:42 P.M., CNA Q and CMT R, both initially said the resident was not on EBP. Both CNA Q and CMT R then looked at the resident's door and noticed the EBP signage on the door to be hanging down via tape and flipped over onto the back side. They then said the resident was on EBP, and the sign was hanging down and turned over. CNA Q said the resident was probably on EBP because he/she was eating regular meals and had a feeding tube. CMT R said he/she wasn't aware the resident on EBP because the resident ate food. Both CNA Q and CMT R said PPE should be worn while providing care for a resident on EBP. Normally they would have had on the gear. CMT R said this was a mishap, and CNA Q agreed. CMT R said they usually knew if someone was on EBP because there would be signage on the door, and they would be made aware during report. CMT R heard the resident yelling for assistance to get out of the bed. He/She went in to help the resident and then the resident had to use the bathroom. Both CMT R and CNA Q said PPE should have been worn while they were assisting the resident in the bathroom. They should have worn a gown and gloves, and the mask was optional. 3. Review of Resident #18's admission MDS, dated [DATE], showed: -Severe cognitive impairment; - Indwelling catheter; -Diagnoses included anemia, heart failure, high blood pressure, MDRO, pneumonia, diabetes, Alzheimer's disease, stroke, hemiplegia, or hemiparesis (weakness or paralysis on one side of the body), anxiety and depression. Review of the resident's care plan, in use at the time of survey, showed: Need: The resident has a suprapubic urinary catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine), on EBP; Goal: The resident will show no signs and symptoms of urinary infection (UTI); Interventions/Tasks: Staff to wear a gown and gloves during close personal care with resident. Monitor, record, or report to physician for signs and symptoms of UTI. Observation on 2/2/25 at 11:41 A.M., showed PPE supplies , stored in a plastic storage drawers, placed in the hallway approximately 4 doors down from the nurses' station. No EBP door signage observed on any rooms in the hall. Resident #18 resided in the same hall. Observation and interview on 2/3/25 at 7:24 A.M., showed an EBP sign on Resident #18's door, but no PPE supplies located near the door. The resident was not in the room. At 7:25 A.M., a female staff propelled the roommate from having breakfast to the room and said the PPE supplies were stored in the bottom shelf of the linen carts. The linen cart was about four doors down from the resident's room. Resident #18's roommate said he/she has been a resident for two years and had never seen that EBP sign. He/She said it was something really new and was not even up that morning prior to breakfast. He/She asked the Surveyor if there was something going on with the roommate and if he/she needed to be transferred. The roommate said no staff explained to him/her the purpose of the door signage. 4. During an interview on 2/6/25 at 3:01 P.M., CNA S said residents are placed on EBP due to wounds and if they had an infection going on. He/She would know which residents were on EBP by the signage on the door, and the nurse would tell them during their rounds. While working with a resident who was on EBP, staff should wear gloves, gowns, and masks. This applies to anyone who was providing care to the resident. There usually is a cart that sat outside the door of a resident on EBP, but they moved it, now the are supplies on the linen cart. 5. During an interview on 2/6/25 at approximately 3:13 P.M., CMT T said residents are placed on EBP due to wounds and an infections going on. He/She knew which residents were on EBP due to the signage on the door, and the nurse would tell them during their rounds. While working with a resident who was on EBP, staff should wear gloves, gowns, and masks. This applies to anyone who was providing care to the resident. There usually was a cart that sat outside the door of a resident who is on EBP, but they moved it, now there are supplies on the linen cart. 6. During an interview on 2/6/25 at 2:34 P.M., RN P said residents who require EBP, should have a sign on the door. The sign should show which resident required EBP. Medical records staff place the signs on the doors. Staff should wear gown and gloves while providing direct resident care such as personal care, toileting, turning and repositioning and while performing catheter care/emptying the drainage bag. 7. During an interview on 2/6/25 at approximately 3:35 P.M., LPN U said he/she just normally knew which residents were on EBP. There was a list at the nurses' station. When residents are first placed on EBP, they let the staff know. LPN U thought it was the nurse supervisor who would let the staff know. When there is signage on the door, he/she was not sure if there was a way to tell which resident in the room was on EBP, but he/she would just go by what the requirements are. Residents who are placed on EBP normally would have a G-tube, catheter, wounds, or something like that. When providing care to a resident, the staff member should have on a gown, gloves, and a mask. That's it. It depends on if the staff person was providing care to the resident or not. If you're not doing care, the staff person just needs to wash their hands and put on gloves before attending to the resident. The PPE should be outside the resident's door. She didn't see any at this time, but usually it is outside the door in a plastic cart. 8. During an interview on 2/7/25 at 1:15 P.M., LPN K, said staff knew which residents require EBP because they get a verbal report at the beginning of each shift and there would be a sign on the resident's door. Staff should wear gown and gloves while proving high care activities. 9. During an interview on 2/7/25 at 5:06 P.M., the Administrator said staff knew which residents required EBP by the sign on their door. Staff should wear gown and gloves while providing direct resident care such as toileting, repositioning residents in bed, and emptying catheters. 45083

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one resident with a gastronomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication) (Resident #3) and one resident with a Suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) (Resident #1). The facility also failed to ensure additional ordered skin treatments were completed for these two residents and four other residents sampled (Residents #2, #4, #5 and #6). The sample size was 6. The census was 88. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Moderate cognitive impairment; -Always incontinent of bowel and bladder; -Skin Assessment: Resident at risk of developing pressure ulcers: Yes; -Does resident have one or more unhealed pressure ulcers at Stage 1 or higher? Yes; -Does resident have pressure ulcer at Stage 2: Yes-1; -Skin and ulcer treatments: pressure reducing device for chair and bed, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, application of ointments/medications -other than to feet; -Diagnoses included neurogenic bladder (bladder does not empty properly due to neurologic condition), seizures, malnutrition, anxiety and depression. Review of the resident's [DATE] Treatment Administration Record (TAR), showed: -An order, dated [DATE], Skin Observation every evening shift every Sunday; -No documentation of treatment completed [DATE], [DATE] and [DATE]; -An order, dated [DATE], Calmoseptine (moisture barrier cream) to buttocks every shift and as needed (PRN); -No documentation of treatment completed: -Day shift- [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -Evening shift- [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], g-tube site care: Remove old dressing, clean with soap and water, allow to dry, place split gauze over and secure with tape daily in the evening; -No documentation of treatment completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], cleanse open area to coccyx with normal saline (NS), apply calcium alginate (highly absorbent wound dressing), cover with silicone border dressing daily and PRN every day shift for wound care; -No documentation of treatment completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the resident's [DATE] TAR, showed: -An order, dated [DATE], Calmoseptine to buttocks every shift and as needed (PRN); -No documentation of treatment completed: -Evening shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], g-tube site care: Remove old dressing, clean with soap and water, allow to dry, place split gauze over and secure with tape daily in the evening; -No documentation of treatment completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], cleanse open area to coccyx with NS, apply calcium alginate, cover with silicone border dressing daily and PRN every day shift for wound care; -No documentation of treatment completed on [DATE] and [DATE]. Observation and interview on [DATE] at 1:05 P.M., showed the resident lay in bed. Hospice Certified Nursing Assistant (CNA) D entered the room to provide the resident's bed bath. Licensed Practical Nurse (LPN) A rolled up the resident's gown to show the resident's g-tube site. The site was bright red with dried reddish material around the site. LPN A said the area should be covered with a dressing. LPN A left the room to get supplies. CNA D said he/she does not work at the facility but assists with bathing the residents on hospice. He/She said most of the time when he/she goes to provide the bed bath there is not a dressing on the resident's g-tube site. CNA D said the day shift nurses try really hard though especially LPN A. The CNA does not think it is possible for the resident to be able to reach and remove the dressing himself/herself. 2. Review of Resident #1's admission MDS, dated [DATE], showed: -Cognitively intact; -Urinary catheter and incontinent of bowel; -Skin assessment: Resident at risk of developing pressure ulcers: Yes; -Does resident have one or more unhealed pressure ulcers at Stage 1 or higher? No; -Skin and ulcer treatments: pressure reducing device for chair; -Diagnoses included neurogenic bladder, enlarged prostate, multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), depression and bipolar disorder. Review of the resident's, [DATE]-[DATE] (Resident was sent to the hospital on [DATE] and returned on [DATE]. Resident expired on [DATE]), TAR showed: -An order, dated [DATE] to [DATE], Zinc Oxide External Ointment 20% Zinc Oxide (Topical) Apply to buttocks excoriation topically two times a day for excoriation; -No documentation of treatment completed: -A.M. Shift: [DATE], [DATE], [DATE], and [DATE] and [DATE]; -HS (bedtime) Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], Flush suprapubic catheter with 30 milliliters (ml) NS every shift at bedtime for catheter care; -No documentation of treatment completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE] to [DATE], Triad Hydrophilic Wound Dress External Paste (Wound Dressings). Apply to buttock topically every shift for prevention; -No documentation of treatment completed: -A.M. Shift: [DATE], [DATE] and [DATE]; -Evening Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE] to [DATE], cleanse open areas to back of left leg with NS. Apply Dakin's (an antiseptic solution used to clean infected topical wounds) wet to dry dressing daily and PRN every day shift for wound care; -No documentation of treatment completed on [DATE], [DATE] and [DATE]; -An order, dated [DATE] to [DATE], Dakin's (,d+[DATE] strength) External Solution 0.25 % (Sodium Hypochlorite). Apply to left leg wound topically one time a day for left leg wound wet to dry dressing; -No documentation of treatment completed on [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], Triad Hydrophilic Wound Dress External Paste (Wound Dressing). Apply to buttock topically every shift for prevention. Cleanse buttock, pat dry, apply after each bowel movement (BM); -No documentation of treatment completed: -A.M. Shift: [DATE] and [DATE]; -Evening Shift: [DATE], [DATE] and [DATE]; -An order, dated [DATE], Cleans area to bilateral lower extremities with Dakin's Wound Cleanser (DWC), pack with iodoform packing strips, cover with abdominal gauze pad (ABD), wrap with kerlix. One time a day every 3 days for open area; -No documentation of treatment completed on [DATE] and [DATE]. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Always incontinent of bowel and bladder; -Skin assessment: Resident at risk of developing pressure ulcers: Yes; -Does resident have one or more unhealed pressure ulcers at Stage 1 or higher? No; -Skin and ulcer treatments: pressure reducing device for chair and bed, application of nonsurgical dressings (with or without topical medications) other than to feet, application of ointments/medications other than to feet; -Diagnoses included diabetes, Alzheimer's, and dementia. Review of the resident's [DATE], TAR showed: -An order, dated [DATE], Miconazole Powder. Apply to affected areas topically every shift for preventative; -No documentation of treatment completed: -A.M. Shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; -Evening Shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE];. -An order, dated [DATE], Skin Observation every evening shift every Saturday; -No documentation of treatment completed [DATE], [DATE], and [DATE]; -An order, dated [DATE], Eucerin External Lotion. Apply to bilateral lower extremities topically two times a day for dry and scaly skin; -No documentation of treatment completed: -A.M. Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; -Evening Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], Santyl (an enzyme used to help the healing of burns, skin wounds, and skin ulcers) External Ointment. Apply to right anterior thigh topically every day shift for wound; -No documentation of treatment completed [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the resident's [DATE], TAR showed: -An order, dated [DATE], Miconazole Powder. Apply to affected areas topically every shift for preventative; -No documentation of treatment completed: -A.M. Shift-[DATE] and [DATE]; -Evening Shift-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], Skin Observation every evening shift every Saturday; -No documentation of treatment completed [DATE]; -An order, dated [DATE], Eucerin External Lotion. Apply to bilateral lower extremities topically two times a day for dry and scaly skin; -No documentation of treatment completed: -A.M. Shift: [DATE] and [DATE]; -Evening Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], Santyl External Ointment. Apply to right anterior thigh topically every day shift for wound; -No documentation of treatment completed [DATE], [DATE], and [DATE]; -TAR marked with 9 (Other-See progress notes) [DATE], [DATE], and [DATE]. Review of the resident's progress notes, did not show documentation related to Santyl treatment not given. Observation on [DATE] at 1:20 P.M., showed the resident in his/her room, in a chair. The resident gave CNA F permission to remove his/her socks and shoes. The resident's lower legs appeared dry and scaly. CNA F said the resident's legs appear fine except for some dry skin. 4. Review of Resident #4's significant change MDS, dated [DATE], showed: -Cognitively impaired; -Always incontinent of bowel and bladder; -Skin assessment: Resident at risk of developing pressure ulcers: Yes; -Does resident have one or more unhealed pressure ulcers at Stage 1 or higher? No; -Skin and ulcer treatments: pressure reducing device for chair, application of ointments/medications other than to feet; -Diagnoses included end stage renal disease (ESRD), arthritis, Alzheimer's, anxiety, and depression. Review of the resident's [DATE], TAR showed: -An order, dated [DATE], Eucerin Lotion. Apply to body topically one time a day for dry skin; -No documentation of treatment completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -An order, dated [DATE], Apply calmoseptine to bilateral buttocks for moisture-associated skin damage (MASD) preventative every shift; -No documentation of treatment completed: -A.M. Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; -Evening Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the resident's [DATE] TAR showed: -An order, dated [DATE], Eucerin Lotion. Apply to body topically one time a day for dry skin; -No documentation of treatment completed on [DATE]; -An order, dated [DATE], Apply calmoseptine to bilateral buttocks for MASD preventative every shift; -No documentation of treatment completed: -A.M. Shift: [DATE]; -Evening Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. 5. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Always incontinent bowel and bladder; -Skin assessment: Resident at risk of developing pressure ulcers: Yes; -Does resident have one or more unhealed pressure ulcers at Stage 1 or higher? No; -Skin and ulcer treatments: pressure reducing device for chair and bed, application of ointments/medications other than to feet; -Diagnoses included dementia, high blood pressure, and heart failure. Review of the resident's [DATE] (Resident hospitalized [DATE]-[DATE]), the TAR showed: -An order, dated [DATE], Calmoseptine ointment. Apply to buttocks topically every shift for wound prevention; -No documentation of treatment completed: -A.M. Shift- [DATE]; -Evening Shift-[DATE] and [DATE]; -Night Shift-[DATE], [DATE] and [DATE];. -An order, dated [DATE], Triad Hydrophilic Wound Dress External Paste. Apply to buttocks topically every shift for skin care; -No documentation of treatment completed: -A.M. Shift- [DATE]; -Evening Shift-[DATE] and [DATE]; -Night Shift-[DATE], [DATE] and [DATE]. Review of the resident's [DATE], TAR showed: -An order, dated [DATE], Calmoseptine ointment. Apply to buttocks topically every shift for wound prevention. -No documentation of treatment completed: -Evening Shift-[DATE], [DATE] and [DATE]; -Night Shift-[DATE]; -An order, dated [DATE], Triad Hydrophilic Wound Dress External Paste. Apply to buttocks topically every shift for skin care; -No documentation of treatment completed: -Evening Shift-[DATE], [DATE] and [DATE]; -Night Shift-[DATE]. 6. Review of Resident #6's significant change MDS, dated [DATE], showed: -Cognitively intact; -Always incontinent of bowel and bladder; -Skin assessment: Resident at risk of developing pressure ulcers: Yes; -Does resident have one or more unhealed pressure ulcers at Stage 1 or higher? No; -Skin and ulcer treatments: pressure reducing device for chair; -Diagnoses included heart failure, acid reflux, ESRD, anxiety, and depression. Review of the resident's [DATE] TAR, showed: -An order, dated [DATE], Nystatin powder. Apply to breasts/abdomen folds topically in the evening for redness and excoriation. Apply to both breasts and to abdominal folds; -No documentation of treatment provided on [DATE], [DATE] and [DATE]. Review of the resident's [DATE] TAR, showed: -An order, dated [DATE], Nystatin powder. Apply to breasts/abdomen folds topically in the evening for redness and excoriation. Apply to both breasts and to abdominal folds; -No documentation of treatment given on [DATE] and [DATE]; -An order, dated [DATE], Triad Hydrophilic Wound Dress External Paste. Apply to buttocks topically every shift for skin breakdown; -No documentation of treatment given: -Evening Shift: [DATE] and [DATE]; -Night Shift: [DATE]. 7. During an interview on [DATE] at 1140 A.M., the Director of Nursing (DON) said she rarely has issues with day shift not being able to get assigned tasks done. She rarely works evenings. The DON has heard of issues with evening staff and agency staff. 8. During an interview on [DATE] at 2:00 P.M., the DON and Administrator said they would absolutely expect staff to follow orders for all shifts. When there is a blank spot on the Medication Administration Record (MAR) or TAR, it means that the medication is not given and/or the treatment is not done. If it is not documented, it is not done. They expected staff to sign the MAR/TAR, document, and notify the physician. Skin assessments and treatments should be completed as ordered. If they are unable to complete them, then they should notify DON. If something is documented with a 9, it means it wasn't done and the reason should be documented. 9. On [DATE] at 10:18 A.M., the physician order policy was requested from the Administrator at the facility. During an interview on [DATE] at 10:50 A.M., the Administrator said the facility follows the state and federal guidelines for physician orders. MO00241601

Based on interview and record review, the facility failed to treat each resident with respect and dignity, when they failed to ensure one resident was assisted by female staff after he/she expressed his/her preference (Resident #7). The sample size was seven. The census was 90. The administrator was notified on 10/30/24, of the past non-compliance. The facility updated the resident's care plan regarding caregiver preferences and the resident was assigned female staff for direct care. Staff are knowledgeable of the resident's wishes and follow the staffing assignments. The deficiency was corrected on 9/27/24. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/18/24, showed: -Cognitively intact; -Diagnoses included heart failure, high blood pressure, renal failure, malnutrition, asthma, and respiratory failure; -Partial/moderate assistance with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear. Review of the resident's medical record, showed: -admitted [DATE]; -A progress note, dated 10/26/21, showed care plan meeting today with resident. Resident wants to keep his/her shower days Wednesday and Saturdays and he/she wants a female shower aide. Review of the facility's investigation, showed: -Date of incident: 9/27/24; -Resident is alert and oriented x 4 and is a reliable historian. Resident stated that he/she wanted to go to bed and needed to use the restroom beforehand. Male staff was there assisting him/her. He/She explained to the CNA how he/she needed help being placed onto the toilet. CNA A tried telling him/her how he/she needed to do it himself/herself and explained how to do it. The resident stated the CNA became frustrated with him/her, but finally helped him/her. The resident always likes to leave his/her panties on for bed. CNA A kept telling him/her no. He/She demanded that he/she be allowed to wear his/her panties to bed. The resident stated that staff grabbed him/her under his/her arms while in the wheelchair and tossed him/her into bed roughly. The resident then said that CNA A moved his/her wheelchair to the wall and refused to leave it by his/her bed where he/she always likes to keep it. When CNA A was leaving the room, he/she moved his/her bedside table away from the bed, out of reach; -The resident said for now on, he/she would only like to have women caregivers other than CNA B, who is male; -He/She also gave a list of people that he/she is okay with providing him/her care to the staffing coordinator. It consists of men and women. Review of the resident's care plan, updated 9/27/24, showed: -Focus: The resident has an Activity of Daily Living (ADL) self-care performance deficit; -Interventions: No Male Certified Nurse Aide (CNA) except CNA B per his/her request. Only female CNAs otherwise. During an interview on 10/30/24 at 1:30 P.M., the resident said he/she remembered the incident. A male, agency CNA came into his/her room. CNA A started to put the resident's pants on and the resident said, no. The resident assumed CNA A was assisting him/her to the bathroom. The resident started kicking CNA A with his/her feet. CNA A tossed the resident's shoes on the floor, and said, I cannot do this and left the room. CNA A returned a few minutes after the resident turned on the call light. The resident said he/she always preferred female staff. He/She will ask who his/her shower aide is and if it is not female, he/she will refuse. Staffing had been a problem and he/she had to swallow his/her pride and allow male staff to assist him/her. During an interview on 10/30/24 at 2:23 P.M., Certified Medication Technician (CMT) E said the resident prefers only female staff. It has always been that way. During an interview on 10/30/24 at 2:28 P.M., CNA B said the resident preferred female aides only for his/her showers. At first, it was always bathing. Now the resident's preference for the past three months has been female staff. During an interview on 10/30/24 at 3:42 P.M., the Administrator and Director of Nursing (DON) said they were not sure when the resident's medical record was updated and female staff only was documented, but it sounds like it was right after the most recent incident. They would have expect the resident's preferences to be care planned. If a resident preferred female only staff, they pass that information during report. They would expect staff to treat residents with dignity and respect. If a resident is uncomfortable with staff, they would expect it to be reported to nursing so they can make arrangements for another staff to assist. MO00242863 44950

Based on interview and record review, the facility failed to treat each resident with respect and dignity, when they failed to ensure one resident was assisted by female staff after he/she expressed his/her preference (Resident #7). The sample size was seven. The census was 90. The administrator was notified on 10/30/24, of the past non-compliance. The facility updated the resident's care plan regarding caregiver preferences and the resident was assigned female staff for direct care. Staff are knowledgeable of the resident's wishes and follow the staffing assignments. The deficiency was corrected on 9/27/24. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/18/24, showed: -Cognitively intact; -Diagnoses included heart failure, high blood pressure, renal failure, malnutrition, asthma, and respiratory failure; -Partial/moderate assistance with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear. Review of the resident's medical record, showed: -admitted [DATE]; -A progress note, dated 10/26/21, showed care plan meeting today with resident. Resident wants to keep his/her shower days Wednesday and Saturdays and he/she wants a female shower aide. Review of the facility's investigation, showed: -Date of incident: 9/27/24; -Resident is alert and oriented x 4 and is a reliable historian. Resident stated that he/she wanted to go to bed and needed to use the restroom beforehand. Male staff was there assisting him/her. He/She explained to the CNA how he/she needed help being placed onto the toilet. CNA A tried telling him/her how he/she needed to do it himself/herself and explained how to do it. The resident stated the CNA became frustrated with him/her, but finally helped him/her. The resident always likes to leave his/her panties on for bed. CNA A kept telling him/her no. He/She demanded that he/she be allowed to wear his/her panties to bed. The resident stated that staff grabbed him/her under his/her arms while in the wheelchair and tossed him/her into bed roughly. The resident then said that CNA A moved his/her wheelchair to the wall and refused to leave it by his/her bed where he/she always likes to keep it. When CNA A was leaving the room, he/she moved his/her bedside table away from the bed, out of reach; -The resident said for now on, he/she would only like to have women caregivers other than CNA B, who is male; -He/She also gave a list of people that he/she is okay with providing him/her care to the staffing coordinator. It consists of men and women. Review of the resident's care plan, updated 9/27/24, showed: -Focus: The resident has an Activity of Daily Living (ADL) self-care performance deficit; -Interventions: No Male Certified Nurse Aide (CNA) except CNA B per his/her request. Only female CNAs otherwise. During an interview on 10/30/24 at 1:30 P.M., the resident said he/she remembered the incident. A male, agency CNA came into his/her room. CNA A started to put the resident's pants on and the resident said, no. The resident assumed CNA A was assisting him/her to the bathroom. The resident started kicking CNA A with his/her feet. CNA A tossed the resident's shoes on the floor, and said, I cannot do this and left the room. CNA A returned a few minutes after the resident turned on the call light. The resident said he/she always preferred female staff. He/She will ask who his/her shower aide is and if it is not female, he/she will refuse. Staffing had been a problem and he/she had to swallow his/her pride and allow male staff to assist him/her. During an interview on 10/30/24 at 2:23 P.M., Certified Medication Technician (CMT) E said the resident prefers only female staff. It has always been that way. During an interview on 10/30/24 at 2:28 P.M., CNA B said the resident preferred female aides only for his/her showers. At first, it was always bathing. Now the resident's preference for the past three months has been female staff. During an interview on 10/30/24 at 3:42 P.M., the Administrator and Director of Nursing (DON) said they were not sure when the resident's medical record was updated and female staff only was documented, but it sounds like it was right after the most recent incident. They would have expect the resident's preferences to be care planned. If a resident preferred female only staff, they pass that information during report. They would expect staff to treat residents with dignity and respect. If a resident is uncomfortable with staff, they would expect it to be reported to nursing so they can make arrangements for another staff to assist. MO00242863

Based on observation, interview and record review, the facility failed to follow their fall policy when the facility failed to assess and complete neurological checks as indicated per facility policy and implement fall interventions as indicated on the plan of care, for three residents (Residents #2, #9, and #8). The sample size was 7. The census was 90. Review of the facility's Fall Risk Reduction policy, revised 2/2019, showed: -Purpose: -To identify residents at risk for falls and implement the interventions to reduce risks; -To ensure appropriate and prompt follow up of resident falls to reduce risk of further falls; -To measure effectiveness of fall reduction interventions; -Procedure: -Residents will be assessed for fall risk at the time of admission/re-admission; and weekly for 3 weeks in conjunction with each quarterly and significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) and after each fall; -Action Steps Following a Fall: -First be sure that the resident is safe; -Do not move the resident until the resident has been assessed by a licensed nurse; -Do not move the resident if you suspect possible fracture; -Provide basic first aid if indicated; -Make sure the resident is comfortable; -Ask the resident what were you doing just prior to the fall, what was different this time (even residents' with dementia may be able to tell you); -Observe and preserve the fall scene. Preserve any faulty equipment involved; -Call 911, as indicated by severity of injury; -Take vital signs; -If the fall was un-witnessed and if the resident is not able to definitively validate that he/she did not strike his/her head, implement neurological checks (neuro-checks, assessment to determine the presence of head injury) and continue for 72 hours; -Schedule for Neurological Assessment Following Potential Head Injury: Every 15 minutes time four, every 60 minutes times four, every 4 hours times four, every shift for 72 hours; -Review the resident's physician's orders for any recent medication additions or changes; -Contact the resident's physician (or physician on-call); -Contact the resident's representative; -Complete a fall scene investigation and begin root cause analysis; -Huddle with staff concerning the fall and gather data; -Update a new fall risk assessment, immediately update the care plan, and implement interventions to further reduce the risk of recurrence; -Investigate the fall and review in Resident At Risk Meeting; -Documentation in the Medical Record: -Time of fall; -What happened-the facts; -Findings of resident physical evaluation/assessment; -Conduct an updated fall risk assessment; -Time physician notified; -Time resident representative notified; -Follow-up care and residents' response; -Review and revise care plan. Review of the facility's Condition Change (Observing, Recording, and Reporting) Policy, revised 2/2019, included: -Policy: To observe, record, and report any condition change to the attending physician so proper treatment will be implemented. -Procedure: After resident falls, injuries, or changes in physical or mental condition, monitor the following which include: -Observe and inquire if resident has headache or pain; -Observe for personality changes; -Observe for alternations in consciousness; -Observe for incontinence; -Observe for sensory weakness; -Observe for generalized weakness; -Observe for speech disorder; -Observe for gait, posture, or balance disorder; -Observe for change in ambulation status; -Observe for changes in ability to eat or drink; -Monitor vital signs: -Post fall or injury: every shift for 72 hours; -Change in condition: every shift until stable; -If resident has sustained trauma to the head or uncertain related to possible head injury, neuro-checks are to be done: -Every 15 minutes x 4 (1st hour post injury); -Every 30 minutes x 4; -Every 4 hours x 4; -Every shift x 72 hours, or until stable; -Neuro-checks to include at minimum assessment of pupil response, motor response (checking hand grasps) and level of consciousness; -Notify physician of change of condition and up-date as needed based on continued observation; -If change of condition is acute, have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director; -Document observations, assessments and communication related to resident change in condition in the medical record providing objective data; -Complete an incident, accident, or task management report per facility policy; -Notify resident's responsible party; -Monitor resident's condition frequently until stable. Review of a sample Neurological Assessment Flow Sheet, showed: -A column for date, time, level of contentiousness, right pupil response, left pupil response, hand grips motor function, extremities motor function, blood pressure, pulse, respirations, comments/nurse signature; -Key: -Level of consciousness: Narrative description of behavior and response to stimuli; -Pupil response: Pupils equal and reactive to light (PERLA), brisk (B), sluggish (S), nonreactive (NR), pinpoint (PP), dilatated (DIL), fixed (FIX); -Motor function hand grasps: Hands grasps equal (=), right hand grasp greater than left (R>L), left hand grasp greater than right (L>R), unable to follow commands (U), absent due to medical condition (AB); -Motor function extremities: Moves all extremities ([NAME]), moves right arm (RUE), Moves left arm (LUE), moves right leg (RLE), moves left leg (LLE), unable to follow commands (U), past medical conation prevents voluntary movements (AB), appropriate pain response (APP). 1. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Functional limitation in range of motion: No impairment to the upper or lower extremities; -Mobility: -Substantial/maximal assistance required to: Roll left and right; sit to lying; lying to sitting on side of bed; -Dependent for: Chair/bed-to-chair transfer; tub/shower transfer; -Sit to stand and toilet transfer not applicable; -Walking 10 feet not attempted due to medical condition or safety concerns; -Always incontinent of bowel and bladder; -Any falls since admission or prior assessment, whichever is more recent: Yes, one with injury (except major); -Diagnoses included diabetes, Alzheimer's disease, and dementia. Review of the facility's incident and accident report, provided on 10/30/24, showed the following for the resident: -The resident had an unwitnessed fall on 9/12/24 and 9/19/24; -The report did not show a fall on 9/30/24. Review of the resident's assessments, for September and October 2024, showed the most recent fall assessment evaluation completed on 9/13/24 with a score of 9. A score of 10 or higher indicates high fall risk. Review of the resident's care plan, updated on 9/25/24, showed: -Need: The resident is at risk for falls related to confusion. Unaware of safety needs/has had actual fall; -Goal: The resident will not sustain serious injury through the review date; -Interventions/Tasks: Anticipate and meet the resident's needs, check and change every 2-3 hours for incontinence, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of the resident's electronic medical record (EMR), showed: -A progress note, dated 9/30/24 at 11:50 P.M., resident fell out of bed face down at approximately 10:10 P.M. Resident had laceration to head with blood on floor. Resident refused to allow assist to turn. Yelling to leave him/her alone. Vitals taken: Temperature: 97.2 (normal 97.8 through 99.1), blood pressure (BP): 112/87 (normal 90/60 through 120/80), pulse: 53 (normal 60 through 100), and respirations 20 (normal 12 through 22). Nurse had certified nursing assistant (CNA) call 911. Resident was transported to the hospital for evaluation. Hospice was called and informed. The resident's family member was called and informed nurse practitioner (NP); -A progress note, dated 10/1/24 at 2:10 A.M., resident returned from hospital with two emergency medical technician's (EMT) and son. Resident transferred into bed, bed in low position. Hematoma (a collection of blood that pools outside of a blood vessel, usually caused by an injury or trauma) noted to top of head and some scrapes, bruising noted to left side of face. Resident has bruise to right wrist with pressure bandage. Pressure bandage also noted to left wrist; -No documentation of neuro-checks every 4 hours times four started or completed after the resident returned from the hospital; -A progress note, dated 10/1/24 at 12: 29 P.M., resident continues on follow-up for fall. Resident has no complaints of pain or discomfort related to fall. Resident up in dining room for all meals today. Resident noted to have bruising on top of head from fall as well. Neuro-checks and range of motion within normal limits for this resident. Will continue to monitor. Vital signs: BP: 131/66, temperature: 98.0, pulse: 80, respirations: 20, SPO2 (percentage of oxygen in the blood) 95% (normal 95% through 100%) room air; -A progress note, dated 10/2/24 at 4:53 A.M., showed resident alert in bed talking. Neuro-check within normal limits. No complaints voiced. Vital signs: BP: 120/68, pulse: 79, respirations: 18, temperature: 98.3; -A progress note, dated 10/3/24 at 5:13 A.M., neuro-check within normal limits for the resident. In low bed with mat at bedside for safety. No complaints voiced. Hematoma still noted to top of scalp. Vital signs: BP: 130/60, pulse: 62, respirations: 18, temperature: 97.6; -No further neuro-checks documented as completed in the progress notes for the 9/30/24 fall; -No neuro-check form completed to show the results of assessment, to include motor function and pupil response of any of the neuro-check documented as completed in the progress notes. During an interview on 10/30/24 at 12:10 P.M., Licensed Practical Nurse (LPN) C said unwitnessed falls have neuro-checks completed. If they are sent to hospital and come back within 24 hours, then staff are to restart the neuro-checks. A fall assessment should be completed even if the resident is sent out. Every fall needs a fall assessment even if they have multiple falls in one day. 2. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Functional limitation in range of motion: No impairment to the upper or lower extremities; -Used a wheelchair; -Mobility: -Independent to: Roll left and right; sit to lying; lying to sitting on side of bed; sit to stand; chair/bed-to-chair transfer; and toilet transfer; -Walk 10 feet: Independent; -Walk 50 feet: Not attempted due to medical condition or safety concerns; -No falls since admission or prior to assessment, whichever is more recent; -Occasionally incontinent of bladder, always continent of bowel; -Diagnoses include end stage renal disease (ESRD), diabetes, heart failure, and high blood pressure. Review of the resident's care plan, revised on 7/2/24, showed: -Need: Resident at risk for falls/actual fall due to neuropathy (weakness, numbness, and pain from nerve damage); -Goal: Resident will be free of falls through the next review; -Interventions/Tasks: Encourage resident to call staff for assistance to transfer, evaluate fall risk on admission and as needed, if fall occurs initiate frequent neuro and bleeding evaluation per facility protocol. Review of the facility's incident and accident report, showed the resident had an un-witnessed fall on 10/21/24 at 2:08 P.M. Review of the resident's EMR, showed: -The most recent fall assessment completed, dated 7/15/24, score of 8. A score of 10 or higher indicate high fall risk; -No fall assessments completed on or after 10/21/24. Review of the resident's progress notes, reviewed 10/30/24 at 11:04 A.M., showed: -A progress note, dated 10/21/24 at 12:19 P.M., resident was found in the bathroom by the dining room, on his/her knees and hands. Resident has a bump on the right side of forehead and left side of face. Resident also has skin tears to left elbow. Steri-strips (thin adhesive strips which can be used to close small wounds) were used to patch the skin tear. Resident also has an abrasion on each knee. These were cleaned and cover with Band-Aids. NP was made aware. Neuro-checks were started, vital signs are within normal limits and resident can move all extremities and stand up and walk as he/she does usually (baseline). POA called and made aware; -A progress note, dated 10/22/24 at 5:30 A.M., this nurse found dried blood on left side of resident's face and on his/her sheets. This nurse gently cleansed his/her face with soap and water. CNA helped resident get dressed and assisted the resident to his/her wheelchair. Vital signs: BP: 158/68, pulse: 100, temperature 97.7; -A progress note, dated 10/23/24 at 4:31 A.M., resident in low bed resting. Neuro-check within normal limit. Dressing and Band-Aids intact. No complaints voiced. Vital signs: BP: 124/69, pulse: 78, respirations: 18, temperature 97.7; -A progress note, dated 10/24/24 at 3:57 A.M., resident in low bed. Alert. Neuro-check within normal limit. No complaints voiced. Vital signs: BP: 114/72, pulse: 90, respirations: 18, temperature 97.8; -No other neuro-checks completed for the 10/21/24 fall with head injury found in the resident's EMR; -No neuro-check form completed to show the results of assessment, to include motor function and pupil response of any of the neuro-check documented as completed in the progress notes. Observation on 10/30/24 at 11:35 A.M., showed the resident lay in bed on his/her right side. The resident's eyes closed. A greenish/yellow bruise (indicated and older healing bruise) noted to his/her left cheek. 3. Review of Resident #8's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Functional limitation in range of motion: No impairment to the upper or lower extremities; -Mobility: -Substantial/maximal assistance required to: Roll left and right; sit to lying; lying to sitting on side of bed; sit to stand; chair/bed-to-chair transfer; toilet transfer; tub/shower transfer; -Walk 10 feet: Not attempted due to medical condition or safety concerns; -Did the resident have a fall any time in the last month prior to admission: Yes; -No falls since admission or prior assessment, whichever is more recent; -Diagnoses include Alzheimer's disease, arthritis, and high blood pressure. Review of the resident's care plan, revised 8/20/24, showed: -Need: Resident is at risk for falls related to confusion, cognitive deficits, weakness, need for maximum/total assistance with activities of daily living, incontinence, history of falls, tries to get up without assistance. Has had an actual fall trying to get out of bed; -Goal: The resident will not sustain serious injury through the review date; -Interventions/Tasks: Follow facility fall protocol, low bed and fall mats on each side of the bed, take to bathroom after meals (initiated 10/9/24). Review of the facility's incident and accident report showed the resident had unwitnessed falls on 9/19/24, 9/21/24, 9/22/24, and 10/6/24. Review of the resident's assessments, for September and October 2024, showed: -One fall assessment evaluation completed on 9/22/24. Score of 17 indicated the resident at high risk or falls; -No fall assessment evaluations completed for the 9/19/24, 9/21/24, and 10/6/24 falls. Review of the resident's EMR showed: -A progress note, dated 10/6/24 at 3:17 P.M., resident found on floor in room lying on right side with head near wall. Denies hitting head alert and oriented times one. Assisted to bed from floor with staff assist of three. Yells out when picked up from floor. No shortening of any limb noted. Vital Signs: BP 141/78, pulse: 76, respirations: 20, oxygen: 96% room air. Physician called to report fall, no answer. Family member called. Resident remains in room now in chair. Bed in lowest position with mat on floor. No redness or swelling noted. Unable to tell what happened. Staff aware of fall, aware of previous fall interventions, aware to monitor resident; -No neuro-checks documented as completed in the progress notes for the 10/6/24 fall; -No neuro-check form completed to show the results of assessment, to include motor function and pupil response of any of the neuro-check documented as completed in the progress notes. During an interview on 10/30/24 at 11:55 A.M., LPN D said if a resident falls then the nurse does an assessment. During the assessment, staff check if the residents are coherent, chart, and fill out a neuro-check sheet. Nurses should always do neuro-checks if the resident is not alert and oriented at baseline. The family and physician should be notified as well. 4. During an interview on 10/30/24 at 3:45 P.M., the Director of Nursing (DON) and Administrator said they would expect the fall policy to be followed when a resident has a fall. Staff should obtain vitals, notify the provider, POA, and DON. A fall risk assessment should be completed for every fall. Neurochecks should be initiated for an unwitnessed fall or when a resident hits their head. If a resident is sent out, the neuro-checks should be restarted. A skin assessment should also be completed and there should be a note charted in the resident's progress notes. MO00243113

Based on observation, interview and record review, the facility failed to follow their fall policy when the facility failed to assess and complete neurological checks as indicated per facility policy and implement fall interventions as indicated on the plan of care, for three residents (Residents #2, #9, and #8). The sample size was 7. The census was 90. Review of the facility's Fall Risk Reduction policy, revised 2/2019, showed: -Purpose: -To identify residents at risk for falls and implement the interventions to reduce risks; -To ensure appropriate and prompt follow up of resident falls to reduce risk of further falls; -To measure effectiveness of fall reduction interventions; -Procedure: -Residents will be assessed for fall risk at the time of admission/re-admission; and weekly for 3 weeks in conjunction with each quarterly and significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) and after each fall; -Action Steps Following a Fall: -First be sure that the resident is safe; -Do not move the resident until the resident has been assessed by a licensed nurse; -Do not move the resident if you suspect possible fracture; -Provide basic first aid if indicated; -Make sure the resident is comfortable; -Ask the resident what were you doing just prior to the fall, what was different this time (even residents' with dementia may be able to tell you); -Observe and preserve the fall scene. Preserve any faulty equipment involved; -Call 911, as indicated by severity of injury; -Take vital signs; -If the fall was un-witnessed and if the resident is not able to definitively validate that he/she did not strike his/her head, implement neurological checks (neuro-checks, assessment to determine the presence of head injury) and continue for 72 hours; -Schedule for Neurological Assessment Following Potential Head Injury: Every 15 minutes time four, every 60 minutes times four, every 4 hours times four, every shift for 72 hours; -Review the resident's physician's orders for any recent medication additions or changes; -Contact the resident's physician (or physician on-call); -Contact the resident's representative; -Complete a fall scene investigation and begin root cause analysis; -Huddle with staff concerning the fall and gather data; -Update a new fall risk assessment, immediately update the care plan, and implement interventions to further reduce the risk of recurrence; -Investigate the fall and review in Resident At Risk Meeting; -Documentation in the Medical Record: -Time of fall; -What happened-the facts; -Findings of resident physical evaluation/assessment; -Conduct an updated fall risk assessment; -Time physician notified; -Time resident representative notified; -Follow-up care and residents' response; -Review and revise care plan. Review of the facility's Condition Change (Observing, Recording, and Reporting) Policy, revised 2/2019, included: -Policy: To observe, record, and report any condition change to the attending physician so proper treatment will be implemented. -Procedure: After resident falls, injuries, or changes in physical or mental condition, monitor the following which include: -Observe and inquire if resident has headache or pain; -Observe for personality changes; -Observe for alternations in consciousness; -Observe for incontinence; -Observe for sensory weakness; -Observe for generalized weakness; -Observe for speech disorder; -Observe for gait, posture, or balance disorder; -Observe for change in ambulation status; -Observe for changes in ability to eat or drink; -Monitor vital signs: -Post fall or injury: every shift for 72 hours; -Change in condition: every shift until stable; -If resident has sustained trauma to the head or uncertain related to possible head injury, neuro-checks are to be done: -Every 15 minutes x 4 (1st hour post injury); -Every 30 minutes x 4; -Every 4 hours x 4; -Every shift x 72 hours, or until stable; -Neuro-checks to include at minimum assessment of pupil response, motor response (checking hand grasps) and level of consciousness; -Notify physician of change of condition and up-date as needed based on continued observation; -If change of condition is acute, have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director; -Document observations, assessments and communication related to resident change in condition in the medical record providing objective data; -Complete an incident, accident, or task management report per facility policy; -Notify resident's responsible party; -Monitor resident's condition frequently until stable. Review of a sample Neurological Assessment Flow Sheet, showed: -A column for date, time, level of contentiousness, right pupil response, left pupil response, hand grips motor function, extremities motor function, blood pressure, pulse, respirations, comments/nurse signature; -Key: -Level of consciousness: Narrative description of behavior and response to stimuli; -Pupil response: Pupils equal and reactive to light (PERLA), brisk (B), sluggish (S), nonreactive (NR), pinpoint (PP), dilatated (DIL), fixed (FIX); -Motor function hand grasps: Hands grasps equal (=), right hand grasp greater than left (R>L), left hand grasp greater than right (L>R), unable to follow commands (U), absent due to medical condition (AB); -Motor function extremities: Moves all extremities ([NAME]), moves right arm (RUE), Moves left arm (LUE), moves right leg (RLE), moves left leg (LLE), unable to follow commands (U), past medical conation prevents voluntary movements (AB), appropriate pain response (APP). 1. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Functional limitation in range of motion: No impairment to the upper or lower extremities; -Mobility: -Substantial/maximal assistance required to: Roll left and right; sit to lying; lying to sitting on side of bed; -Dependent for: Chair/bed-to-chair transfer; tub/shower transfer; -Sit to stand and toilet transfer not applicable; -Walking 10 feet not attempted due to medical condition or safety concerns; -Always incontinent of bowel and bladder; -Any falls since admission or prior assessment, whichever is more recent: Yes, one with injury (except major); -Diagnoses included diabetes, Alzheimer's disease, and dementia. Review of the facility's incident and accident report, provided on 10/30/24, showed the following for the resident: -The resident had an unwitnessed fall on 9/12/24 and 9/19/24; -The report did not show a fall on 9/30/24. Review of the resident's assessments, for September and October 2024, showed the most recent fall assessment evaluation completed on 9/13/24 with a score of 9. A score of 10 or higher indicates high fall risk. Review of the resident's care plan, updated on 9/25/24, showed: -Need: The resident is at risk for falls related to confusion. Unaware of safety needs/has had actual fall; -Goal: The resident will not sustain serious injury through the review date; -Interventions/Tasks: Anticipate and meet the resident's needs, check and change every 2-3 hours for incontinence, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of the resident's electronic medical record (EMR), showed: -A progress note, dated 9/30/24 at 11:50 P.M., resident fell out of bed face down at approximately 10:10 P.M. Resident had laceration to head with blood on floor. Resident refused to allow assist to turn. Yelling to leave him/her alone. Vitals taken: Temperature: 97.2 (normal 97.8 through 99.1), blood pressure (BP): 112/87 (normal 90/60 through 120/80), pulse: 53 (normal 60 through 100), and respirations 20 (normal 12 through 22). Nurse had certified nursing assistant (CNA) call 911. Resident was transported to the hospital for evaluation. Hospice was called and informed. The resident's family member was called and informed nurse practitioner (NP); -A progress note, dated 10/1/24 at 2:10 A.M., resident returned from hospital with two emergency medical technician's (EMT) and son. Resident transferred into bed, bed in low position. Hematoma (a collection of blood that pools outside of a blood vessel, usually caused by an injury or trauma) noted to top of head and some scrapes, bruising noted to left side of face. Resident has bruise to right wrist with pressure bandage. Pressure bandage also noted to left wrist; -No documentation of neuro-checks every 4 hours times four started or completed after the resident returned from the hospital; -A progress note, dated 10/1/24 at 12: 29 P.M., resident continues on follow-up for fall. Resident has no complaints of pain or discomfort related to fall. Resident up in dining room for all meals today. Resident noted to have bruising on top of head from fall as well. Neuro-checks and range of motion within normal limits for this resident. Will continue to monitor. Vital signs: BP: 131/66, temperature: 98.0, pulse: 80, respirations: 20, SPO2 (percentage of oxygen in the blood) 95% (normal 95% through 100%) room air; -A progress note, dated 10/2/24 at 4:53 A.M., showed resident alert in bed talking. Neuro-check within normal limits. No complaints voiced. Vital signs: BP: 120/68, pulse: 79, respirations: 18, temperature: 98.3; -A progress note, dated 10/3/24 at 5:13 A.M., neuro-check within normal limits for the resident. In low bed with mat at bedside for safety. No complaints voiced. Hematoma still noted to top of scalp. Vital signs: BP: 130/60, pulse: 62, respirations: 18, temperature: 97.6; -No further neuro-checks documented as completed in the progress notes for the 9/30/24 fall; -No neuro-check form completed to show the results of assessment, to include motor function and pupil response of any of the neuro-check documented as completed in the progress notes. During an interview on 10/30/24 at 12:10 P.M., Licensed Practical Nurse (LPN) C said unwitnessed falls have neuro-checks completed. If they are sent to hospital and come back within 24 hours, then staff are to restart the neuro-checks. A fall assessment should be completed even if the resident is sent out. Every fall needs a fall assessment even if they have multiple falls in one day. 2. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Functional limitation in range of motion: No impairment to the upper or lower extremities; -Used a wheelchair; -Mobility: -Independent to: Roll left and right; sit to lying; lying to sitting on side of bed; sit to stand; chair/bed-to-chair transfer; and toilet transfer; -Walk 10 feet: Independent; -Walk 50 feet: Not attempted due to medical condition or safety concerns; -No falls since admission or prior to assessment, whichever is more recent; -Occasionally incontinent of bladder, always continent of bowel; -Diagnoses include end stage renal disease (ESRD), diabetes, heart failure, and high blood pressure. Review of the resident's care plan, revised on 7/2/24, showed: -Need: Resident at risk for falls/actual fall due to neuropathy (weakness, numbness, and pain from nerve damage); -Goal: Resident will be free of falls through the next review; -Interventions/Tasks: Encourage resident to call staff for assistance to transfer, evaluate fall risk on admission and as needed, if fall occurs initiate frequent neuro and bleeding evaluation per facility protocol. Review of the facility's incident and accident report, showed the resident had an un-witnessed fall on 10/21/24 at 2:08 P.M. Review of the resident's EMR, showed: -The most recent fall assessment completed, dated 7/15/24, score of 8. A score of 10 or higher indicate high fall risk; -No fall assessments completed on or after 10/21/24. Review of the resident's progress notes, reviewed 10/30/24 at 11:04 A.M., showed: -A progress note, dated 10/21/24 at 12:19 P.M., resident was found in the bathroom by the dining room, on his/her knees and hands. Resident has a bump on the right side of forehead and left side of face. Resident also has skin tears to left elbow. Steri-strips (thin adhesive strips which can be used to close small wounds) were used to patch the skin tear. Resident also has an abrasion on each knee. These were cleaned and cover with Band-Aids. NP was made aware. Neuro-checks were started, vital signs are within normal limits and resident can move all extremities and stand up and walk as he/she does usually (baseline). POA called and made aware; -A progress note, dated 10/22/24 at 5:30 A.M., this nurse found dried blood on left side of resident's face and on his/her sheets. This nurse gently cleansed his/her face with soap and water. CNA helped resident get dressed and assisted the resident to his/her wheelchair. Vital signs: BP: 158/68, pulse: 100, temperature 97.7; -A progress note, dated 10/23/24 at 4:31 A.M., resident in low bed resting. Neuro-check within normal limit. Dressing and Band-Aids intact. No complaints voiced. Vital signs: BP: 124/69, pulse: 78, respirations: 18, temperature 97.7; -A progress note, dated 10/24/24 at 3:57 A.M., resident in low bed. Alert. Neuro-check within normal limit. No complaints voiced. Vital signs: BP: 114/72, pulse: 90, respirations: 18, temperature 97.8; -No other neuro-checks completed for the 10/21/24 fall with head injury found in the resident's EMR; -No neuro-check form completed to show the results of assessment, to include motor function and pupil response of any of the neuro-check documented as completed in the progress notes. Observation on 10/30/24 at 11:35 A.M., showed the resident lay in bed on his/her right side. The resident's eyes closed. A greenish/yellow bruise (indicated and older healing bruise) noted to his/her left cheek. 3. Review of Resident #8's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Functional limitation in range of motion: No impairment to the upper or lower extremities; -Mobility: -Substantial/maximal assistance required to: Roll left and right; sit to lying; lying to sitting on side of bed; sit to stand; chair/bed-to-chair transfer; toilet transfer; tub/shower transfer; -Walk 10 feet: Not attempted due to medical condition or safety concerns; -Did the resident have a fall any time in the last month prior to admission: Yes; -No falls since admission or prior assessment, whichever is more recent; -Diagnoses include Alzheimer's disease, arthritis, and high blood pressure. Review of the resident's care plan, revised 8/20/24, showed: -Need: Resident is at risk for falls related to confusion, cognitive deficits, weakness, need for maximum/total assistance with activities of daily living, incontinence, history of falls, tries to get up without assistance. Has had an actual fall trying to get out of bed; -Goal: The resident will not sustain serious injury through the review date; -Interventions/Tasks: Follow facility fall protocol, low bed and fall mats on each side of the bed, take to bathroom after meals (initiated 10/9/24). Review of the facility's incident and accident report showed the resident had unwitnessed falls on 9/19/24, 9/21/24, 9/22/24, and 10/6/24. Review of the resident's assessments, for September and October 2024, showed: -One fall assessment evaluation completed on 9/22/24. Score of 17 indicated the resident at high risk or falls; -No fall assessment evaluations completed for the 9/19/24, 9/21/24, and 10/6/24 falls. Review of the resident's EMR showed: -A progress note, dated 10/6/24 at 3:17 P.M., resident found on floor in room lying on right side with head near wall. Denies hitting head alert and oriented times one. Assisted to bed from floor with staff assist of three. Yells out when picked up from floor. No shortening of any limb noted. Vital Signs: BP 141/78, pulse: 76, respirations: 20, oxygen: 96% room air. Physician called to report fall, no answer. Family member called. Resident remains in room now in chair. Bed in lowest position with mat on floor. No redness or swelling noted. Unable to tell what happened. Staff aware of fall, aware of previous fall interventions, aware to monitor resident; -No neuro-checks documented as completed in the progress notes for the 10/6/24 fall; -No neuro-check form completed to show the results of assessment, to include motor function and pupil response of any of the neuro-check documented as completed in the progress notes. During an interview on 10/30/24 at 11:55 A.M., LPN D said if a resident falls then the nurse does an assessment. During the assessment, staff check if the residents are coherent, chart, and fill out a neuro-check sheet. Nurses should always do neuro-checks if the resident is not alert and oriented at baseline. The family and physician should be notified as well. 4. During an interview on 10/30/24 at 3:45 P.M., the Director of Nursing (DON) and Administrator said they would expect the fall policy to be followed when a resident has a fall. Staff should obtain vitals, notify the provider, POA, and DON. A fall risk assessment should be completed for every fall. Neurochecks should be initiated for an unwitnessed fall or when a resident hits their head. If a resident is sent out, the neuro-checks should be restarted. A skin assessment should also be completed and there should be a note charted in the resident's progress notes. MO00243113

Based on interview and record review, the facility failed to prevent misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) for 11 residents (Residents #11, #14, #15, #16, #17, #18, #13, #10, #19, #12 and #20) who resided on both the Northeast and Southwest side of the facility. The census was 103. Review of the facility's Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, revised date 1/2017, showed: -Policy: The facility affirms the right of our residents to be free from verbal, sexual, physical, mental abuse, neglect, misappropriation of resident property, crime, corporal punishment, exploitation and/or involuntary seclusion. This facility is committed to establishing a resident sensitive and secure environment. The facility will not knowingly employ or otherwise engage a person who has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, and involuntary seclusion, mistreatment of residents or misappropriation of resident property or exploitation. Individuals who have been convicted of abusing, neglecting, mistreating individuals, or criminal activity prohibited by license and regulation, will not be employed; -Investigating and reporting of abuse and neglect: -2. There are two types of reporting procedures; (internal reporting procedures and external reporting procedures) for the reporting of all alleged, suspected or witnessed incidents of abuse; -3. The internal reporting procedures are distinct and based on the facility reporting procedures. The investigation will consist of: -a. An interview with the person(s) reporting the incident; -b. Interviews with any witnesses to the incident; -c. An interview with the resident; -d. A review of the resident's medical record; -e. An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident; -f. Interviews with the resident's roommate, family members, and visitors; and; -g. A review of circumstances surrounding the incident; -4. Refer to the Guidelines for Facility Self-Report Form (See Attachment B) to report to Department of Health and Senior Services (DHSS); - The facility will follow the external reporting process based on the licensure requirements for the facility. Skilled nursing facilities will follow Centers for Medicare & Medicaid Services (CMS) guidelines and state licensure; -5. Any unusual incident involving the reporting of a reasonable suspicion of a crime involving a resident will be reported to DHSS and any local police department per regulatory requirement and CMS guidelines; -6. The facility will immediately investigate reports by staff and board members under this policy, and third party reports of abuse or neglect, in accordance with the investigation procedures addressed in this policy; -7. The Executive Director (ED) and/or their designee, in conjunction with other executive staff as appropriate, will ensure that it takes appropriate action in response to alleged, witnessed or un-witnessed incident of resident abuse or neglect; -8. The ED and/or their designee will notify the facility management services, the DHSS Regional Office (or the DHSS Hotline), resident representative, personal attending physician and medical director of the ensuing investigation and any action taken so far; -9. The ED and/or their designee will report to the facility management services, the DHSS Regional Office, resident representative, personal attending physician and medical director the results of the reasonable alleged, suspected or witnessed incident of abuse and neglect investigations. -10. The ED and/or their designee in conjunction with the facility management services will determine the appropriate management action(s) to be taken as a result of the findings of investigation, confirm action to be taken with Human Resources at the facility and notify DHSS Regional Office and police (if deemed necessary) of actions taken; -Management roles and responsibilities: -4. The ED and/or their designee will assure the employee(s) whom are alleged to have committed the abuse or neglect are suspended pending investigation until the investigation is completed and a final report is made. -6. If the events indicate there is a reasonable suspicion of crime involving a resident that results in serious bodily injury, the report must be made immediately after forming the suspicion, but not later than two hours after forming the suspicion. Otherwise, the report must be made within twenty-four hours to the DHSS Regional Office and the local police department; -7. Maintain the security and integrity of the physical evidence at the incident, including documenting this evidence appropriately; -8. Reporting must be done by either calling the DHSS Regional Office or calling the Hotline within the specified timelines of the law; -Theft/Misappropriation: -The facility must timely report any reasonable suspicion of a crime against a resident of, or who is receiving care from the facility; -Reports must be submitted to the DHSS Regional Office during normal business hours or through the DHSS Hotline and at least one law enforcement agency of jurisdiction. (Law enforcement is defined as the full range of potential responders to elder abuse, neglect and exploitation including: police, sheriffs, detectives, public safety officers, prosecutors, medical examiners, investigators and coroners.); -If there is not serious bodily injury, the report must be made not later than 24 hours after forming the suspicion; -The facility is subjected to civil money penalty and exclusion sanctions for failure to meet the reporting obligations of the statute; therefore, any reasonable suspicion of a crime against a resident shall be reported to the DHSS and to the police department if warranted; -Investigation Path: -Definition: Misappropriation (theft) of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent; -Decision to Proceed: -If there is a suspicion of theft involved, proceed with investigation procedures mentioned in steps 6 and 7 of investigating and reporting of abuse and neglect; -6. The facility will immediately investigate reports by staff and board members under this policy, and third party reports of abuse or neglect, in accordance with the investigation procedures addressed in this policy; -7. The ED and/or their designee, in conjunction with other executive staff as appropriate, will ensure that it takes appropriate action in response to alleged, witnessed or un-witnessed incident of resident abuse or neglect; -Additional considerations: -Reasonable suspicion of crime: -If the events indicate there is a reasonable suspicion of crime involving a resident that results in serious bodily injury, the report must be made immediately after forming the suspicion, but not later than two hours after forming the suspicion. Otherwise, the report must be made within twenty-four hours to the DHSS Regional Office and local law enforcement; -Reporting can be done by telephone, electronic mail, fax or other means within the specified timelines of the law; -Attachment B, facility self-report form: -3. The reporting facility's documentation must include the following information: -A. Specific description of the incident (the date, time, and location of the alleged incident); -B. The names, social security numbers, date of birth and cognitive status of the resident(s); -C. A description of the resident(s) injury; -D. Names, addresses, telephone numbers and position or relationship of the witness(es). For employees, also include date of birth and social security number; -E. What corrective actions the facility has taken to prevent the incident from reoccurring; -F. Statements must be signed and dated; -G. All pertinent information on staff/resident perpetrators; -H. Any other supporting information, i.e., nursing notes, monthly summaries, resident assessment instrument, care plan, physician notes, etc; -Attachment C, Notice reporting reasonable suspicion of a crime: -All employees of the facility have the following responsibilities and rights under Federal law: -If you reasonably suspect that a crime has occurred against a resident or person receiving care in the facility you must report that suspicion to the ED, who will then coordinate timely reporting to the police and DHSS Regional Office/Hotline or you may report it directly to those agencies; -You must make the report within two hours after you first suspect that a crime has occurred if the suspected crime involves serious bodily injury to the individual or within twenty-four hours if there is no serious bodily injury involved; -Note: If you fail to report your reasonable suspicion of a crime, you may be subject to a civil monetary penalty of up to $300,000 and/or you may be excluded from participation in any Federal health care program. Review of the facility's Discrepancies, Loss, and/or Diversion of Medications policy, effective 5/2018, showed: -Policy: All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed; -Procedures: -A. Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator/ED, Director of Nursing (DON) and Consultant Pharmacist are notified, and an investigation conducted. The DON leads the investigation: -1. The information is not to be discussed with other individuals; -2. During the process, the Consultant Pharmacist will verify suspected loss; -B. Discrepancy in a drug count: -1. The DON investigates the discrepancy and researches all the records related to medication administration and the supply of the medication, including medication reconciliation. Medication reconciliation is made from the last known date and time of reconciliation (e.g., during the last shift count, receipt of a full medication container, etc.). A thorough search in all drug storage areas, the resident's room and other locations where medications may have been used/placed during the medication administration are made to locate any missing container or medication supply; -2. After a thorough investigation has been completed and the discrepancy cannot be reconciled, the remaining supply is documented with date and time and the accountability process restarts at this point. The discrepancy is documented unable to reconcile.; -3. Accountability of the medication in question should be checked several times in the following days to assure that accountability is being maintained; -4. Any corrective action that the DON feels is appropriate should be taken; -5. Appropriate agencies, required by state regulation will be notified; -C. Loss of a supply of a medication: -1. The DON investigates the suspected loss and researches all the records related to medication receipt, its use since receipt, all persons involved with medication administration and the supply of the medication and identifies the last known point in time that the medication was available. The dispensing pharmacy should be notified, and the pharmacy should verify that the medication was actually dispensed. A thorough search in all drug storage areas, the resident's room and other locations where medications may have been used/placed during the medication administration are made to locate any missing container or medication supply; -2. After a thorough investigation has been completed and the supply cannot be found, a supply must be obtained for the resident; -3. Document the loss and the investigation process. Notify the prescriber and family if doses have been missed; -4. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited; -5. If the audit reveals a particular individual(s) who might be suspected of involvement with the loss, appropriate disciplinary actions arc taken and deferred to human resource policies; -6. Appropriate agencies, required by state and federal law, will be notified; -D. Robbery: -1. In the event of a robbery, the nurse is to give the individual(s) any medications demanded without resistance; -2. Immediately following the robbery: -a. Make notes regarding the description of the individual; -b. Notify administration or person in charge; -c. Notify the police; -d. Notify the Consultant Pharmacist or Pharmacy emergency number; -e. Itemize the items removed. Review of the facility's Controlled Substance policy, effective date of 5/2018, showed: -Policy Statement: Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations; -Procedures: -A. The DON and the consultant pharmacist in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications; -B. Medications supplied by the provider pharmacy shall identify medications as controlled medicines, either as a part of the label (i.e., a red letter C stamped on the label), or by sending a controlled medicine count sheet with the medication, or both; -C. All controlled substances, Schedule two controlled substance (CII, medication with higher potential of dependency and abuse), Schedule three controlled medication (CIII, medication with low to moderate potential of dependency and abuse), Schedule four controlled substance (CIV, medication with low potential of dependency and abuse), Schedule five controlled substance (CV, lowest potential of dependency and abuse)) CII through CV are stored and maintained in a locked cabinet or compartment. If refrigeration is required, the refrigerator or a container kept in the refrigerator is locked; -E. Accurate accountability of the inventory of all controlled medicines is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR): -1. Date and time of administration (MAR, Accountability Record); -2. Amount administered (Accountability Record); -3. Remaining quantity (Accountability Record); -4. Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record); -F. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container (i.e., not back in inventory). It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules. This does not apply to controlled medicines packaged in unit-dose containers that are unopened (vials, ampules, patches); -H. All controlled medications arc reordered when a minimum five-day supply remains to allow time for acquisition and transmittal of the required original written prescription to the provider pharmacy, if necessary. Review of the facility's Controlled Substance Audit policy, review date of 2/2019, showed: -Policy statement: To keep accurate records of all controlled substances in accordance with State and Federal laws; -Equipment: -1. Key to locked box where controlled substances for residents on the division for which the Certified Medication Technician (CMT)/Certified Medication Aide (CMA)/Nurse is assuming responsibility are kept; -2. Individual Resident's Controlled Substance Record and Narcotic Count Sign-In Sheet for CMT/CMA/Charge Nurse to inventory together at change of shift; -Procedure: -1. Drugs are to be stored in the same order as the Controlled Records for a fast and efficient audit; -2. When a controlled substance is administered to a resident the Medication Card is to be initialed next to where the pill is punched out by the person who is administering the drug; -3. When a controlled substance is administered to a resident the CMT/CMA/Nurse will sign his/her name under administered by, fill in the date, time, total on hand, amount given and amount remaining; -4. On-coming CMT/CMA/Nurse will actually count drugs. Off-going CMA/CMT/Charge Nurse will follow and verify record; -5. All controlled drugs will be counted between each shift for safe, accurate accountability; -6. When audit is complete, both CMA/CMT/Charge Nurse from each shift will sign audit sheet in appropriate spaces; -7. Narcotic keys will only be carried by the CMT/CMA or by the Nurse, but not by both the CMT/CMA and a Nurse; -8. When a controlled substance record is full, the form is to be forwarded to the Wellness Director/Resident Care Director/DON. 1. Review of the facility's investigation, not dated, showed: -Interview regarding allegation of missing narcotics: It was brought to the attention of the DON on 1/22/24 that there were some irregularities noted on the narcotic sign out sheets. The DON began investigating narcotic sign out sheets and Medication Administration Records for comparison. On 1/24/24, the pharmacy consultant reported to DON and ED that four oxycodone (opioid used to treat moderate to severe pain) were missing from the emergency kit; -Interview of Resident #12 was interviewed by Nurse Manager B. Resident #12 was asked when he/she usually takes his/her pain medication. The resident reported typically he/she just takes it one time in the evening around bedtime; -Interview with witness: On 1/26/24, Licensed Practical Nurse (LPN) B was brought in for interview regarding the medications in question. The DON explained the facility was investigating some medication that has been in question and just speaking with the nurses who have been signing out the medications. The facility asked LPN B for a urine specimen. LPN B said, If you give me a few minutes, I can. DON asked LPN B, How do you decide when to give a resident pain medication? LPN B said, When they express they are in pain or look like they are in pain, then I give them something. DON asked, Have you ever had this type of thing happen anywhere you worked before? LPN B responded, No. LPN B said, I am not going to be able to do your drug screen because my back hurts and I took some of my spouse's medication. The facility does have a few video clips where it appears that LPN B put narcotic medications in his/her pocket. The facility also has MARs and Narcotic Sign Out Sheets that demonstrate this complaint; -Interviews with other staff working at the time: Not Applicable (NA); -Interview with other residents on the same hall: NA; -Interview of other staff members: NA; -Review of resident's chart: NA; -Outcome: LPN B voluntarily resigned on 1/26/24, families were notified, the local police department was notified and the Missouri Board of Nursing was notified; -Complaint report to the Missouri Board of Nursing, dated 2/2/24: -On 1/20/24, it was brought to the attention of the DON that residents who do not usually take much pain medication are suddenly taking more doses than expected. DON began auditing narcotic sign out sheets and noted same signature appearing multiple times for numerous residents. Upon comparison of narcotic sign out sheets to the MAR, it was noted that 60 times a narcotic was signed out but not documented by the same nurse. It was also noted a narcotic was signed out for a resident who did not have an active order. On 1/22/24, pharmacy consultant was in to audit the emergency medication kit and noted four oxycodone to be missing from a card. Pharmacy consultant stated at that time there is no way for the pharmacy to tell who may have taken the four oxycodone because they only audit once a month and the camera only shows the face of the person using the system, not their hands. LPN B was identified as the signature that continued to show as the individual signing out the narcotics on the individual resident count sheets. On 1/26/24, LPN B was brought in for interview in regard to the medications in question. DON explained the facility was investigating some medication that has been in question and just speaking with the nurses who have been signing out the medications. The DON requested a urine specimen. LPN B said, If you give me a few minutes, I can. DON asked LPN B, How do you decide when to give a resident pain medication? LPN B said, When they express they are in pain or look like they are in pain, then I give them something. DON asked, Have you ever had this type of thing happen anywhere you worked before? LPN B said, No. LPN B said, I am not going to be able to do your drug screen because my back hurts and I took some of my spouse's medication. The facility does have a few video clips where it appears that LPN B put the narcotic medications in his/her pocket. The facility also has MAR and narcotic sign out sheets that demonstrate this complaint; -Description of complaint: -Date of incidents: 1/26/24; -Time: 3:00 P.M.; -Has this complaint been reported to any other agency, court, or other entity: yes; -Name: DHSS; -The facility included MARs and controlled drug records (narcotic sign out sheets) for 10 residents (Residents #19, #17, #12, #13, #16, #18, #20, #15, #11 and #14); -The facility did not recognize the additional resident, Resident #10 in the investigation, who was reported to the DON on 1/22/24. 2. Review of Police Department Investigative Report, dated 2/2/24, showed: -Date/Time received: 2/2/24 at 2:30 P.M.; -Date/Time dispatch: 2/2/24 at 2:31 P.M.; -Date/Time arrival: 2/2/24 at 2:35 P.M.; -Offense: Stealing/Elder Abuse; -Victim #1 information: Resident #18; -Victim #2 information: Resident #15; -Victim #3 information: Resident #13; -Victim #4 information: Resident #16; -Victim #5 information: Resident #12; -Victim #6 information: Resident #11; -Victim #7 information: Resident #14; -Victim #8 information: Resident #17; -Victim #9 information: Resident #19; -Victim #10 information: Resident #20; -Resident #10 was not identified; -Additional party #1 information: ED; -Additional party #2 information: DON; -Subject information: LPN B; -Charges: Elder Abuse, third degree, stealing - controlled substance/meth (CII) manufacturing material; -Property #1 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: oxycodone; -Property value: $200.00; -Property #2 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: acetaminophen/hydrocodone (Norco, opioid, used for moderate-to-severe pain control); -Property value: $1.00; -Property #3 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: Percocet (Percocet, opioid, used for moderate-to-severe pain control); -Property value: $1.00; -Property #4 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: Ativan (Lorazepam, used to treat anxiety); -Property value: $1.00; -Incident property totals: -Total stolen value: $203.00; -Narrative: - On 02/02/2024 at 2:31 P.M., Police Officer (PO) A was dispatched to the facility for a theft of narcotics. Upon PO A arrival, he/she met with the ED and DON who stated their employee LPN B had been observed on video stealing various narcotics which included: Oxycodone, Norco, Percocet and Ativan which were all controlled substances. The narcotics totaled 60 Units on 10 different days. Per the facility policy, the facility investigated LPN B where he/she could be observed taking the medication from the lock box and placing it into his/her pocket. LPN B was informed by the facility someone had been removing medication and not providing it to the residents in the facility and was requested to complete a drug screen on 1/26/2024. LPN B declined to provide a drug screen and voluntarily resigned that day. The facility was made aware LPN B's nursing license was placed on probation which was terminated on 12/23/2023 for a previous charge of possession of a controlled substance. LPN B was hired by the facility on 1/08/2024 and officially started on 1/10/2024. Upon review of the video surveillance, LPN B can be observed stealing the narcotics on: 1/10/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/18/2024, 1/19/2024, 1/22/2024, 1/23/2024, 1/24/24. It should be noted there were also four Oxycodone missing from the facility's emergency kit, but cannot be tied to LPN B. The facility has a Narcotic Sign Out sheet which was audited due to the medication concern. Upon the audit, one signature was noted signing out several medications for several different patients, including one who did not have a medication order in their file. The facility reported LPN B to the State Board of Nursing, as well as DHSS. At this time, I have not received the videos from the facility. Once obtained, will be attached to this report. Charges will be submitted to the Prosecuting Attorney's Office; -Investigative information: -Narrative: -On 02/03/2024 at approximately 11:00 A.M., PO A attempted to make contact with the facility in an attempt to obtain the video footage of the incident. I was informed the video was still unavailable and would likely not be available until 02/05/2024; -On 02/07/2024, 02/08/2024, and 02/12/2024, PO A attempted to obtain the video footage from the facility in which PO A was informed the footage was not ready; -On 02/09/2024, I sent an email to DON and the ED of the facility requesting the video footage - which I have not received a response to at this time; -PO A will continue to follow up; -Narrative: On 02/13/2024, PO A entered a Wanted into REJIS (provides data processing services and online information systems for police) for LPN B; -Narrative: On 02/15/2024, PO A received video footage which appeared to show LPN B placing the medication into his/her pocket and leaving. The video has been uploaded and placed into evidence per department policy. 3. Review of summary of termination conversation with LPN B, dated 2/28/24, showed: -Summary of termination conversation with LPN B from: ED: On 1/26/24, LPN B was asked to meet with the DON and ED regarding our investigation into missing narcotics. The ED and DON informed LPN B at the start of the investigation that we would also be completing a drug screen at the conclusion of our meeting and LPN B was agreeable to submitting a drug test. The DON asked LPN B if he/she was aware of any misappropriation of medications during the time he/she was working or if he/she may have knowledge or information from any co-workers. LPN B said no, he/she was not aware of anything missing or had no knowledge of anyone else that he/she works with here at the facility. The ED asked LPN B if at any time in his/her career had concerns been brought up against him/her regarding misappropriation of medications and LPN B once again stated no - nothing. The ED took a second and asked again and he/she repeated no, there were never any concerns of this nature. The ED then excused himself from the conversation to go and print off a letter addressed to LPN B from the State Board of Nursing regarding an investigation against him/her about misappropriation of medications (in his/her past). The letter was a follow up (warning), requesting that LPN B complete a treatment program and after a period of time with approval, he/she was allowed to continue working in the nursing field as an LPN. I asked LPN B to review the letter that I printed, and he/she read the letter and stated that the letter was inaccurate (meaning they messed up that facts) of this investigation. LPN B stated that he/she understood that this did not look good on his/her behalf (meaning that we caught him/her in a lie when asked earlier in the conversation). At this point, LPN B said he/she would not be able to participate in a drug test and we informed him/her that he/she would be self-terminating his/her position at the facility and LPN B said he/she understood. LPN B collected his/her personal belongings and was escorted out the front door by the DON. Immediately following, we contacted the State Board of Nursing, the DHSS, and the ED spent the rest of the afternoon making calls to the families to make them aware of the incident. 4. Review of statement from LPN C, undated, showed: -On January 22 LPN C noticed that one of Resident #14's Oxycodone had been slowly being signed out by the same nurse. Since LPN C has been employed at the facility this resident has not had complaints of pain or requested pain medication, nor has the resident showed non-verbal signs of pain. LPN C also noticed that Resident #10's Ativan had two tablets taken and signed out wasted. LPN C reported this to the DON immediately. 5. Review of LPN B's Employee Timesheet, dated 1/7/24 through 2/3/24, showed: -Monday, 1/8/24, from 9:30 A.M. to 1:00 P.M., LPN, Inservice/Orientation; -Monday, 1/8/24, from 3:20 P.M. to 11:45 P.M., LPN Skilled Nursing Facility (SNF); -Tuesday, 1/9/24, from 2:30 P.M. to Wednesday 1/10/24 12:00 A.M., LPN SNF; -Wednesday, 1/10/24, from 2:30 P.M. to 11:20 P.M., LPN SNF; -Friday, 1/12/24, from 2:30 P.M. to Saturday 1/13/23 7:45 A.M., LPN SNF; -Saturday, 1/13/24, from 2:30 P.M. to Sunday 1/14/24 7:15 A.M., LPN SNF; -Sunday, 1/14/24, from 2:30 P.M. to Monday 1/15/24 7:30 A.M., LPN SNF; -Monday, 1/15/24, from 8:30 P.M. to Tuesday 1/16/24 7:40 A.M., LPN SNF; -Tuesday, 1/16/24, from 2:53 P.M. to Wednesday 1/17/24 3:55 A.M., LPN SNF; -Thursday, 1/18/24, from 2:32 P.M. to 11:37 P.M., LPN SNF; -Friday, 1/19/24, from 2:41 P.M. to Saturday 1/20/24 8:11 A.M., LPN SNF; -Monday, 1/22/24, from 2:37 P.M. to 11:22 P.M., LPN SNF; -Tuesday, 1/23/24, from 7:43 A.M. to 11:40 P.M., LPN SNF; -Wednesday, 1/24/24, from 2:51 P.M. to Thursday 1/25/24 12:00 A.M., LPN SNF. 6. Review of Resident #11's quarterly Minimum Data Set (MDS). a federally mandated assessment completed by facility staff, dated 1/3/24, showed: -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, no; -Received PRN pain medications, no; -Pain presence, no; -Pain frequency, not rated; -Pain effect on sleep, not rated; -Pain interference with day-to-day activities, not rated; -Diagnoses included hip fracture, pain in right hip, scoliosis (curvature of the spine), asthma and cognitive communication deficit. Review of the Physician Order Sheet (POS), dated 11/1/23 through 2/29/24, showed, Hydrocodone-Acetaminophen (Norco, opioid, used for moderate-to-severe pain control) 5-325 milligram (mg) one tablet every six hours as needed (PRN) for pain, with an order date of 11/7/23 and a discontinue date of 2/19/24. Review of the resident's controlled drug record for Norco 5-325 mg every six hours PRN for pain, dispensed 11/8/23, showed LPN B signed out the medication on the following dates: -One tablet on 1/10/24 at 5:00 P.M.; -One tablet on 1/13/24 at 7:00 P.

Based on interview and record review, the facility failed to ensure all alleged violations involving misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) were reported within twenty-four hours to the Department of Health and Senior Services (DHSS), law enforcement, and the Board of Nursing after the facility was made aware of allegations of diversion for 11 residents (Residents #11, #14, #15, #16, #17, #18, #13, #10, #19, #12 and #20) by two nurses, Licensed Practical Nurse (LPN) C and LPN D on the morning of 1/22/24. The census was 103. Review of the facility's Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, revised date 1/2017, showed: -Policy: The facility affirms the right of our residents to be free from verbal, sexual, physical, mental abuse, neglect, misappropriation of resident property, crime, corporal punishment, exploitation and /or involuntary seclusion. This facility is committed to establishing a resident sensitive and secure environment. The facility will not knowingly employ or otherwise engage a person who has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, and involuntary seclusion, mistreatment of residents or misappropriation of resident property or exploitation. Individuals who have been convicted of abusing, neglecting, mistreating individuals, or criminal activity prohibited by license and regulation, will not be employed; -Investigating and reporting of abuse and neglect: -2. There are two types of reporting procedures; (internal reporting procedures and external reporting procedures) for the reporting of all alleged, suspected or witnessed incidents of abuse; -3. The internal reporting procedures are distinct and based on the facility reporting procedures. The investigation will consist of: -a. An interview with the person(s) reporting the incident; -b. Interviews with any witnesses to the incident; -c. An interview with the resident; -d. A review of the resident's medical record; -e. An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident; -f. Interviews with the resident's roommate, family members, and visitors; and; -g. A review of circumstances surrounding the incident; -4. Refer to the Guidelines for Facility Self-Report Form (See Attachment B) to report to DHSS; - The facility will follow the external reporting process based on the licensure requirements for the facility. Skilled nursing facilities will follow Centers for Medicare & Medicaid Services (CMS) guidelines and state licensure; -5. Any unusual incident involving the reporting of a reasonable suspicion of a crime involving a resident will be reported to DHSS and any local police department per regulatory requirement and CMS guidelines; -6. The facility will immediately investigate reports by staff and board members under this policy, and third party reports of abuse or neglect, in accordance with the investigation procedures addressed in this policy; -7. The Executive Director (ED) and/or their designee, in conjunction with other executive staff as appropriate, will ensure that it takes appropriate action in response to alleged, witnessed or un-witnessed incident of resident abuse or neglect; -8. The ED and/or their designee will notify the facility management services, the DHSS Regional Office (or the DHSS Hotline), resident representative, personal attending physician and medical director of the ensuing investigation and any action taken so far; -9. The ED and/or their designee will report to the facility management services, the DHSS Regional Office, resident representative, personal attending physician and medical director the results of the reasonable alleged, suspected or witnessed incident of abuse and neglect investigations. -10. The ED and/or their designee in conjunction with the facility management services will determine the appropriate management action(s) to be taken as a result of the findings of investigation, confirm action to be taken with Human Resources at the facility and notify DHSS Regional Office and police (if deemed necessary) of actions taken; -Management roles and responsibilities: -4. The ED and/or their designee will assure the employee(s) whom are alleged to have committed the abuse or neglect are suspended pending investigation until the investigation is completed and a final report is made. -6. If the events indicate there is a reasonable suspicion of crime involving a resident that results in serious bodily injury, the report must be made immediately after forming the suspicion, but not later than two hours after forming the suspicion. Otherwise, the report must be made within twenty-four hours to the DHSS Regional Office and the local police department; -7. Maintain the security and integrity of the physical evidence at the incident, including documenting this evidence appropriately; -8. Reporting must be done by either calling the DHSS Regional Office or calling the Hotline within the specified timelines of the law; -Theft/Misappropriation: -The facility must timely report any reasonable suspicion of a crime against a resident of, or who is receiving care from the facility; -Reports must be submitted to the DHSS Regional Office during normal business hours or through the DHSS Hotline and at least one law enforcement agency of jurisdiction. (Law enforcement is defined as the full range of potential responders to elder abuse, neglect and exploitation including: police, sheriffs, detectives, public safety officers, prosecutors, medical examiners, investigators and coroners.); -If there is not serious bodily injury, the report must be made not later than 24 hours after forming the suspicion; -The facility is subjected to civil money penalty and exclusion sanctions for failure to meet the reporting obligations of the statute; therefore, any reasonable suspicion of a crime against a resident shall be reported to the DHSS and to the police department if warranted; -Investigation Path: -Definition: Misappropriation (theft) of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent; -Decision to Proceed: -If there is a suspicion of theft involved, proceed with investigation procedures mentioned in steps 6 and 7 of investigating and reporting of abuse and neglect; -6. The facility will immediately investigate reports by staff and board members under this policy, and third party reports of abuse or neglect, in accordance with the investigation procedures addressed in this policy; -7. The ED and/or their designee, in conjunction with other executive staff as appropriate, will ensure that it takes appropriate action in response to alleged, witnessed or un-witnessed incident of resident abuse or neglect; -Additional considerations: -Reasonable suspicion of crime: -If the events indicate there is a reasonable suspicion of crime involving a resident that results in serious bodily injury, the report must be made immediately after forming the suspicion, but not later than two hours after forming the suspicion. Otherwise, the report must be made within twenty-four hours to the DHSS Regional Office and local law enforcement; -Reporting can be done by telephone, electronic mail, fax or other means within the specified timelines of the law; -Attachment B, facility self-report form: -3. The reporting facility's documentation must include the following information: -A. Specific description of the incident (the date, time, and location of the alleged incident); -B. The names, social security numbers, date of birth and cognitive status of the resident(s); -C. A description of the resident(s) injury; -D. Names, addresses, telephone numbers and position or relationship of the witness(es). For employees, also include date of birth and social security number; -E. What corrective actions the facility has taken to prevent the incident from reoccurring; -F. Statements must be signed and dated; -G. All pertinent information on staff/resident perpetrators; -H. Any other supporting information, i.e., nursing notes, monthly summaries, resident assessment instrument, care plan, physician notes, etc; -Attachment C, Notice reporting reasonable suspicion of a crime: -All employees of the facility have the following responsibilities and rights under Federal law: -If you reasonably suspect that a crime has occurred against a resident or person receiving care in the facility you must report that suspicion to the ED, who will then coordinate timely reporting to the police and DHSS Regional Office/Hotline or you may report it directly to those agencies; -You must make the report within two hours after you first suspect that a crime has occurred if the suspected crime involves serious bodily injury to the individual or within twenty-four hours if there is no serious bodily injury involved; -Note: If you fail to report your reasonable suspicion of a crime, you may be subject to a civil monetary penalty of up to $300,000 and/or you may be excluded from participation in any Federal health care program. Review of the facility's Discrepancies, Loss, and/or Diversion of Medications policy, effective 5/2018, showed: -Policy: All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed; -Procedures: -A. Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator/ED, Director of Nursing (DON) and Consultant Pharmacist are notified, and an investigation conducted. The DON leads the investigation: -1. The information is not to be discussed with other individuals; -2. During the process, the Consultant Pharmacist will verify suspected loss; -B. Discrepancy in a drug count: -1. The DON investigates the discrepancy and researches all the records related to medication administration and the supply of the medication, including medication reconciliation. Medication reconciliation is made from the last known date and time of reconciliation (e.g., during the last shift count, receipt of a full medication container, etc.). A thorough search in all drug storage areas, the resident's room and other locations where medications may have been used/placed during the medication administration are made to locate any missing container or medication supply; -2. After a thorough investigation has been completed and the discrepancy cannot be reconciled, the remaining supply is documented with date and time and the accountability process restarts at this point. The discrepancy is documented unable to reconcile.; -3. Accountability of the medication in question should be checked several times in the following days to assure that accountability is being maintained; -4. Any corrective action that the DON feels is appropriate should be taken; -5. Appropriate agencies, required by state regulation will be notified; -C. Loss of a supply of a medication: -1. The DON investigates the suspected loss and researches all the records related to medication receipt, its use since receipt, all persons involved with medication administration and the supply of the medication and identifies the last known point in time that the medication was available. The dispensing pharmacy should be notified, and the pharmacy should verify that the medication was actually dispensed. A thorough search in all drug storage areas, the resident's room and other locations where medications may have been used/placed during the medication administration are made to locate any missing container or medication supply; -2. After a thorough investigation has been completed and the supply cannot be found, a supply must be obtained for the resident; -3. Document the loss and the investigation process. Notify the prescriber and family if doses have been missed; -4. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited; -5. If the audit reveals a particular individual(s) who might be suspected of involvement with the loss, appropriate disciplinary actions arc taken and deferred to human resource policies; -6. Appropriate agencies, required by state and federal law, will be notified; -D. Robbery: -1. In the event of a robbery, the nurse is to give the individual(s) any medications demanded without resistance; -2. Immediately following the robbery: -a. Make notes regarding the description of the individual; -b. Notify administration or person in charge; -c. Notify the police; -d. Notify the Consultant Pharmacist or Pharmacy emergency number; -e. Itemize the items removed. Review of the facility's Controlled Substance policy, effective date of 5/2018, showed: -Policy Statement: Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations; -Procedures: -A. The DON and the consultant pharmacist in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications; -B. Medications supplied by the provider pharmacy shall identify medications as controlled medicines, either as a part of the label (i.e., a red letter C stamped on the label), or by sending a controlled medicine count sheet with the medication, or both; -C. All controlled substances, Schedule two controlled substance (CII, medication with higher potential of dependency and abuse), Schedule three controlled medication (CIII, medication with low to moderate potential of dependency and abuse), Schedule four controlled substance (CIV, medication with low potential of dependency and abuse), Schedule five controlled substance (CV, lowest potential of dependency and abuse)) CII through CV are stored and maintained in a locked cabinet or compartment. If refrigeration is required, the refrigerator or a container kept in the refrigerator is locked; -E. Accurate accountability of the inventory of all controlled medicines is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR): -1. Date and time of administration (MAR, Accountability Record); -2. Amount administered (Accountability Record); -3. Remaining quantity (Accountability Record); -4. Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record); -F. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container (i.e., not back in inventory). It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules. This does not apply to controlled medicines packaged in unit-dose containers that are unopened (vials, ampules, patches); -H. All controlled medications arc reordered when a minimum five-day supply remains to allow time for acquisition and transmittal of the required original written prescription to the provider pharmacy, if necessary. Review of the facility's Controlled Substance Audit policy, review date of 2/2019, showed: -Policy statement: To keep accurate records of all controlled substances in accordance with State and Federal laws; -Equipment: -1. Key to locked box where controlled substances for residents on the division for which the Certified Medication Technician (CMT)/Certified Medication Aide (CMA)/Nurse is assuming responsibility are kept; -2. Individual Resident's Controlled Substance Record and Narcotic Count Sign-In Sheet for CMT/CMA/Charge Nurse to inventory together at change of shift; -Procedure: -1. Drugs are to be stored in the same order as the Controlled Records for a fast and efficient audit; -2. When a controlled substance is administered to a resident the Medication Card is to be initialed next to where the pill is punched out by the person who is administering the drug; -3. When a controlled substance is administered to a resident the CMT/CMA/Nurse will sign his/her name under administered by, fill in the date, time, total on hand, amount given and amount remaining; -4. On-coming CMT/CMA/Nurse will actually count drugs. Off-going CMA/CMT/Charge Nurse will follow and verify record; -5. All controlled drugs will be counted between each shift for safe, accurate accountability; -6. When audit is complete, both CMA/CMT/Charge Nurse from each shift will sign audit sheet in appropriate spaces; -7. Narcotic keys will only be carried by the CMT/CMA or by the Nurse, but not by both the CMT/CMA and a Nurse; -8. When a controlled substance record is full, the form is to be forwarded to the Wellness Director/Resident Care Director/DON. 1. Review of the facility investigation, not dated, showed: -Interview regarding allegation of missing narcotics: It was brought to the attention of the DON on 1/22/24 that there were some irregularities noted on the narcotic sign out sheets. The DON began investigating narcotic sign out sheets and Medication Administration Records for comparison. On 1/24/24, the pharmacy consultant reported to DON and ED that 4 oxycodone (opioid used to treat moderate to severe pain) were missing from the emergency kit; -Resident #12 was interviewed by Nurse Manager B. Resident #12 was asked when he/she usually takes his/her pain medication. The resident reported typically he/she just takes it one time in the evening around bedtime; -Interview with witness: On 1/26/24, LPN B was brought in for interview regarding the medications in question. The DON explained the facility was investigating some medication that has been in question and just speaking with the nurses who have been signing out the medications. The facility asked LPN B for a urine specimen. LPN B said, If you give me a few minutes, I can. DON asked LPN B, How do you decide when to give a resident pain medication? LPN B said, When they express they are in pain or look like they are in pain, then I give them something. DON asked, Have you ever had this type of thing happen anywhere you worked before? LPN B responded, No. LPN B said, I am not going to be able to do your drug screen because my back hurts and I took some of my spouse's medication. The facility does have a few video clips where it appears that LPN B put narcotic medications in his/her pocket. The facility also has MARs and Narcotic Sign Out Sheets that demonstrate this complaint; -Interviews with other staff working at the time: Not Applicable (NA); -Interview with other residents on the same hall: NA; -Interview of other staff members: NA; -Review of resident's chart: NA; -Outcome: LPN B voluntarily resigned on 1/26/24, families were notified, the local police department was notified and the Missouri Board of Nursing was notified; -Complaint report to the Missouri Board of Nursing, dated 2/2/24: -On 1/20/24, it was brought to the attention of the DON that residents who do not usually take much pain medication are suddenly taking more doses than expected. DON began auditing narcotic sign out sheets and noted same signature appearing multiple times for numerous residents. Upon comparison of narcotic sign out sheets to the MAR, it was noted that 60 times a narcotic was signed out but not documented by the same nurse. It was also noted a narcotic was signed out for a resident who did not have an active order. On 1/22/24, pharmacy consultant was in to audit the emergency medication kit and noted 4 oxycodone to be missing from a card. Pharmacy consultant stated at that time there is no way for the pharmacy to tell who may have taken the 4 oxycodone because they only audit once a month and the camera only shows the face of the person using the system, not their hands. LPN B was identified as the signature that continued to show as the individual signing out the narcotics on the individual resident count sheets. On 1/26/24, LPN B was brought in for interview in regard to the medications in question. DON explained the facility was investigating some medication that has been in question and just speaking with the nurses who have been signing out the medications. The DON requested a urine specimen. LPN B said, If you give me a few minutes, I can. DON asked LPN B, How do you decide when to give a resident pain medication? LPN B said, When they express they are in pain or look like they are in pain, then I give them something. DON asked, Have you ever had this type of thing happen anywhere you worked before? LPN B said, No. LPN B said, I am not going to be able to do your drug screen because my back hurts and I took some of my spouses medication. The facility does have a few video clips where it appears that LPN B put the narcotic medications in his/her pocket. The facility also has MAR and narcotic sign out sheets that demonstrate this complaint; -Description of complaint: -Date of incidents: 1/26/24; -Time: 3:00 P.M.; -Has this complaint been reported to any other agency, court, or other entity: yes; -Name: DHSS; -The facility included MARs and controlled drug records (narcotic sign out sheets) for 10 residents (Residents #19, #17, #12, #13, #16, #18, #20, #15, #11 and #14); -The facility did not recognize the additional resident, Resident #10 in the investigation, who was reported to the DON on 1/22/24. 2. Review of Police Department Investigative Report, dated 2/2/24, showed: -Date/Time received: 2/2/24 at 2:30 P.M.; -Date/Time dispatch: 2/2/24 at 2:31 P.M.; -Date/Time arrival: 2/2/24 at 2:35 P.M.; -Offense: Stealing/Elder Abuse; -Victim #1 information: Resident #18; -Victim #2 information: Resident #15; -Victim #3 information: Resident #13; -Victim #4 information: Resident #16; -Victim #5 information: Resident #12; -Victim #6 information: Resident #11; -Victim #7 information: Resident #14; -Victim #8 information: Resident #17; -Victim #9 information: Resident #19; -Victim #10 information: Resident #20; -Resident #10 was not identified; -Additional party #1 information: ED; -Additional party #2 information: DON; -Subject information: LPN B; -Charges: Elder Abuse, third degree, stealing - controlled substance/meth (CII) manufacturing material; -Property #1 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: oxycodone; -Property value: $200.00; -Property #2 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: acetaminophen/hydrocodone (Norco, opioid, used for moderate-to-severe pain control); -Property value: $1.00; -Property #3 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: Percocet (Percocet, opioid, used for moderate-to-severe pain control); -Property value: $1.00; -Property #4 information: -Property roles: stolen; -Property classification: drug/narcotics; -Quantity: one; -Article: Ativan (Lorazepam, used to treat anxiety); -Property value: $1.00; -Incident property totals: -Total stolen value: $203.00; -Narrative: - On 02/02/2024 at 2:31 P.M., Police Officer (PO) A was dispatched to the facility for a theft of narcotics. Upon PO A arrival, he/she met with the ED and DON who stated their employee LPN B had been observed on video stealing various narcotics which included: Oxycodone, Norco, Percocet and Ativan which were all controlled substances. The narcotics totaled 60 Units on 10 different days. Per the facility policy, the facility investigated LPN B where he/she could be observed taking the medication from the lock box and placing it into his/her pocket. LPN B was informed by the facility someone had been removing medication and not providing it to the residents in the facility and was requested to complete a drug screen on 1/26/2024. LPN B declined to provide a drug screen and voluntarily resigned that day. The facility was made aware LPN B's nursing license was placed on probation which was terminated on 12/23/2023 for a previous charge of possession of a controlled substance. LPN B was hired by the facility on 1/08/2024 and officially started on 1/10/2024. Upon review of the video surveillance, LPN B can be observed stealing the narcotics on: 1/10/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/18/2024, 1/19/2024, 1/22/2024, 1/23/2024, 1/24/24. It should be noted there were also four Oxycodone missing from the facility's emergency kit, but cannot be tied to LPN B. The facility has a Narcotic Sign Out sheet which was audited due to the medication concern. Upon the audit, one signature was noted signing out several medications for several different patients, including one who did not have a medication order in their file. The facility reported LPN B to the State Board of Nursing, as well as DHSS. At this time, I have not received the videos from the facility. Once obtained, will be attached to this report. Charges will be submitted to the Prosecuting Attorney's Office; -Investigative information: -Narrative: -On 02/03/2024 at approximately 11:00 A.M., PO A attempted to make contact with the facility in an attempt to obtain the video footage of the incident. I was informed the video was still unavailable and would likely not be available until 02/05/2024; -On 02/07/2024, 02/08/2024, and 02/12/2024, PO A attempted to obtain the video footage from the facility in which PO A was informed the footage was not ready; -On 02/09/2024, I sent an email to DON and the ED of the facility requesting the video footage - which I have not received a response to at this time; -PO A will continue to follow up; -Narrative: On 02/13/2024, PO A entered a Wanted into REJIS (provides data processing services and online information systems for police) for LPN B; -Narrative: On 02/15/2024, PO A received video footage which appeared to show LPN B placing the medication into his/her pocket and leaving. The video has been uploaded and placed into evidence per department policy. 3. Review of summary of termination conversation with LPN B, dated 2/28/24, showed: -Summary of termination conversation with LPN B from: ED: On 1/26/24, LPN B was asked to meet with the DON and ED regarding our investigation into missing narcotics. The ED and DON informed LPN B at the start of the investigation that we would also be completing a drug screen at the conclusion of our meeting and LPN B was agreeable to submitting a drug test. The DON asked LPN B if he/she was aware of any misappropriation of medications during the time he/she was working or if he/she may have knowledge or information from any co-workers. LPN B said no, he/she was not aware of anything missing or had no knowledge of anyone else that he/she works with here at the facility. The ED asked LPN B if at any time in his/her career had concerns been brought up against him/her regarding misappropriation of medications and LPN B once again stated no - nothing. The ED took a second and asked again and he/she repeated no, there were never any concerns of this nature. The ED then excused himself from the conversation to go and print off a letter addressed to LPN B from the State Board of Nursing regarding an investigation against him/her about misappropriation of medications (in his/her past). The letter was a follow up (warning), requesting that LPN B complete a treatment program and after a period of time with approval, he/she was allowed to continue working in the nursing field as an LPN. I asked LPN B to review the letter that I printed, and he/she read the letter and stated that the letter was inaccurate (meaning they messed up that facts) of this investigation. LPN B stated that he/she understood that this did not look good on his/her behalf (meaning that we caught him/her in a lie when asked earlier in the conversation). At this point, LPN B said he/she would not be able to participate in a drug test and we informed him/her that he/she would be self-terminating his/her position at the facility and LPN B said he/she understood. LPN B collected his/her personal belongings and was escorted out the front door by the DON. Immediately following, we contacted the State Board of Nursing, the DHSS, and the ED spent the rest of the afternoon making calls to the families to make them aware of the incident. 4. Review of statement from LPN C, undated, showed: -On January 22 LPN C noticed that one of the Resident #14's, Oxycodone had been slowly being signed out by the same nurse. Since LPN C has been employed at the facility this resident has not had complaints of pain or requested pain medication, nor has the resident showed non-verbal signs of pain. LPN C also noticed that Resident #10's Ativan had two tablets taken and signed out wasted. LPN C reported this to the DON immediately. 5. Review of LPN B's Employee Timesheet, dated 1/7/24 through 2/3/24, showed: -Monday, 1/8/24, from 9:30 A.M. to 1:00 P.M., LPN, Inservice/Orientation; -Monday, 1/8/24, from 3:20 P.M. to 11:45 P.M., LPN Skilled Nursing Facility (SNF); -Tuesday, 1/9/24, from 2:30 P.M. to Wednesday 1/10/24 12:00 A.M., LPN SNF; -Wednesday, 1/10/24, from 2:30 P.M. to 11:20 P.M., LPN SNF; -Friday, 1/12/24, from 2:30 P.M. to Saturday 1/13/23 7:45 A.M., LPN SNF; -Saturday, 1/13/24, from 2:30 P.M. to Sunday 1/14/24 7:15 A.M., LPN SNF; -Sunday, 1/14/24, from 2:30 P.M. to Monday 1/15/24 7:30 A.M., LPN SNF; -Monday, 1/15/24, from 8:30 P.M. to Tuesday 1/16/24 7:40 A.M., LPN SNF; -Tuesday, 1/16/24, from 2:53 P.M. to Wednesday 1/17/24 3:55 A.M., LPN SNF; -Thursday, 1/18/24, from 2:32 P.M. to 11:37 P.M., LPN SNF; -Friday, 1/19/24, from 2:41 P.M. to Saturday 1/20/24 8:11 A.M., LPN SNF; -Monday, 1/22/24, from 2:37 P.M. to 11:22 P.M., LPN SNF; -Tuesday, 1/23/24, from 7:43 A.M. to 11:40 P.M., LPN SNF; -Wednesday, 1/24/24, from 2:51 P.M. to Thursday 1/25/24 12:00 A.M., LPN SNF. 6. Review of Resident #11's quarterly Minimum Data Set (MDS). a federally mandated assessment completed by facility staff, dated 1/3/24, showed: -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, no; -Received PRN pain medications, no; -Pain presence, no; -Pain frequency, not rated; -Pain effect on sleep, not rated; -Pain interference with day-to-day activities, not rated; -Diagnoses included hip fracture, pain in right hip, scoliosis (curvature of the spine), asthma and cognitive communication deficit. Review of the Physician Order Sheet (POS), dated 11/1/23 through 2/29/24, showed, Hydrocodone-Acetaminophen (Norco, opioid, used for moderate-to-severe pain control) 5-325 milligram (mg) one tablet every six hours as needed (PRN) for pain, with an order date of 11/7/23 and a discontinue date of 2/19/24. Review of the resident's controlled drug record for Norco 5-325 mg every six hours PRN for pain, dis

Based on interview and record review, the facility failed to prevent further misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) by not following the facility's policy for suspension during an investigation. Licensed Practical Nurse (LPN) C and LPN D reported alleged violations of misappropriation/diversion by LPN B on the morning of 1/22/24. The facility allowed LPN B to continue working on 1/22/24, 1/23/24, and 1/24/24, while the facility investigated the allegation. LPN B continued the misappropriation/diversion with nine residents (Resident #11, #15, #16, #17, #18, #13, #19, #12 and #20) during the three days LPN B was not suspended. The facility also failed to submit a completed investigation of a resident's missing [NAME] (a device that allow you to use your voice to access information from the web, play music and control smart home devices) to the Department of Health and Senior Services (DHSS) within the required timeframe (Resident #1). In addition, the facility failed to conduct a thorough investigation, by not interviewing additional staff and residents, regarding a resident's missing wallet and money (Resident #8). The sample was 20. The census was 103. Review of the facility's Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, revised date 1/2017, showed: -Policy: The facility affirms the right of our residents to be free from verbal, sexual, physical, mental abuse, neglect, misappropriation of resident property, crime, corporal punishment, exploitation and/or involuntary seclusion. This facility is committed to establishing a resident sensitive and secure environment. The facility will not knowingly employ or otherwise engage a person who has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, and involuntary seclusion, mistreatment of residents or misappropriation of resident property or exploitation. Individuals who have been convicted of abusing, neglecting, mistreating individuals, or criminal activity prohibited by license and regulation, will not be employed. -Investigating and reporting of abuse and neglect: -2. There are two types of reporting procedures; (internal reporting procedures and external reporting procedures) for the reporting of all alleged, suspected or witnessed incidents of abuse; -3. The internal reporting procedures are distinct and based on the facility reporting procedures. The investigation will consist of: -a. An interview with the person(s) reporting the incident; -b. Interviews with any witnesses to the incident; -c. An interview with the resident; -d. A review of the resident's medical record; -e. An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident; -f. Interviews with the resident's roommate, family members, and visitors; and; -g. A review of circumstances surrounding the incident; -4. Refer to the Guidelines for Facility Self-Report Form (See Attachment B) to report to DHSS; -The facility will follow the external reporting process based on the licensure requirements for the facility. Skilled nursing facilities will follow Centers for Medicare & Medicaid Services (CMS) guidelines and state licensure; -5. Any unusual incident involving the reporting of a reasonable suspicion of a crime involving a resident will be reported to DHSS and any local police department per regulatory requirement and CMS guidelines; -6. The facility will immediately investigate reports by staff and board members under this policy, and third party reports of abuse or neglect, in accordance with the investigation procedures addressed in this policy; -7. The Executive Director (ED) and/or their designee, in conjunction with other executive staff as appropriate, will ensure that it takes appropriate action in response to alleged, witnessed or un-witnessed incident of resident abuse or neglect; -8. The ED and/or their designee will notify the facility management services, the DHSS Regional Office (or the DHSS Hotline), resident representative, personal attending physician and medical director of the ensuing investigation and any action taken so far; -9. The ED and/or their designee will report to the facility management services, the DHSS Regional Office, resident representative, personal attending physician and medical director the results of the reasonable alleged, suspected or witnessed incident of abuse and neglect investigations. -10. The ED and/or their designee in conjunction with the facility management services will determine the appropriate management action(s) to be taken as a result of the findings of investigation, confirm action to be taken with Human Resources at the facility and notify DHSS Regional Office and police (if deemed necessary) of actions taken; -Management roles and responsibilities: -4. The ED and/or their designee will assure the employee(s) whom are alleged to have committed the abuse or neglect are suspended pending investigation until the investigation is completed and a final report is made. -6. If the events indicate there is a reasonable suspicion of crime involving a resident that results in serious bodily injury, the report must be made immediately after forming the suspicion, but not later than two hours after forming the suspicion. Otherwise, the report must be made within twenty-four hours to the DHSS Regional Office and the local police department; -7. Maintain the security and integrity of the physical evidence at the incident, including documenting this evidence appropriately; -8. Reporting must be done by either calling the DHSS Regional Office or calling the Hotline within the specified timelines of the law; -Theft/Misappropriation: -The facility must timely report any reasonable suspicion of a crime against a resident of, or who is receiving care from the facility; -Reports must be submitted to the DHSS Regional Office during normal business hours or through the DHSS Hotline and at least one law enforcement agency of jurisdiction. (Law enforcement is defined as the full range of potential responders to elder abuse, neglect and exploitation including: police, sheriffs, detectives, public safety officers, prosecutors, medical examiners, investigators and coroners.); -If there is not serious bodily injury, the report must be made not later than 24 hours after forming the suspicion; -The facility is subjected to civil money penalty and exclusion sanctions for failure to meet the reporting obligations of the statute; therefore, any reasonable suspicion of a crime against a resident shall be reported to the Department of Health and Senior Services and to the police department if warranted; -Investigation Path: -Definition: Misappropriation (theft) of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent; -Determination whether a missing item is theft: All missing items need to be investigated in accordance with the facility's missing items protocol. However, the loss of an item in and of itself does not constitute theft. The theft of socks, underwear, housecoats. glasses, or dentures, IS very unlikely, despite the initial concerns of an upset resident or family member; -There are two specific instances where theft should be considered: -The theft value of a piece of property. Any missing money, jewelry, watches, or large fixed property, such as radios or TVs should be considered and treated as a possible theft, until there are clear indications that the property was mislaid or lost by means other than theft; -Decision to Proceed: -If there is a suspicion of theft involved, proceed with investigation procedures mentioned in steps six and seven of investigating and reporting of abuse and neglect; -6. The facility will immediately investigate reports by staff and board members under this policy, and third party reports of abuse or neglect, in accordance with the investigation procedures addressed in this policy; -7. The ED and/or their designee, in conjunction with other executive staff as appropriate, will ensure that it takes appropriate action in response to alleged, witnessed or un-witnessed incident of resident abuse or neglect; -Additional considerations: -Reasonable suspicion of crime: -If the events indicate there is a reasonable suspicion of crime involving a resident that results in serious bodily injury, the report must be made immediately after forming the suspicion, but not later than two hours after forming the suspicion. Otherwise, the report must be made within twenty-four hours to the DHSS Regional Office and local law enforcement; -Reporting can be done by telephone, electronic mail, fax or other means within the specified timelines of the law; -Attachment B, facility self-report form: -3. The reporting facility's documentation must include the following information: -A. Specific description of the incident (the date, time, and location of the alleged incident); -B. The names, social security numbers, date of birth and cognitive status of the resident(s); -C. A description of the resident(s) injury; -D. Names, addresses, telephone numbers and position or relationship of the witness(es). For employees, also include date of birth and social security number; -E. What corrective actions the facility has taken to prevent the incident from reoccurring; -F. Statements must be signed and dated; -G. All pertinent information on staff/resident perpetrators; -H. Any other supporting information, i.e., nursing notes, monthly summaries, resident assessment instrument, care plan, physician notes, etc; -Attachment C, Notice reporting reasonable suspicion of a crime: -All employees of the facility have the following responsibilities and rights under Federal law: -If you reasonably suspect that a crime has occurred against a resident or person receiving care in the facility you must report that suspicion to the ED, who will then coordinate timely reporting to the police and DHSS Regional Office/Hotline or you may report it directly to those agencies; -You must make the report within two hours after you first suspect that a crime has occurred if the suspected crime involves serious bodily injury to the individual or within twenty-four hours if there is no serious bodily injury involved; -Note: If you fail to report your reasonable suspicion of a crime, you may be subject to a civil monetary penalty of up to $300,000 and/or you may be excluded from participation in any Federal health care program. Review of the facility's Discrepancies, Loss, and/or Diversion of Medications policy, effective 5/2018, showed: -Policy: All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed; -Procedures: -A. Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the administrator/ED, Director of Nursing (DON) and Consultant Pharmacist are notified, and an investigation conducted. The DON leads the investigation: -1. The information is not to be discussed with other individuals; -2. During the process, the Consultant Pharmacist will verify suspected loss; -B. Discrepancy in a drug count: -1. The DON investigates the discrepancy and researches all the records related to medication administration and the supply of the medication, including medication reconciliation. Medication reconciliation is made from the last known date and time of reconciliation (e.g., during the last shift count, receipt of a full medication container, etc.). A thorough search in all drug storage areas, the resident's room and other locations where medications may have been used/placed during the medication administration are made to locate any missing container or medication supply; -2. After a thorough investigation has been completed and the discrepancy cannot be reconciled, the remaining supply is documented with date and time and the accountability process restarts at this point. The discrepancy is documented unable to reconcile.; -3. Accountability of the medication in question should be checked several times in the following days to assure that accountability is being maintained; -4. Any corrective action that the DON feels is appropriate should be taken; -5. Appropriate agencies, required by state regulation will be notified; -C. Loss of a supply of a medication: -1. The DON investigates the suspected loss and researches all the records related to medication receipt, its use since receipt, all persons involved with medication administration and the supply of the medication and identifies the last known point in time that the medication was available. The dispensing pharmacy should be notified, and the pharmacy should verify that the medication was actually dispensed. A thorough search in all drug storage areas, the resident's room and other locations where medications may have been used/placed during the medication administration are made to locate any missing container or medication supply; -2. After a thorough investigation has been completed and the supply cannot be found, a supply must be obtained for the resident; -3. Document the loss and the investigation process. Notify the prescriber and family if doses have been missed; -4. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited; -5. If the audit reveals a particular individual(s) who might be suspected of involvement with the loss, appropriate disciplinary actions arc taken and deferred to human resource policies; -6. Appropriate agencies, required by state and federal law, will be notified; -D. Robbery: -1. In the event of a robbery, the nurse is to give the individual(s) any medications demanded without resistance; -2. Immediately following the robbery: -a. Make notes regarding the description of the individual; -b. Notify administration or person in charge; -c. Notify the police; -d. Notify the Consultant Pharmacist or Pharmacy emergency number; -e. Itemize the items removed. Review of the facility's Controlled Substance policy, effective date of 5/2018, showed: -Policy Statement: Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations; -Procedures: -A. The DON and the consultant pharmacist in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications; -B. Medications supplied by the provider pharmacy shall identify medications as controlled medicines, either as a part of the label (i.e., a red letter C stamped on the label), or by sending a controlled medicine count sheet with the medication, or both; -C. All controlled substances, (schedule two controlled substance (CII, medication with higher potential of dependency and abuse), Schedule three controlled medication (CIII, medication with low to moderate potential of dependency and abuse), Schedule four controlled substance (CIV, medication with low potential of dependency and abuse), Schedule five controlled substance (CV, lowest potential of dependency and abuse)) CII through CV are stored and maintained in a locked cabinet or compartment. If refrigeration is required, the refrigerator or a container kept in the refrigerator is locked; -E. Accurate accountability of the inventory of all controlled medicines is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR): -1. Date and time of administration (MAR, Accountability Record); -2. Amount administered (Accountability Record); -3. Remaining quantity (Accountability Record); -4. Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record); -F. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container (i.e., not back in inventory). It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules. This does not apply to controlled medicines packaged in unit-dose containers that are unopened (vials, ampules, patches); -H. All controlled medications arc reordered when a minimum five-day supply remains to allow time for acquisition and transmittal of the required original written prescription to the provider pharmacy, if necessary. Review of the facility's Controlled Substance Audit policy, review date of 2/2019, showed: -Policy statement: To keep accurate records of all controlled substances in accordance with State and Federal laws; -Equipment: -1. Key to locked box where controlled substances for residents on the division for which the Certified Medication Technician (CMT)/ Certified Medication Aide (CMA)/Nurse is assuming responsibility are kept; -2. Individual Resident's Controlled Substance Record and Narcotic Count Sign-In Sheet for CMT/CMA/Charge Nurse to inventory together at change of shift; -Procedure: -1. Drugs are to be stored in the same order as the Controlled Records for a fast and efficient audit; -2. When a controlled substance is administered to a resident the Medication Card is to be initialed next to where the pill is punched out by the person who is administering the drug; -3. When a controlled substance is administered to a resident the CMT/CMA/Nurse will sign his/her name under administered by, fill in the date, time, total on hand, amount given and amount remaining; -4. On-coming CMT/CMA/Nurse will actually count drugs. Off-going CMA/CMT/Charge Nurse will follow and verify record; -5. All controlled drugs will be counted between each shift for safe, accurate accountability; -6. When audit is complete, both CMA/CMT/Charge Nurse from each shift will sign audit sheet in appropriate spaces; -7. Narcotic keys will only be carried by the CMT/CMA or by the Nurse, but not by both the CMT/CMA and a Nurse; -8. When a controlled substance record is full, the form is to be forwarded to the Wellness Director/Resident Care Director/DON. 1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 1/3/24, showed: -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, no; -Received PRN pain medications, no; -Pain presence, no; -Pain frequency, not rated; -Pain effect on sleep, not rated; -Pain interference with day-to-day activities, not rated; -Diagnoses included hip fracture, pain in right hip, scoliosis (curvature of the spine), asthma and cognitive communication deficit. Review of the physician order summary (POS), dated 11/1/23 through 2/29/24, showed Hydrocodone-Acetaminophen (Norco, opioid, used for moderate-to-severe pain control) 5-325 milligram (mg) one tablet every six hours as needed (PRN) for pain, with an order date of 11/7/23 and a discontinue date of 2/19/24. Review of the resident's controlled drug record for Norco 5-325 mg every six hours PRN for pain, dispensed 11/8/23, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24: -One tablet on 1/23/24 at 10:00 A.M.; -The medication was signed out six times by LPN B in January. The medication was only signed out one other time in January as administered by another nurse. Review of the electronic MAR (eMAR), dated 1/1/24 through 1/31/24, showed 1/23/24 Norco 5-325 mg every six hours PRN for pain, no documentation that PRN pain medication was administered at 10:00 A.M., pain level for day shift was documented as zero by LPN B. 2. Review of Resident #15's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -High-Risk drug classes use and indication, opioid: -Checked as taking; -Checked as indicated; -Pain management: -Been on scheduled pain medication regimen, yes; -Received PRN pain medications, no; -Pain presence, yes; -Pain frequency, almost constantly; -Pain effect on sleep, frequently; -Pain interference with day-to-day activities, almost constantly; -Pain intensity, rating scale 0-10 (pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain), 10; -Diagnoses included dementia, heart failure, respiratory failure, high blood pressure, low back pain and chronic pain. Review of the POS, dated 11/1/23 through 2/29/24, showed: -Oxycodone-Acetaminophen (Percocet, opioid, used for moderate-to-severe pain control) 10-325 mg 1 tablet every six hours PRN for pain, with an order date of 9/11/23; -Morphine Sulfate (MS Contin, opioid, used for moderate-to-severe pain control) 15 mg extended release (ER) 1 tablet four times daily (6:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M.) for pain, with an order date of 10/23/23, discontinue date of 2/16/23. Review of the resident's controlled drug record for Percocet 10-325 mg every 6 hours PRN for pain, dispensed 12/20/23, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24: -One tablet on 1/22/24 at 3:00 P.M.; -One tablet on 1/22/24 at 10:00 P.M.; -One tablet on 1/23/24 at 9:00 A.M.; -One tablet on 1/23/24 at 3:00 P.M.; -One tablet on 1/23/24 at 8:00 P.M.; -One tablet on 1/24/24 at 3:00 P.M.; -One tablet on 1/24/24 at 8:00 P.M.; -LPN B signed out the Percocet 10-325 mg every 6 hours PRN for pain on 1/23/24 at 3:00 P.M. and 8:00 P.M., which was more frequent than the physician order of one tablet every 6 hours; -LPN B signed out the Percocet 10-325 mg every 6 hours PRN for pain on 1/24/24 at 3:00 P.M. and 8:00 P.M., which was more frequent than the physician order of one tablet every 6 hours. Review of the resident's controlled drug record for MS Contin 15 mg four times (6:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M.) daily for pain, dispensed 1/15/24, showed LPN B signing out the medication on the following dates between 1/22/24 and 1/24/24: -One tablet on 1/22/24 at 4:00 P.M.; -One tablet on 1/22/24 at 9:00 P.M. Review of the resident's controlled drug record for MS Contin 15 mg four times (6:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M.) daily for pain, dispensed 1/19/24, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24: -One tablet on 1/23/24 at 12:00 P.M.; -One tablet on 1/23/24 at 4:00 P.M.; -One tablet on 1/23/24 at 9:00 P.M.; -One tablet on 1/24/24 at 4:00 P.M.; -One tablet on 1/24/24 at 9:00 P.M. Review of the eMAR, dated 1/1/24 through 1/31/24, showed MS Contin 15 mg four times (6:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M.) daily for pain, no documentation as administered between 1/22/24 and 1/24/24, on 1/23/24 at 9:00 P.M. 3. Review of Resident #16's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, yes; -Received PRN pain medications, no; -Pain presence, no; -Pain frequency, occasionally; -Pain effect on sleep, rarely or not at all; -Pain interference with day-today activities, rarely or not at all; -Diagnoses included Alzheimer's (dementia), high blood pressure, cognitive communication deficit and stroke. Review of the POS, dated 11/1/23 through 2/29/24, showed: -Lorazepam (Ativan, used to treat anxiety) 0.5 mg every 24 hours PRN for anxiety for 14 days, order date of 10/23/23, discontinue date of 11/14/23; -Lorazepam 0.5 mg every 24 hours PRN for anxiety for 14 days, with an order date of 1/16/24, discontinue date of 1/30/24. Review of the resident's controlled drug record for Lorazepam 0.5 mg 1 tablet every 24 hours PRN for anxiety, dispensed 9/12/23, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24, one tablet on 1/24/24 at 4:00 P.M. Review of the eMAR, dated 1/1/24 through 1/31/24, showed Lorazepam 0.5 mg 1 tablet every 24 hours PRN for anxiety, no documentation that PRN anxiety medication was administered on 1/24/24 at 4:00 P.M. 4. Review of Resident #17's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -High-Risk drug classes use and indication, opioid: -Checked as taking; -Checked as indicated; -Pain management: -Been on scheduled pain medication regimen, no; -Received PRN pain medications, yes; -Pain presence, yes; -Pain frequency, rarely or not at all; -Pain effect on sleep, rarely or not at all; -Pain interference with day-today activities, rarely or not at all; -Pain intensity, rating scale 0-10, 3; -Diagnoses included coronary artery disease (CAD, arteries that supply blood to heart muscle become hardened and narrowed), high blood pressure, muscle weakness, difficulty in walking and repeated falls. Review of the POS, dated 11/1/23 through 2/29/24, showed Tramadol (Ultram, used to relieve moderate to moderately severe pain) 50 mg 1 tablet every six hours PRN for pain, order date of 10/11/23. Review of the resident's controlled drug record for Tramadol 50 mg 1 tablet every six hours PRN for pain, dispensed 12/18/23, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24: -One tablet on 1/23/24 at 8:00 A.M.; -One tablet on 1/24/24 at 3:00 P.M. Review of the eMAR, dated 1/1/24 through 1/31/24, showed, the following between 1/22/24 and 1/24/24: -1/23/24 Tramadol 50 mg every six hours PRN for pain, no documentation that PRN pain medication was administered at 8:00 A.M., pain level for day shift was documented as zero by LPN B; -1/24/24 Tramadol 50 mg every six hours PRN for pain, no documentation that PRN pain medication was administered at 3:00 P.M., pain level for evening shift was documented as zero by LPN B. 5. Review of Resident #18's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, yes; -Received PRN pain medications, yes; -Pain presence, yes; -Pain frequency, frequently; -Pain effect on sleep, rarely or not at all; -Pain interference with day-today activities, rarely or not at all; -Pain intensity, rating scale 0-10, 5; -Diagnoses included dementia, high blood pressure and respiratory failure. Review of the POS, dated 11/1/23 through 2/29/24, showed, Norco 5-325 mg one tablet every 12 hours PRN for pain, ordered 11/22/23, discontinue date 3/18/24. Review of the resident's controlled drug record for Norco 5-325 mg one tablet every 12 hours PRN for pain, dispensed 11/22/23, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24: -One tablet on 1/22/24 at 4:00 P.M.; -One tablet on 1/23/24 at 9:00 A.M.; -One tablet on 1/24/24 at 4:00 P.M. Review of the eMAR, dated 1/1/24 through 1/31/24, showed the following between 1/22/24 and 1/24/24: -1/22/24 Norco 5-325 mg one tablet every 12 hours PRN for pain, no documentation that PRN pain medication was administered at 4:00 P.M., pain level for evening shift was documented as zero by LPN B; -1/23/24 Norco 5-325 mg one tablet every 12 hours PRN for pain, no documentation that PRN pain medication was administered at 9:00 A.M., pain level for day shift was documented as zero by LPN B; -1/24/24 Norco 5-325 mg one tablet every 12 hours PRN for pain, no documentation that PRN pain medication was administered at 4:00 P.M., pain level for evening shift was documented as zero by LPN B. 6. Review of Resident #13's annual MDS, dated [DATE], showed: -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Checked as taking; -Checked as indicated; -Pain management: -Been on scheduled pain medication regimen, yes; -Received PRN pain medications, no; -Pain presence, yes; -Pain frequency, almost constantly; -Pain effect on sleep, rarely or not at all; -Pain interference with day-today activities, almost constantly; -Pain intensity, rating scale 0-10, 8; -Diagnoses included a-fib, heart failure, respiratory failure, intervertebral disc degeneration (breakdown of one or more of the discs that separate the bones of the spine, causing pain in the back or neck) and chronic pain. Review of the POS, dated 11/1/23 through 2/29/24, showed: -Morphine sulfate (opioid, used to help relieve moderate to severe pain) solution 20 MG/Milliliter (ML), give 0.25 ml two times a day (10:00 A.M. and 4:00 P.M.) for chronic pain, order date 12/27/23, discontinued 2/23/24; -Methadone Hydrochloride (HCL) (opioid, used to treat moderate to severe pain) 10 mg one tablet three times a day (6:00 A.M., 2:00 P.M., 9:00 P.M.) for pain, ordered on 12/29/24, discontinued 3/8/24; -Oxycodone HCL (opioid, used to treat moderate to severe pain) 5 mg one tablet every eight hours PRN for pain, ordered on 6/19/23. Review of the resident's controlled drug record for Oxycodone HCL 5 mg one tablet every eight hours PRN for pain, dispensed 6/19/23, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24: -One tablet on 1/22/24 at 5:00 P.M.; -One tablet on 1/23/24 at 10:00 A.M.; -One tablet on 1/24/24 at 6:00 P.M.; -LPN B signed out the residents scheduled pain medication at the same time as the PRN medication on 1/23/24 at 10:00 A.M. Review of the resident's controlled drug record for Methadone HCL 10 mg one tablet three times a day (6:00 A.M., 2:00 P.M., 9:00 P.M.), second sheet labeled dispensed 1/10/24, showed LPN B signed out the medication on the following dates between 1/22/24 and 1/24/24:: -One tablet on 1/22/24 at 8:00 P.M.; -One tablet on 1/23/24 at 2:00 P.M.; -One tablet on 1/23/24 at 9:00 P.M.; -One tablet on 1/24/24 at 9:00 P.M. Review of the resident's controlled drug record for Morphine sulfate 0.25 ml two times a day (10:00 A.M. and 4:00 P.M.) for chronic pain, received 6/3/23, showed LPN B signed out the medication on the following dates, between 1/22/24 and 1/24/24: -1/22/24, 0.25 ml at 4:00 P.M.; -1/23/24, 0.25 ml at 10:00 A.M.; -1/23/24, 0.25 ml at 4:00 P.M.; -1/24/24, 0.25 ml at 4:00 P.M. Review of the eMAR, dated 1/1/24 through 1/31/24, showed: -Methadone HCL 10 mg one tablet three times a day (6:00 A.M., 2:00 P.M., 9:00 P.M.) for pain: -Signed out on 1/22/24 at 9:00 P.M.; -Signed out on 1/23/24 at 2:00 P.M.; -Signed out on 1/23/24 at 9:00 P.M.; -Signed out on 1/24/24 at 9:00 P.M. Review of the eMAR, dated 1/1/24 through 1/31/24, showed: -Morphine sulfate solution 20 MG/ML give 0.25 ml two times a day (10:00 A.M. and 4:00 P

Based on observation, interview and record review, the facility failed to prevent and treat pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one resident (Resident #1) admitted to the facility on [DATE] with redness to the buttocks. On [DATE], a skin assessment showed a 2.5 centimeter (cm) x 1 cm open area. The area was not staged and no wound description was documented. The physician was not notified and no treatment was documented as applied. On [DATE], staff added a treatment to the Treatment Administration Record (TAR), but did not obtain a treatment order from the physician. On [DATE], an order for the specialized wound management clinic was obtained, but the resident was not added to the facility wound report tracking record. On [DATE], the wound was documented as blackened with odors and drainage. The physician was not notified of the change, and no orders were obtained. On [DATE], a student nurse documented the area as necrotic (black, hard and leathery dead tissue) with odor and drainage. The physician was not notified and no new orders were obtained. On [DATE], the specialty wound clinic arrived for the initial assessment, and due to the condition of the wound and the resident, the resident was sent emergently to the hospital. The resident expired at the hospital on [DATE] due to septic shock from a sacral (tailbone/coccyx) decubitus ulcer. This affected 1 of 3 residents sampled for wound review. The census was 101. The administrator was informed on [DATE] of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's Pressure Sore Care policy, dated ,d+[DATE], showed: -Purpose: to prevent pressure sores and/or prevent deterioration of existing pressure sores; -Causes: Moisture from sweat, urine, feces; Inadequate nutrition and fluid intake; Impaired circulation; Lack of cleanliness; Improper or careless transferring causing bruising or other injury; Wrinkles, lumps, crumbs in the bedding or chair; Fragile skin; Skin touching skin; -Pressure sores can occur on bony prominence (areas where bones under the skin are close to the skin surface): Coccyx; Knees, ankles/heels; Anywhere bone is close to the skin; -Warning signals: Observe daily for the following signs of potential pressure signs and report accordingly: -Redness or a darker, deeper bruise like color; -Heat, tenderness; -Pain or discomfort; -Cracks in the skin; -Excessive dryness; -Sores, cuts or abrasions; -Report any changes of condition to the charge nurse; -Prevention: Frequent application of lotion, or approved ointment to skin surfaces with special attention to pressure prone areas; Frequent turning and repositioning no less than every two hours; Use of anti-pressure devices; Air mattress/or specialty mattress to the bed; Air cushion to the wheelchair; Keep the resident clean and dry; Pad skin on skin areas with soft material; -Procedure: -Observe reddened or pressure sore prone areas; -Wash skin area with soap and water if soiled; -Rub skin with lotion, or approved ointment; -Place clean linen on the bed if necessary; -Tighten linen, keep free from wrinkles; -Turn the resident to the side listed on the turning schedule; -Report any abnormalities to the charge nurse; -For Stage II (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow, stringy-like dead tissue) or bruising) or greater pressure sore: -Any time a Stage II or greater pressure sore is noticed on the resident, the charge nurse must initiate a nutritional consult form along with a pressure sore form; -Notify the physician of the pressure sore for treatment orders; -Weekly treatment summaries for pressure sores must be done; -Notify the physician if no improvement occurs after two weeks of treatment; -Treatment and objective: to be done by licensed personnel and promote healing of existing pressure sores and to protect an area from contamination; -Treatment summary should include: -Location; -Size: width, length, and depth; -Stage; -Wound appearance: Signs and symptoms of infection; Drainage/color (consistency and amount); Odor; Any granulating tissue (new tissue growth); Color of the wound and surrounding tissue; -Continuation of current treatment or new treatment order; -Complete the above on each pressure sore; -When an open area is first found, the above must be completed the same day. Review of Resident #1's discharging facility's progress note, dated [DATE] at 4:12 P.M., showed the resident continues on charting for left lower leg, continues to be non-weight bearing. He/She wears a boot except for hygiene. Skin is pink, warm, dry and intact. He/She is alert, and oriented to person, place and time (A&O x 3). Needs assistance with hygiene and transfers. Review of the resident's medical record, showed: -admitted : [DATE]; -Diagnoses included fracture of the left lower leg with repair, deep vein thrombosis (blood clot in the vein), heart disease, breast cancer and diabetes. Review of the resident's admission progress note, dated [DATE] at 2:43 P.M., showed the resident was admitted to the facility. He/She transferred with assist of one staff. He/She is A&O x 3. He/She was noted to have a brace on the left lower extremity that cannot come off. The skin is pink, dry and intact. Review of the resident's care plan, dated [DATE], showed: -Need: The resident has limited physical mobility: -Goal: The resident will demonstrate the appropriate use of the wheelchair to increase mobility; -Interventions: The resident uses a wheelchair for mobility, he/she is non-weight bearing, wearing a boot to the left leg for a fracture; -Need: the resident has an altercation in the musculoskeletal status related to fracture of the left ankle related to ankle surgery on [DATE]; -Goal: (blank); -Interventions: Monitor fatigue, plan activities during times when pain and stiffness is lower. Monitor/document for fall risk, educate resident/family/caregivers on safety measures to reduce fall risk; -Need: The resident has potential/actual impairment to skin integrity. His/Her coccyx is red from mid to lower left and right buttock. Light pink/red in color, present on admission: -Goal: The resident will maintain or develop clean and intact skin; -Interventions: Educate the family/resident of the causative factors and measures to prevent skin injury, encourage good nutrition and hydration to promote healthy skin, identify causative action and resolve where possible. Pressure reducing Roho cushion (pressure reliving cushion with pockets of air) by therapy on [DATE]. Keep skin clean, dry, use lotion on the skin. Treatment to open area as ordered, monitor the skin under the boot to the left leg daily for breakdown, monitor the surgical wound to the left lower leg, turn and reposition during rounds and as needed; -Need: The resident is incontinent of bladder: -Goal: The resident will remain free of skin breakdown; -Interventions: Use disposable briefs, provide cleansing, monitor of signs of infection. Review of the resident's admission Braden evaluation (an assessment tool used to assess a resident's risk for skin breakdown and pressure ulcers), dated [DATE], showed: -Sensory perception: Slightly limited; -Moisture: Rarely moist; -Activity: Chair fast; -Mobility: Slightly limited; -Nutrition: Adequate; -Friction and shear: No apparent problem; -Result/score: 18-at risk; -Clinical suggestions: (Blank). Review of the resident's admission electronic Physician Order Sheet (ePOS), dated [DATE], showed an order for skin observation tool every Wednesday. Review of the resident's [DATE] TAR, dated [DATE] through [DATE], showed an order, dated [DATE] for skin observation tool every Wednesday. Documented as completed on [DATE]. Review of the resident's progress note, dated [DATE] at 4:12 A.M., showed the resident was a new admission. Incontinent of bowel and bladder. Boot is in place to left lower extremity. Review of the resident's physician history and physical note, dated [DATE] at 11:04 A.M., showed the resident had a surgical repair to the left ankle and transferred from another facility to the current facility for long term care; -Musculoskeletal/extremities: Left lower extremity in boot; -Skin: Warm, dry and intact. No rash noted; -Neurological: A&O x 3. Review of the resident's progress note, dated [DATE] at 8:52 P.M., showed the resident alert and cooperative with care. Incontinent of bowel and bladder, perineal care (cleaning between the front of the hips, between the legs and the buttocks) every two hours. Boot to left lower leg in place. Review of the resident's skin observation tool, dated [DATE] at 10:21 A.M., showed: -Site: Right buttock -Type: Pressure; -Length, width, depth and stage: (Blank); -Notes: Measured 2.5 cm x 1 cm wound on right buttock. Review of the facility's wound report, dated [DATE], showed the resident not listed. Review of the resident's July, 2023 ePOS, showed an order dated [DATE], to apply Xerofoam (non-adherent dressing, used on wounds with little to no drainage) to the right buttock wound bed and cover with silicone dressing until healed, one time daily. Review of the resident's [DATE] TAR, reviewed for the dates of [DATE] through [DATE], showed: -An order dated [DATE]: Apply Xerofoam to the right buttock wound bed and cover with silicone dressing until healed, one time daily. Scheduled for the day shift. Documented as completed on [DATE]: -Administration blank on ,d+[DATE], ,d+[DATE] and [DATE]; -Documented as completed on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]; -An order dated [DATE]: For skin observation tool every Wednesday. Noted as blank on [DATE]. Review of the resident's progress notes, dated [DATE], showed: -At 1:02 P.M., left message on machine with next of kin requesting submission to specialized wound management for buttock wound; -At 1:25 P.M., the next of kin returned call and approved the resident to see the specialized wound management team. Review of the facility's wound report, dated [DATE], showed the resident not listed on the report. Review of the resident's [DATE] ePOS and TAR, showed an order dated [DATE], to apply Xerofoam to the right buttock wound bed and cover with silicone dressing until healed. Documented as completed on ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Review of the resident's skin/wound note, dated [DATE] at 8:55 A.M., showed cleaned wound on the coccyx with normal saline. Applied Xerofoam and covered area with a foam dressing. The wound appeared black and malodorous (having a bad odor) with yellowish drainage. The resident made verbal cues of pain but unable to rate pain. The resident left on his/her right side to relieve pain. Reassessed pain level and the facility wound nurse was notified of the wound odor and appearance. Review of the resident's skin/wound note, dated [DATE], showed: -At 12:18 P.M., cleaned wound on right buttock with normal saline. Applied Xerofoam and covered with a foam dressing. The wound appeared necrotic and malodorous with yellow drainage. The resident was noted as diaphoretic (sweating), temperature 98.2. The resident stated he/she was in pain and pointed toward his/her the wound site. The resident placed on his/her left side with a pillow at the back to relieve pain. Reassessed pain level and notified nurse of the wound odor and appearance. -At 1:01 P.M., wound assessment completed. The wound is 80 percent (%) necrotic, unstageable (full depth of the wound unable to be assessed due to covering with dead tissue) upon assessment with malodorous drainage noted. Photo obtained for staging purposes as the resident is waiting for specialized wound management approval. Area cleaned with normal saline, Santyl (used to heal wounds by removing dead skin and tissue) and collagen (used to promote tissue growth) applied to wound bed, covered with large silicone dressing, wound culture ordered and culture obtained. The resident tolerated well. Will continue to monitor. Review of the resident's [DATE], ePOS and TAR, dated [DATE] through [DATE], showed: -An order dated [DATE], to apply Xerofoam to right buttock wound bed and cover with silicone dressing until healed. Documented as completed on [DATE] and [DATE]. Documented on [DATE] as not completed, due to the resident being hospitalized ; -New order of Santyl not documented on the TAR. Review of the resident's progress note, dated [DATE], showed: -At 8:28 A.M., the resident seen by specialized wound management and the nurse practitioner (NP), ordered to send the resident to the hospital for the wound to the buttocks to be assessed. Next of kin and physician notified. Emergency services called, paperwork sent with the resident; -At 1:31 P.M., the specialized wound management NP assessed the resident's coccyx wound. The wound measured 11 cm x 9 cm x unable to determine (UTD) with 4.5 cm induration (redness, swelling). The NP recommends the resident be sent to the hospital for wound evaluation. Review of the resident's skin observation tool, dated [DATE] at 1:34 P.M., showed: -Site: (Blank); -Type: (Blank); -Length, width, depth, stage: (Blank); -Notes: Coccyx wound measured 11 cm x 9 cm x UTD with a 4.5 cm induration. Review of the resident's skin/wound note, dated [DATE] at 4:47 P.M., showed the Director of Nursing (DON) made aware of the wound today. She asked staff to change from current overlay to a Roho overlay and place the resident on a turn every two hour schedule from back to left side. Review of the resident's hospital emergency room (ER) admission records, dated [DATE] at 8:16 A.M., showed: -History of present illness: Patient presents to the emergency room for chief complaint of wound check; -Subjective (from patient): Information limited due to communication deficit. She/He presents to the ER with worsening wound to the right buttock and increased pain to the buttock; -Physical exam: -Blood pressure: ,d+[DATE] (B/P, normal ,d+[DATE]); -Heart rate: 99 (normal ,d+[DATE]); -Respiration: 24 (normal ,d+[DATE]); -Temperature: 98.7 degrees (normal 96XXX,d+[DATE].0); -Skin intact, except see wound images; -Radiology CAT scan of the pelvis impression: -Sacral decubitus ulcer with extensive subcutaneous (under the skin) fat extending from posterior (back) to the sacrum inferiorly (below) to the left ischial (hip) anal fat. No drainable fluid collection. Associated acute on chronic osteomyelitis (bone infection) of the sacrum and coccyx; -Pulmonary (lung) embolism (PE, blood clot) in the right lower lobe and a deep venous thrombosis (DVT, blood clot) in the left femoral and illac veins (leg vessels); -Small left pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity); -Critical care dated [DATE] at 11:34 A.M., showed: -Critical care was necessary to treat or prevent imminent of life-threatening deterioration of the following conditions: Sepsis (blood infection); -Medical decision making: Foul-smelling wound with necrotic tissue present on examination. Showed low blood pressure, given broad spectrum antibiotics, obtained a CT to assess the ulcer which also showed both a DVT and PE as well; -Final diagnoses: Sepsis due to skin infection, pressure injury of the sacral region unspecified stage and acute PE. Review of resident's the acute general surgery consultation note, dated [DATE] at 7:52 A.M., showed: -Chief complaint: Wound check-right buttocks; -History of present illness: Presented with altered mental status and stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer to the coccyx from a nursing facility. Per the ED the patient had been complaining of severe pain to his/her coccyx for the last 2 days. Surgery was consulted for debridement (surgical removal of dead tissue) of the pressure ulcer, however the patient was a rapid response this morning with a BP of ,d+[DATE] and heart rate of 132. He/She was transferred to the intensive care unit (ICU). The family decided to make the resident comfort measures only (CMO) and the patient passed at 12:30 P.M., on [DATE]. Review of the resident's hospital discharge summary, dated [DATE] at 12:30 P.M., showed: -admitted : [DATE]; -discharged : [DATE]; -Discharge diagnoses and relevant hospital course: -Acute on chronic osteomyelitis; -Severe sepsis with septic shock; -Pressure injury of skin to the sacral region; -Summary: Significant history of osteomyelitis due to a stage IV sacral decubitus ulcer and admitted [DATE] for worsening sacral wound. Found to have right lower lobe subacute PE and admitted for worsening sacral wound and PE. In the morning of [DATE], the patient became more hypoxic (low oxygen in the blood) and hypotensive (low blood pressure) and less responsive. Plan of care discussed with family and code status changed to do no resuscitate and transferred to the intensive care unit. Patient given fluids and medications without much improvement in BP. Further discussions with family and based on overall poor prognosis and BP not improving with fluids and medications, family decided to make the patient comfort measures only; -Patient expired at 12:30 P.M. on [DATE]; -Cause of death: Septic shock from sacral decubitus ulcer. During an interview on [DATE] at 12:40 P.M., Licensed Practical Nurse (LPN) A said he/she had not received in-servicing regarding wound or skin care issues. School training taught him/her to assess changes in skin, document and call the physician. He/She was uncertain of the facility policy to report changes in skin condition to nursing management or skin documentation. During an interview on [DATE] at 5:05 A.M., LPN B said he/she had been taught in school to assess the skin, call the physician and implement orders. He/She is unaware of the facility policy regarding changes in wound condition or notifying nursing management. During an interview on [DATE] at 5:10 A.M., LPN C said he/she had assisted with the care of Resident #1 during the night shifts. The resident's aide did not report resident discomfort. LPN C had not received wound or skin in-servicing. During an interview on [DATE] at 1:15 P.M., the facility wound nurse said she was new to the facility. She was notified of the resident's coccyx wound on [DATE]. It was the first time she worked on the floor at the facility and the first time she observed the wound. The wound was very large, black and odorous. She notified the former Assistant Director of Nursing (ADON). The wound nurse requested cultures of the wound and was told by the ADON to apply Xerofoam and dry dressing and the ADON would contact the physician and the ADON would get family consent for specialized wound management to see the resident. She did not see the resident again until [DATE] with the specialized wound management team, as she was completing facility orientation training. The resident did not have wound care orders from the physician. The orders on the POS and TAR were put into the system by the ADON. During an interview on [DATE] at 2:57 P.M., the Director of Nursing (DON) said the Certified Nurse Aides (CNA) are the front line staff and responsible to report changes in skin conditions immediately to the charge nurse. The nurse should conduct a skin assessment, document and notify the wound nurse. The wound nurse will complete all wound treatments and conduct wound rounds weekly with specialized wound management. The charge nurse is responsible to complete wound treatments on weekends. The DON was unaware of the resident's wound until after he/she went to the hospital. During an interview on [DATE] at 3:14 P.M., the specialized wound management NP said she was notified on [DATE] by the former ADON she needed to see the resident the morning of [DATE] when she entered the facility. The ADON said the physician was aware of the wound and a treatment was in place. On [DATE], the resident lay on his/her back in the bed. As he/she was turned onto his/her side, the resident moaned out but was not verbally communicating. The NP was unsure of the resident's alertness and orientation on admission or baseline. The wound site was covered with a treatment. Upon assessment, the wound was 100 % necrotic and measured 11 cm x 9 cm x UTD with approximately 4.5 cm of induration that was red, warm and drainage noted on the dressing. The wound was odorous. The NP said she did not like how the wound appeared and ordered the resident to the hospital emergently. The staff should have assessed, and obtained orders much earlier in the wound development. The NP was concerned the resident's wound was infected and needed advanced care. The NP was notified later the resident expired from sepsis as a result of the sacral wound. During an interview on [DATE] at 7:41 A.M., the DON said the resident did not have any bath or shower sheets completed. CNAs should fill out weekly shower sheets. The sheets are initialed by the charge nurse and then given to the DON. If the CNA indicates changes in the skin, the nurse should perform a skin assessment immediately, document the findings, notify the wound nurse and management and call the physician for orders. The lack of shower/bath sheets indicates the resident did not receive a shower or bath. CNA's should assess and report any changes in the resident's skin at any time during care and bathing. During an interview on [DATE] at 8:37 A.M., the resident's physician said he was never notified the resident had developed skin impairments. He did not issue any wound care orders. He was notified of the resident's wound when he/she was sent to the hospital emergently on [DATE]. He was notified the resident's cause of death was sepsis related to the wound. During an interview on [DATE] at 9:33 A.M., the resident's next of kin (NOK) said when the resident admitted into the facility, his/her skin was intact. The facility called him/her on [DATE] to ask if the resident could be evaluated by specialized wound management for a wound. The facility did not provide detailed information regarding the wound. The facility called on [DATE] regarding the resident going to the hospital. When the NOK arrived at the hospital, the ER physician's said the resident's buttock wound was so bad, it was going to kill him/her. 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 review 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 a the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that a prompt remedial action to taken to address Class 1 violation(s). MO00222689

Based on observation, interview and record review, the facility failed to ensure pain assessments and pain management were provided consistent with professional standards of practice, by failing to ensure a resident who developed a large coccyx (tailbone) pressure ulcer and expressed pain was assessed timely and accurately (Resident #1). The sample was 5. The census was 101. Review of the pain management policy, revised ,d+[DATE], showed: -Policy: As advocates for the elderly, we are committed to assure that the residents do not suffer needlessly from pain. We believe our residents have the right to have their pain assessed and continuously and appropriately managed within the frame work of psychosocial and physical adaptations. A formal pain assessment will be done; -Procedure: -Pain will be assessed on an on-going basis and an appropriate treatment for pain will be developed; -The elements of pain assessment include: -Frequency; -Intensity (measured using pain scale); -Location; -Duration; -Aggravating and alleviating factors, pharmaceutical and non-pharmaceutical; -An appropriate pain scale will be used based on the resident's cognitive and functional ability to assess the resident's pain level and assess relief of pain as a result of interventions aimed at pain relief; -A pain assessment tool will be completed by a licensed nurse to assess cognitively intact and cognitively impaired residents: -As soon as practicable after admission; -As soon as practicable on significant change of condition; -Semi-annually; -The goal of pain management is to provide relief to the extent acceptable to the resident and to the extent practical to improve the resident's comfort, optimize the resident's ability to perform activities of daily living (ADLs, the ability to care for oneself), and reduce depression and anxiety; -Non-pharmaceutical interventions will be used prior to pharmaceutical interventions unless it is determined that non-pharmaceutical interventions have not been effective; -In the event that medications are used to treat pain, the effectiveness of as needed (PRN) medications will be evaluated within a timeframe appropriate to the route of administration. Effectiveness will be evaluated using an appropriate pain scale before and after analgesic administration; -The resident's physician will be notified in the event that pain relief interventions are ineffective; -A plan for pain management will be incorporated into the resident's individualized service plan. The service provider will work with the attending physician and will consider both pharmacological and non-pharmacological interventions; -Analgesics will be monitored for side effect prevention/treatment (such as constipation, nausea, vomiting) and will implement interventions to alleviate these side effects/adverse reactions. Review of Resident #1's admission transfer records, dated [DATE], showed -Open reduction and internal fixation (ORIF, surgical repair of a fractured bone) of the left lower leg; -Diagnoses included fall history, urinary incontinence, diabetes, history of cancer of the skin and breast and rib fracture; -Upon discharge, ordered to wear a boot at all times to the left lower extremity except during assessment and hygiene. Needs assistance with daily care. Review of the resident's medical record, showed: -admitted : [DATE]; -Diagnoses included fracture of the left lower leg with repair, deep vein thrombosis (blood clot in the vein), diabetes, heart disease and breast cancer. Review of the progress note, dated [DATE] at 2:23 P.M., showed the resident arrived to the facility and transferred with assist of one staff. The resident is alert to person, place and time (A&O x 3). He/She presents with a brace on the left lower extremity that cannot be removed. The skin is pink, warm, dry and intact. Review of the admission physician order sheet (POS), dated [DATE], showed: -Acetaminophen (Tylenol, used to treat fever or pain) 325 milligram (mg). Take two tablets to equal 650 mg every six hours as needed for pain or fever; -Tramadol (narcotic used to treat moderate to severe pain) 50 mg, may take one tablet every six hours as needed. Review of the care plan, initiated [DATE], showed: -Need: the resident has an ADL self-care performance deficit; -Goal: the resident will maintain current level in ADL performance; -Interventions: staff assist with bathing/showering, bed mobility, dressing, toileting, transfers; -Need: the resident has an alteration in musculoskeletal status related to surgical repair of the left ankle; -Goal: blank; -Interventions: Monitor fatigue, monitor and document risk for falls; -Need: the resident has acute and chronic pain related to fracture and surgical repair to the left ankle; -Goal: the resident will not have an interruption in normal activities due to pain; -Interventions: administer analgesia as ordered-give half an hour before treatments or care, anticipate the resident's need for pain relief and respond immediately, evaluate effectiveness, monitor/document the side effects of pain medication, monitor/record pain characteristics every shift and as needed include quality, severity, location, onset, duration, aggravating factors, relieving factors. Monitor/record/report to the nurse resident complaints of pain or requests for pain treatment. Notify the physician if interventions are unsuccessful of if current complaint is a significant change from residents past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, resistance to care. Review of the resident's medical record, dated [DATE], showed no admission pain evaluation was documented. Review of the physician admission visit note, dated [DATE], showed: -Prior history: prior fall with left ORIF repair. admitted for long-term care. Musculoskeletal left lower extremity in boot. The skin is warm, dry and intact. He/She is non-weight bearing until seen by orthopedic surgery follow up. Left fourth and fifth ribs were fractured at the time of the prior fall. Review of the progress note, showed: -On [DATE] at 8:52 P.M., resident admission, alert and staff assist with care. Left leg brace in place. PRN Tramadol given for pain; -No follow up assessment after administration of pain medication. Review of the skin observation tool, dated [DATE] at 10:21 A.M., showed: -Site: right buttock; -Type: pressure (skin injury related to prolonged pressure); -Notes: 2.5 centimeters (cm) x 1 cm; -No pain evaluation or assessment noted. Review of the progress notes and the July medication administration record (MAR), showed: -An order dated [DATE] for Tramadol 50 mg, take one tablet every six hours PRN for moderate/severe pain; -On [DATE] at 6:00 A.M., Tramadol administered for pain. No location, assessment or pain indicators. Documented at a pain scale of 4 on the MAR; -On [DATE] at 8:02 A.M., Tramadol effective. Pain scale was 2; -On [DATE] at 1:25 P.M., notified next of kin to request resident to be seen by specialty wound management (SWM) to assess knee skin tear and buttock; -No pain scale or pain assessment documented for buttock wound. Review of the July progress notes, showed: -On [DATE] at 6:00 A.M., one tablet of Tramadol administered for pain to the left ankle. Pain scale documented at a 4. No pain assessment documented; -On [DATE] at 9:32 A.M., PRN administration was effective, follow up pain scale was: 0. Review of the August progress notes, showed: -On [DATE] at 8:55 A.M., a skin/wound note: wound to the coccyx cleaned and treatment applied. Wound appeared black and odorous with yellow drainage. Patient made verbal cues of pain but unable to rate pain. Patient left on his/her right side to relieve pain and appeared relaxed. Wound nurse notified of odor and appearance. No documentation of pain assessment or administration of pain medication; -On [DATE] at 3:00 P.M., a nurse note: the resident experience a fall, lying on his/her right side and abrasion to the right knee. The resident stated he/she had some pain, but pain goes away. Physician notified and new orders given for x-rays. No documentation of pain assessment of administration of pain medication; -On [DATE] at 12:57 A.M., the resident remained in bed, x-rays obtained. Denied pain at 7:00 P.M.; -On [DATE] at 12:18 P.M., cleaned wound to the right buttock and treatment applied. The wound appeared necrotic (black, dead tissue) and odorous with yellow drainage. The patient was diaphoretic (sweating) and stated he/she is in pain and pointed to the wound site. He/She was placed on the left side with pillow for support. Reassessed pain level. Notified the wound nurse. No follow up pain medication documented; -On [DATE] at 1:01 P.M., wound assessment completed. The wound is 80% necrotic and unstageable (unable to visualize the wound bed, covered with black tissue) with odorous drainage. No pain assessment completed. Review of the progress notes and August MAR, showed: -On [DATE] at 4:31 P.M., Tramadol 50 mg administered for right hip and leg pain. Pain scale documented as a 3 and no further assessment documented; -On [DATE] at 7:32 P.M., Tramadol administration was effective. Follow up pain scale was: 0; -On [DATE] at 8:28 P.M., Tramadol 50 mg administered for general pain, moaning. Pain scale documented as a 4 and no further assessment documented; -On [DATE] at 9:43 P.M., Tramadol administration was effective. Follow up pain scale was: 0. Review of the hospital emergency department (ED) admission, dated [DATE], showed: -History of present illness: presents to the ED for a complaint of a wound check; -Subjective: the patient states he/she has had increased pain to the right buttock; -Radiology: ulcer with extensive fat extending from posterior (back) to the sacrum to the left ischial (hip) anal fat. Associated acute on chronic osteomyelitis (bone infection) of the sacrum and coccyx; -Medical decision making: foul smelling sacral wound with necrotic tissue. Given broad spectrum antibiotics; -Clinical impression: sepsis (blood infection) due to skin infection and unstageable pressure injury of the sacral region; -Pain medication ordered included: -Tramadol 50 mg; -Norco ,d+[DATE] for severe pain, 1 tablet every 6 hours PRN; -Morphine give 0.5 ml for pain every 6 hours PRN. Review of the hospital discharge summary, dated [DATE], showed the resident expired at the hospital related to septicemia from a decubitus ulcer. During an interview on [DATE] at 1:15 P.M., the facility Wound Nurse said she assessed the resident's wound on [DATE]. The resident said the wound had hurt earlier in the afternoon, but could not recall if he/she had received pain medication. The Wound Nurse did not complete a pain assessment and did not review the MAR to determine if pain medications had been administered. The charge nurse is responsible to assess and document pain assessments. If a resident voiced pain, a complete pain assessment should be completed. If a resident's pain level changes, the physician should be notified. During an interview on [DATE] at 2:57 P.M., the Director of Nursing (DON) said all residents should have an admission baseline pain assessment. A pain assessment should be completed when a resident expresses pain. The assessment should include severity, location, non-medicated pain relief options, medication administered and effectiveness. Pain should be assessed each shift and documented. Residents with wounds should have frequent pain monitoring. The DON said she was not notified of the severity of the resident's wound until after his/her discharge to the ED on [DATE]. Pressure injuries can be painful. The resident should have received more frequent pain monitoring. During an interview on [DATE] at 3:14 P.M., the SWM Nurse Practitioner (NP) said the first time she assessed the resident's coccyx wound was on [DATE]. The NP said pressure injuries can be painful during development. Residents who develop pressure injuries should receive frequent pain monitoring and receive pain medication prior to wound care if needed. During an interview on [DATE] at 8:37 A.M., the resident's physician said residents should receive a baseline admission pain assessment. When a resident voiced pain, the nurse should conduct a pain assessment and determine the location, severity, cause and if medications relieve the pain. Residents with wounds should have frequent pain assessments and receive pain medication if needed prior to wound care. During an interview on [DATE] at 9:33 A.M., the resident's Family Member (FM) said he/she visited the resident daily. The resident was recovering from a prior surgical repair to the left ankle and needed staff assistance for care. Soon after his/her admission, the resident started complaining daily of pain to his/her buttocks. The FM reported the pain to the staff multiple times, but was unaware if staff provided medication. He/She was notified of the buttock wound when the facility obtained consent for the resident to be seen by the wound specialist. When the resident was admitted to the hospital on [DATE], the wound looked painful but the resident did not respond verbally to events in the ED. The hospital staff provided pain medication immediately in the ED.

Based on interview and record review, the facility failed to provide acceptable nursing standards of care for one of seven sampled residents (Resident #1). The resident was left in a raised bed with an air mattress on top of the regular mattress and fell on to the floor. The resident had notable bleeding, facial lacerations and bruising. Staff failed to assess the resident on the floor and moved him/her back into the bed and failed to perform and document neurological assessments, vital signs or pain assessments. Staff failed to report a change in mental status to the physician in a timely manner. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The census was 87. On 7/9/21 at 4:50 P.M., the Administrator was notified of the immediate jeopardy of an Immediate Jeopardy (IJ) which began on 6/14/21. The IJ was removed on 7/9/21, as confirmed by surveyor onsite verification. Review of the Adaptive or assistive device and potential restraint policy, dated 2/17, showed: -Purpose: To ensure that adaptive or assistive device will be used only when it has been determined through an evaluation process that it is necessary to treat a resident's medical condition or as a therapeutic intervention to enhance the resident's functional abilities to promote the resident's highest level of wellbeing and after evaluation of the risks; -Policy: -An adaptive or assistive device will only be used when it has been determined through an evaluation process that it is necessary to treat the resident's medical condition or as a therapeutic intervention to enhance the resident's functional abilities; -Adaptive or assistive devices such as low air loss mattresses or other devices that are not assessed as a restraint will be evaluated for necessity and risk prior to being placed quarterly, upon significant change in condition and when the mattress is changed; -Low air loss mattresses will only be used when conventional pressure reduction mattresses are inadequate to heal or prevent wounds, or when other means of providing comfort and pain control have proven inadequate. Only low air loss mattresses with built-in, head to toe bolsters will be used. Review of the facility's action steps following a fall policy, revised 2/19, showed: -First be sure the resident is safe; -Do not move the resident until the resident has been assessed by a licensed nurse; -Do not move the resident if a fracture is suspected; -Provide basic first aid if indicated; -Observe and preserve the fall scene. Preserve any faulty equipment involved; -Call 911, as indicated by severity of the injuries; -Take vital signs; -If the fall is without obvious cause, do a pulse oximetry (reading used to detect level of oxygen saturation in the blood cells); -If the fall was unwitnessed and if the resident is not able to definitively validate that he/she did not strike his/her head, implement neurological checks and continue for 72 hours; -Schedule of neurological assessment following potential head injury is every 15 minutes for four hours, every hour for four hours, every four hours for four hours then every shift for 72 hours; -Review the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Contact the resident's physician or the on-call physician; -If the fall is without obvious cause, complete a Request of Medication Review, fax to the pharmacy and place in the medical record; -Contact the resident's representative; -Take additional appropriate action as indicated. Review of Resident #1's medical record, showed: -admitted on [DATE]; -discharged [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record, showed no admission baseline care plan. Review of the fall risk evaluation, started on 6/14/21 at 10:31 P.M. and signed as completed on 6/15/21 at 1:01 A.M., showed: -Upon admission and quarterly, at a minimum, thereafter, assess the resident status in the eight clinical condition parameters listed which best describes the resident. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan; -Level of consciousness/mental status: Intermittent confusion; -History of falls in the last three months: one to two falls in the past three months; -Ambulation/elimination status: Chair bound, required restraints and assist with elimination; -Vision status: Adequate with or without glasses; -Gait/balance: Required the use of assistive devices such as a cane, walker, wheelchair or furniture; -Systolic blood pressure: No noted drop between lying and standing; -Medication: Took three to four medications currently; -Resident had a change in medication or change in dosage in the past five days: was left blank; -Predisposing disease: One to two present; -Clinical suggestions: Rubber soled shoes or non-skid slippers work for ambulation: was left blank -Utilize toileting program: was left blank -Total score: 15.0, at risk for falls. During an interview on 7/7/21 at 2:50 P.M., Certified Nurse Aide (CNA) B said the resident had been admitted around 8:00 P.M. CNA B had been attending to other residents on the floor when the resident was admitted and did not assist the resident into bed. During an interview on 7/8/21 at 7:49 A.M., Licensed Practical Nurse (LPN) C said the resident arrived with ambulance staff to the facility around 8:30 P.M. on 6/14/21. LPN C directed the ambulance staff to the resident's room. He/she notified RN A the resident had arrived. He/she worked the evening and night shift when the resident fell . He/she assisted with the resident's admission paperwork. The charge nurse should have conducted pain, neurological assessments and vital signs after the fall. Since he/she had not been the resident's charge nurse, he/she did not assist with the resident's care, post-fall or provide any assessments. Review of the resident's progress notes, dated 6/14/21 at 11:00 P.M., showed the resident fell out of bed and lay face down. His/her left nostril was bloody and his/her left lower lip had a pea sized area of bleeding on the inner lip. The left lower lip had a 0.7 centimeter (cm) laceration and staff applied one steri-strip (tacky narrow strip dressing used to close small lacerations). The left chin, under the jaw, was noted to have a laceration that measured 1.1 cm x 0.2 cm, steri-strips applied. The left eye orbital (eye bone) area was noted to have mild swelling and faint bruising that measured 4 cm x 4 cm. The left outer elbow was bruised and it measured 2.5 cm x 3 cm. The left thumbnail was noted to be bent back and bloody, staff trimmed the nail. The left hip was bruised and it measured 4 cm x 4.5 cm. A message was left for the resident's family to call the facility and the on call physician was notified, no new orders were received; -No further assessments were documented. No vital signs, pain, or neurological assessments were documented. During an interview on 7/7/21 at 2:50 P.M., CNA B said he/she walked down the hallway and noted the resident lay face down on the floor next to his/her raised bed. CNA B did not enter the resident's room, and quickly located Registered Nurse (RN) A at the opposite end of the building and notified him/her of the fall. CNA B said the resident's bed had an air mattress on top of the facility mattress. The bed was approximately 3 or 3 1/2 feet high. CNA B entered the resident's room with RN A and Licensed Practical Nurse (LPN) C and noted an area of circular pooled blood under the resident's face that measured approximately 3 to 4 inches around. CNA B, RN A and LPN C turned the resident onto a sheet and lifted him/her back into the bed. CNA B left the resident's room and RN A and LPN C remained in the resident's room. During an interview on 7/7/21 at 2:36 P.M., RN A said he/she was the charge nurse on duty when the resident arrived to the facility in the evening for admission. The resident arrived to the facility around 8:30 P.M., and fell out of bed around 10:00 P.M. CNA B notified RN A that the resident had fallen out of bed and lay on the floor on his/her face. RN A entered the room and noted the resident, face down on the floor and an area of pooled blood under his/her face. RN A said the resident's bed had been at hip height or approximately 3 to 3 1/2 feet high. On top of the facility mattress was a plastic air mattress from the hospital. The air mattress was approximately 2 or 3 inches high and inflated. RN A lowered the bed and removed and disposed of the plastic air mattress. RN A with CNA B and LPN C placed a sheet on the floor next to the resident and turned the resident onto his/her back, onto the sheet and lifted the resident into the bed. RN A performed a skin assessment and facial wound care. RN A and LPN C did not assess the resident on the floor before transferring the resident into the bed. RN A did not answer when asked why he/she did not assess the resident on the floor. RN A said he/she did not know why the resident had an air mattress on the bed. The facility does not allow air mattresses. RN A had not been in the resident's room when he/she arrived with ambulance staff. He/she had been notified by LPN C the resident had arrived shortly before the resident's fall and RN A had not seen the resident prior to his/her fall. RN A said it was his/her job to assess the resident. RN A said the resident should have been assessed before the resident was moved. RN A stated he/she started the paper neurological assessment checks, but no documentation of the neurological assessments were provided. RN A said neurological assessments should be completed with any unwitnessed fall and those falls with noted head injury. During an interview on 7/8/21 at 7:49 A.M., LPN C said around 10:00 P.M., RN A notified him/her the resident had fallen out of the bed and lie on the floor and bleeding. LPN C, RN A, and CNA B responded to the resident's room. The resident lie face down next to his/her raised bed and a circular pool of blood that measured approximately 6 to 7 inches was noted under the resident's head. The resident's bed was noted to be approximately 3 to 3 1/2 feet high. A blue air mattress was on top of the facility's mattress. He/she did not know why the extra mattress was on the bed. The staff removed the air mattress, lowered the bed and turned the resident onto his/her back. They used a sheet to transfer the resident back into his/her bed. LPN C assisted the resident to reposition in the bed while RN A completed the post fall skin assessment. LPN C worked on the resident's admission paperwork and contacted the on-call physician regarding the fall. The physician instructed the staff to monitor the resident. LPN C said the oncoming night shift nurse, agency RN G took over the resident's care. LPN C worked the night shift and did not check on the resident during the night as he/she was not the residents charge nurse. LPN C did not conduct neurological assessments or contact nursing management of the fall. LPN C did not do the neurological assessments or contact nursing management, because he/she was not the resident's charge nurse. LPN C just did admission paperwork. He/she had been unsure if charge nurses RN A or RN G contacted management. LPN C said he/she did not know the facility's policy. During an interview on 7/9/21 at 2:00 P.M., the on-call physician said he/she was on call the evening the resident fell out of bed. He/she could not recall if the facility notified him of the fall specifically. Had he/she been notified of a fall, he/she would have asked several follow up questions regarding injuries or potential head trauma. He/she would have also ordered neurological assessments and vital signs to be completed frequently. He/she said the nurses should conduct a full assessment prior to moving a resident to a different location. All unwitnessed falls should have neurological assessments completed. Neurological assessments and frequent vital signs can detect a change in condition quickly and allow for quicker care. The nurses should immediately notify the physician of any change in condition. Had he/she been notified of the resident's injuries from the fall, he/she would have likely sent the resident out to the hospital for evaluation. During an interview on 7/8/21 at 3:50 P.M., LPN H said he/she was the nurse on call the evening the resident fell out of bed. Staff did not call and report the fall to him/her during his/her time on call. He/she expected the staff to notify him/her of the fall given the resident's injuries. During an interview on 7/8/21 at 1:27 P.M., CNA E said he/she worked the night shift after the resident's fall. He/she entered the resident's room around 10:30 P.M., and noted the resident's left eye was swollen shut and bruised. He/she notified RN G and was told by RN G the resident had fallen during the evening shift. The resident appeared confused and had been talking to him/herself. The resident did not sleep during the night. CNA E provided care to the resident during the night and the resident had been frightened to turn in the bed. The resident would not drink any fluids and told CNA E he/she hurt. CNA E notified RN G of the resident's reported pain. He/she did not know if RN G provided an assessment or pain medications. Review of the admission June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated, 6/15/21 for pain screening every shift: Pain assessments were left blank; -An order dated, 6/15/21 for [MEDICATION(S)] (used to treat moderate to severe pain) give 25 milligrams (mg) for arthritis to the knees as needed three times daily: no administration of the [MEDICATION(S)] was documented. During an interview on 7/9/21 at 10:33 A.M., RN G said he/she worked for an agency and worked the night shift after the resident's fall from bed. LPN C worked on the resident's admission forms, but refused to become the resident's charge nurse and instead told RN G to become the charge nurse. RN G had been told in report the resident fell out of bed during the evening shift and struck his/her head on the floor. RN G had not been instructed what forms or paperwork to complete for post fall assessments, what documentation needed to be filled out, or the frequency of the neurological assessments. He/she did not complete a pain evaluation, neurological assessments, or vital signs. He/she did not observe any documentation in the resident's record from the previous shift regarding the fall, pain evaluations, neurological assessments or vital signs. RN G said he/she came onto shift around 10:30 P.M. or 11 P.M. and his/her first assessment of the resident was at approximately 1:45 A.M. The resident had bruising and swelling to his/her left eye and appeared confused and answered Hi, but did not answer in full sentences to RN G's questions. The resident seemed confused. RN G did not know the resident's baseline as the resident was a new admission. At 3:30 A.M. and 5:00 A.M., RN G looked into the resident's room from the hallway and the resident appeared calm and awake. None of the CNAs reported pain during the night shift. At 5:00 A.M., LPN C came to assist with morning duties and provided report to the oncoming day shift nurse. RN G did not complete neurological assessments during the night shift. He/she did not document in the resident's record and documented a late entry note four days later on his/her next shift. RN G said he/she didn't know they were supposed to complete neurological assessments,he/she didn't know the facility policy regarding post fall assessments, or where to find the neurological check assessment forms. He/she had not been educated by the facility on what or where to document the assessments. Standard nursing practice is to complete pain, neurological assessments, and vital signs on all post fall head injuries. Further review of the progress notes, dated 6/19/21, showed a late entry note for 6/15/21 at 1:45 A.M., the resident lie awake in bed and talking to staff, holding writer's hand during assessment. Vital signs were blood pressure 137/77 (normal range 120/80), respirations 20 (normal range 12-25 breaths per minute), pulse 74 (normal range 60-80 beats per minute, temperature 97.4 F (normal range 97.0 - 98.8 F) and oxygen saturation 90 percent (%), (normal range is 90-100 %). Further review of the progress notes, showed no further vital signs, pain assessments, or neurological assessments documented. During an interview on 7/8/21 at 2:22 P.M., CNA F said he/she worked the morning after the resident's fall out of bed. He/she arrived to the resident's unit around 6:30 A.M. and did rounds with CNA E. CNA E told him/her the resident fell out of bed the evening before and CNA E left the resident in bed. CNA F said the resident appeared to have bruising and swelling to the left side of his/her face and a cut under his/her chin. The resident appeared to have stroke like symptoms because he/she had unclear speech, and was mumbling. He/she notified the day shift charge nurse and the charge nurse got the former Director of Nursing (DON), RN D. The resident's physician saw the resident a few hours later and the resident was sent to the hospital. Further review of the resident's progress notes, showed: -On 6/15/21 at 9:45 A.M., the resident noted with lethargic mood and uneven hand grips, the resident's physician noted to be at the facility and assessed the resident. Per the physician new orders to send the resident back to the emergency room for a head cat scan (CT, uses x-ray machines to create cross-sectional images of the body) due to lethargy and altered mental status to rule out a brain bleed. The resident's family notified; -No further vital signs documented since 1:45 A.M. and no neurological or pain assessments were documented between 6/14/21 after the fall until the resident was sent to the hospital. -On 6/15/21 at 4:20 P.M., the resident's family called the facility and notified the facility that the resident had been diagnosed with a cerebral hemorrhage and has been transferred from the first hospital to a trauma hospital for surgical consults. During an interview on 7/7/21 at 2:18 P.M., the nursing supervisor said the former Director of Nursing (DON), RN D had been responsible to ensure fall tracking had occurred. RN D was responsible at the time for all incident reports and nursing follow ups. The nursing supervisor was notified of the resident's fall on the morning of 6/15/21, the resident was seen by his/her physician and sent out to the hospital emergently. The facility had no documentation of the neurological assessments completed post fall. He/she expected neurological assessments to be completed on all residents with an observed head injury and an unwitnessed fall. The neurological assessments would also include a full set of vital signs. The facility had no post fall neurological assessments or vital signs documented for the resident. During an interview on 7/8/21 at 8:53 A.M., RN D said he/she had been the DON at the facility at the time of the resident's fall. He/she was not notified of the resident's fall or of the facility injuries. He/she was notified the next morning by the day shift agency nurse of the resident's fall. The resident had been assessed by his/her physician and was getting sent out emergently due to a change in mental status. RN D said the nurses on duty should have called the on call nursing supervisor and called the DON as the resident had obvious facial injury. The resident should have been sent to the hospital with noted injuries for evaluation. During an interview on 7/8/21 at 12:30 P.M., the resident's physician said he/she came to the facility around 9:00 A.M. He/she said the day shift nurse told her the resident rolled out of bed the evening before and was not very awake. He/she performed an assessment and found the resident did not speak and only moaned, he/she had a visible chin laceration and bruising around the eye. He/she was very concerned and decided to send the resident to the hospital emergently. He/she said the discharge assessment from hospital showed the resident had been alert to him/herself and place. When the resident was nonverbal upon his/her assessment, this revealed a significant change in condition. The day shift nurse did not tell him/her when the change of condition occurred, and only reported the resident was very lethargic. The physician was not certain if the resident received neurological assessments. He/she expected staff to conduct neurological assessments for all falls with facial injuries. The staff should have immediately notified the physician at the time of a change in condition. Nurses should never move residents until a full assessment is completed, and any suspected head injury should be sent to the emergency room for evaluation. Review of the trauma hospital's admission records, dated 6/15/21 at 4:52 P.M., showed: -Trauma admission history and physical: The patient had an unwitnessed fall at the facility last evening. He/she had right eye bruising and swelling and a chin laceration. He/she was seen at an outside hospital for an initial work-up with a head CT and spine and then transferred to the trauma hospital for further care; -Assessment from previous fall: -Small left subarachnoid hemorrhage (SAH) remained unchanged; -Left periorbital fracture; -Left zygomatic fracture; -Right mandibular condylar head fracture; -Plan: -Continue cervical collars (c-collar, used to support your spinal cord and head, provide rigidity to prevent neck and head injury); - Magnetic resonance imaging (MRI, used to produce detailed images of the organs and tissues) of the neck; -Consult for orthopedics, neurology and plastic surgery; -Admit to the trauma floor; -Neurosurgical consult on 6/15/21 at 5:07 P.M., showed: -Reason for consult: fall, traumatic SAH; -History of present illness (HPI): The patient had dementia and presented to the emergency department as a transfer for evaluation of face fractures and left temporal SAH after a fall; -Plan: no surgical intervention needed, repeat the CT scan now, hold blood thinner medications and admit to the trauma floor; -Plastic surgery consult on 6/15/21 at 5:44 P.M., showed: -HPI: the patient had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she was taken to an offsite hospital and transferred to the current trauma hospital for a higher level of care. The patient is unable to follow commands and is alert to him/herself only; -Assessment and Plan: -Left zygomatic complete fracture moderately displaced; -Right mandible condylar head fracture minimally displaced; -Superficial chin laceration; -Admit to trauma; -Apply antibiotic ointment to facial lacerations three times a day; -Oral antibiotics for mandible fracture for seven days; -Soft diet for healing; -[MEDICATION(S)] (antibacterial mouth rinse) rinse use three times a day. During an interview on 7/9/21 at 12:09 P.M., the resident's responsible party said before the resident's admission, the resident lived at home independently. He/she had difficulty walking at times due to arthritis in his/her knees. The resident was to receive therapy at the facility for several weeks and discharge back home. The facility notified him/her the resident arrived that evening around 9:30 P.M., and staff placed the resident into bed. He/she had fallen asleep and missed a call from the facility at approximately 12:45 A.M. At 4:30 A.M., when he/she noticed the missed call, he/she called the facility and the nurse informed him/her of the fall and the resident had been comfortable. At 10:30 A.M., the facility nurse called and said the resident's physician examined the resident and determined the resident needed to go to the hospital emergently for evaluation. The ambulance took the resident to the closest hospital, and after finding facial fractures, transferred the resident to a trauma hospital for the higher level of care. The resident remained in the hospital for a week and was discharged to a different facility. The family member said the resident is a completely different person since the fall and now needed full care and is not able to participate in therapy. He/she does not communicate and only used simple one word answers. 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, it was determined the facility had implemented corrective action to address and lower the violation at that time by in-servicing staff on assessment of falls and prompt assessment and follow up after a fall. Fall logs will also be reviewed. A final revisit will be conducted to determine if the facility is in substantial compliance with the 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 198.0261 RSMo) requiring that prompt remedial action be taken to address Class I violation(s).need lowering statement MO 850

Based on observation, interview and record review, the facility failed to ensure the safety, well-being and right to be free from sexual abuse for three of 18 sampled residents (Residents #63, #16 and #83). Additionally, the facility failed to ensure care plans were updated and interventions were initiated (Residents #19 and #7). The facility failed to follow the resident abuse policy by not notifying management, conducting head to toe assessments of alleged violated residents and documenting in the resident's medical record. The census was 87. Review of the facility's Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, last updated (MONTH) (YEAR), showed the following: -Policy: The facility affirms the right of our residents to be free from verbal, sexual, physical, mental abuse, neglect, misappropriation of resident property, crime, corporal punishment, exploitation and or involuntary seclusion; -The facility is committed to protecting our residents from abuse by anyone, including, but not limited to facility staff, other residents, consultants, contractors, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. -Abuse Prevention Program: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical, mental, emotional pain or anguish. It includes deprivation by an individual of goods or services necessary to attain or maintain physical, mental and psychological well-being. Also, verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. -Staff Role and Responsibilities: 1. Intervene if safe to do so, or call for immediate assistance to ensure resident/staff safety and well-being, when an incident of witnessed or un-witnessed abuse or neglect is occurring or has occurred; 2. Immediately report any witnessed, suspected, or alleged abuse to a supervisor, Executive Director (ED) and or their designee; 3. The ED will obtain a factual note containing information pertinent to the alleged incident from the staff member(s); 4. Maintain confidentiality regarding the report and the names of those involved in the incident; 5. Cooperate fully with those responsible for the investigation at the facility, Department of Health and Senior Services (DHSS) Complaint surveyor(s) and or the police department; 6. Report any retaliation actions experienced related to the reporting of abuse or neglect under the policy. -Management Roles and Responsibilities: 1. Nursing supervisor/charge nurse or senior manager on duty is to immediately notify the Director of Nursing (DON) who notifies the ED and or their designee, or DON designee or senior manager on duty immediately upon receipt of the report of alleged abuse or neglect witnessed or un-witnessed resulting in serious bodily injury; 2. The ED and or their designee will immediately initiate an investigation into the alleged incident; 3. The ED and or designee will immediately notify management services of the alleged abuse or neglect witnessed or unwitnessed of all steps of the investigation process; 4. The ED and or their designee will assure the employee(s) whom are alleged to have committed the abuse or neglect are suspended pending investigation until the investigation is completed and a final report is made; 5. Accused individuals not employed by the facility will be denied unsupervised access to the resident; 6. If the events indicate there is a reasonable suspicion of crime involving a resident that results in serious bodily injury, the report must be made immediately after forming the suspicion, but not later than two hours after forming the suspicion. Otherwise, the report must be made within twenty-four hours to the DHSS Regional office and the local police department; 7. Maintain the security and integrity of the physical evidence at the incident, including documenting this evidence appropriately. -Clinical Staff Responsibilities: 1. Ensure the safety of resident(s) under his or her care; 2. Conduct head to toe physical assessment on the alleged victim and document findings if physical abuse or negligence is alleged; 3. If necessary, contact physician for further assessment, treatment and follow-up, based on nursing assessment of injury, pain or suspected injury such as fractures or head injury; 4. Document and communicate the status of the resident's medical condition and mental/emotional condition to the ED and or their designee; 5. Maintain confidentiality regarding the report and names of all those involved in the incident. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Brief interview for mental status (BIMS) score of 15 out of 15, which showed no cognitive impairment; -Ambulated with a walker and propelled self in the wheelchair; -Required supervision with ambulation; -Diagnoses included heart failure and right hip pain. Review of the resident's facility face sheet, showed diagnoses included sexual disorders, hypertrophy of breast (a mass of breast tissue beneath the nipple and areola) and androgen excess (increase in testosterone levels that can affect both men and women). Review of the electronic physician's orders [REDACTED]. Review of the progress note, dated [DATE], showed the following: -At 11:57 A.M., the resident grabbed a staff member by the butt and said to meet him/her in his/her room. The resident had a big smile the whole time he/she flirted ; -At 12:39 P.M., the resident was being walked by the restorative therapy aide and he/she tried to kiss the aide and asked for the aide to kiss him/her. He/she also attempted to put his/her hand in the genital area of a housekeeper and a nurse aide, grabbed a nurse and nurse aides buttocks and made sexual innuendos to several members of the opposite sex. The nurse contacted the physician and left a message. Review of the care plan, dated [DATE], showed no updates or interventions added after the incidents on [DATE]. Review of the progress notes, dated [DATE], showed the following: -At 2:27 P.M., observed the resident in the hallway touching another resident inappropriately. Activity Director informed the resident that the behavior was inappropriate and maybe he/she should keep his/her hands to himself/herself. Both residents had shared the same dining room table and they were both placed at separate tables; -At 3:34 P.M., Registered Nurse (RN) J notified supervisor Licensed Practical Nurse (LPN) M of the incident as well as the resident's responsible party (RP). Further review of the care plan, dated [DATE], showed staff did not add interventions to the care plan after the incident on [DATE]. Review of the progress note, dated [DATE] at 3:10 P.M., showed the resident was talking to the Certified Nurse Aides (CNA)s and was being sexually inappropriate by grabbing their bottoms and saying inappropriate things to them. LPN K spoke to the resident's RP who said he/she wanted to wait until the attending physician returned to find out if the behavior is a side effect from the Mucuna Pruriens Seed Extract and if the medication should be discontinued. Further review of the progress notes, showed no documentation from [DATE] through [DATE] that the physician returned the call from [DATE]. Review of the progress notes, dated [DATE], showed the following: -At 10:10 A.M., LPN L obtained an order for [REDACTED].>-At 10:19 A.M., the resident entered the room of a resident of the opposite sex. He/she kissed the resident's hand and caressed his/her arm. The other resident told him/her to stop and he/she stated there's more where that came from. The note went on to say that the nurse spoke with him/her about the unwanted inappropriate behavior and staff would monitor both residents. Review of the progress note, dated [DATE] at 12:47 P.M., showed the attending physician wrote an order to discontinue Mucuna Pruriens Seed Extract due to increase in sexual activity with staff and other residents. Staff will monitor for decrease in behaviors. Review of the laboratory report, dated [DATE], showed a testosterone level of 381 (normal testosterone level is ,[DATE]). Review of the care plan, dated [DATE] and updated on [DATE], showed the following: -Problem: Resident has had sexual behaviors toward several residents of the opposite sex, such as kissing their hands and making inappropriate sexual comments; -Goal: Resident will decrease behaviors towards residents of the opposite sex who are uninterested; -Interventions: Social worker will talk with the resident to reinforce acceptable behaviors, monitor labs as ordered especially testosterone and the physician discontinued Mucuna Pruriens Seed Extract so monitor for a decrease in inappropriate sexual behaviors. Review of the physician's visit summary, dated [DATE], showed resident seen for management of chronic conditions, right hip pain, [MEDICAL CONDITION] (protective cartilage at the ends of bones wears down causing pain), [MEDICAL CONDITION] (damage to the optic nerve) and artificial eye. All remain stable. The nurse or resident do not voice any other complaints. The summary did not mention the resident's sexual behaviors. Review of the progress note, dated [DATE] at 11:41 A.M., showed a note that the physician evaluated the resident, discontinued the testosterone and believed all sexual urges found to be uncontrollable urges. Review of the progress note, dated [DATE], at 1:57 P.M., showed resident continues to flirt with many female residents and is very handsy with them as well. Review of the progress notes, dated [DATE], showed the following: -At 11:22 A.M., LPN M received a verbal order from the attending physician for the resident to receive counseling; -At 4:34 P.M., showed an entry by the social worker (SW) that the management team determined that counseling would be beneficial for the resident, because they believed he/she was lonely and needed companionship. A call was placed to the RP for permission to proceed with counseling. Review of the physician's monthly visit report, dated [DATE], showed an entry that the resident is becoming more insistent in displaying sexual behaviors and becomes highly upset when redirection is attempted, but the nurse thinks these episodes are becoming less frequent. Review of the ePOS, showed an order, dated [DATE], to administer [MEDICATION NAME] (a hormone used to treat inappropriate sexual behaviors) 10 mg one tablet daily. Further review of the care plan, dated [DATE], showed no further update or new interventions recorded. Further review of the progress notes, dated [DATE] at 3:27 P.M., showed a note written by the SW regarding a meeting with the resident's family to discuss his/her continued approach to residents of the opposite sex and touching them without consent. Resident's family visits daily and feels he/she is lonely. The SW discussed moving him/her to a different room on the same hallway with an alert resident to provide companionship. The SW performed another BIMS and he/she scored a 14 out of 15, which showed the resident as cognitively intact. The SW's note went on to say that the resident voiced remorse for what he/she had been doing, but could not remember any of the incidents. The SW wrote that he/she would continue to monitor the resident. Review of the attending physician's monthly visit report, dated [DATE], showed no documentation regarding the resident's inappropriate sexual behaviors. Review of the progress notes, dated [DATE] (Saturday), showed the following: -8:00 P.M., at approximately 1700 (5:00 P.M.), this resident was observed by a CNA fondling and kissing a resident of the opposite sex in that resident's room. The resident was removed from the room and taken to the dining room for supper. Staff notified the DON and one on one observation was initiated; -10:34 P.M., attending physician was notified of resident's behavior earlier this evening. He/she ordered a testosterone level for Monday. Review of the progress notes, dated [DATE], showed the following: -At 2:59 P.M., LPN E received a verbal order from the attending physician to obtain a urine specimen for a urinalysis (UA). LPN E went on to say that the resident could not produce a sample; -At 3:39 P.M., the SW interviewed the resident and he/she said that he/she had no recollection of the occurrence from the day before. He/she believed the staff when they spoke with him/her about what occurred, but found it frustrating that he/she could not remember the incident. She performed a BIMS and found the result to be 9 out of 15, which showed moderate cognitive impairment. Further review of the care plan, dated [DATE] and last updated on [DATE], showed the following: -Problem: Sexually inappropriate behavior noted [DATE]; -No goal listed; -Interventions: Give [MEDICATION NAME] 10 mg daily, testosterone level as ordered, provide 1:1 care, give [MEDICATION NAME] (antidepressant) 20 mg daily for impulsive behavior (ordered by the physician on [DATE]), notify physician of change in condition and notify RP of behaviors. Review of the laboratory section of the medical record, showed a testosterone level, dated [DATE] with a result of 268. No UA results found. Review of the progress note, dated [DATE] at 4:13 P.M., showed the SW spoke with the family to discuss different living arrangements for the resident. During an interview on [DATE] at 11:15 A.M., the resident said that he/she could not remember the incident that occurred on [DATE], but did believe the staff when they told him/her what occurred. He/she said that he/she felt guilty and then offered no more information other than he/she was leaving the facility on this date to move to another home. During an interview on [DATE] at 9:10 A.M., the SW said she had been working with the family regarding the resident's behaviors. They wanted things to work out so that he/she would not have to move, so they visited on a daily basis. She said this was new behavior for the resident and they were trying different things to resolve the issues. When pressed regarding what was done, she said they started counseling, tried to move him to a different room on a different unit but given the types of clientele on the other units it would not work out. She said she often stopped by the resident's room to see how things were going and spoke with the staff. She provided a form that she taped at the nurses' desk and spoke to the staff about. The information, dated [DATE], showed the following: -Attention all staff regarding sexual behaviors: -We need everyone's help to stay on the same page regarding (resident's name) sexual behaviors; -A referral has been sent to the contracted therapy company for grief counseling (spouse died on e year ago and roommate recently died ). They will also work on sexual behaviors; -The physician is working on medications and trying to find a better balance; -We need everyone's efforts to introduce him/her to other members of the same sex for conversation and companionship; -Family is supportive of our efforts and has given permission to manage these behaviors however we feel is best; -We need all staff to communicate and immediately address behaviors (if they are comfortable), or pass along to someone who is. This includes housekeeping, activities, dining, etc; -We will discuss this at our behavioral wellness committee next week. During an interview on [DATE] at 9:30 A.M., the DON and Assistant Director of Nursing (ADON) said it was never okay for a resident to act or speak sexually inappropriate to any resident or staff member. They stayed in touch with the physician and other things were tried before starting him/her on medication. They talked to him/her about the behavior and the family visited daily which always helped at the time. Moving him/her to a different unit was not practical given the clientele on the other units. They said that all encounters should have been added to the care plan and staff members should have been aware of the effects of Mucuna Pruriens. During an interview on [DATE] at 11:55 A.M., the attending physician said he started the resident on Mucuna Pruriens because of swelling of the breast. Tests showed his/her prolactin (hormone that tells the body to make breast milk) level was high. When the level returned to normal, he discontinued the medication. He said that he did not believe that the sexual behavior had anything to do with the medication, but instead believed it to be from dementia. Further review of the face sheet, the care plan, dated [DATE], the POS used during the survey and the quarterly MDS, dated [DATE], showed no [DIAGNOSES REDACTED]. 2. Review of Resident #63's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Unable to ambulate; -Dependent on staff for all mobility and personal hygiene; -Incontinent of bowel and bladder; -Diagnoses included dementia, [MEDICAL CONDITION] (affects the nerve cells in the brain causing muscle rigidify, tremors and changes in speech and gait) and [MEDICAL CONDITION]. Review of the progress notes, dated [DATE], showed the following: -At 7:56 P.M., at approximately 5:00 P.M., a male resident was observed fondling and kissing her. The two were separated. The resident was redressed and taken to the dining room for supper. The RP and ADON were notified; -At 9:55 P.M., RN H performed a skin assessment. No abrasions or open areas found. Skin warm and dry and no signs or symptoms of discomfort. Review of the facility self report, dated [DATE], showed earlier in the evening, CNA G assisted Resident #63 in to the broda (reclining wheeled) chair in preparation for dinner. CNA G left the room to tend to other residents and when he/she returned at approximately 5:00 P.M., he/she found Resident #19 seated in his wheelchair next to the broda chair leaning over her. Resident #63's dress was off, her undershirt was raised exposing her breasts and the tabs of her brief were removed and the brief loosened in the front. Resident #19 grabbed at Resident #63's breast's and was kissing her with his tongue in her mouth. Resident #63 was mumbling. CNA G unlocked Resident #19's wheelchair and pulled him/her away from the broda chair while he/she tried to hold on to the chair and not leave the room. CNA G told him/her that he/she can not do this to other residents and he/she responded she wanted this. CNA G tried to explain to him that she cannot tell him what she wants and Resident #19 screamed ask her yourself, she'll tell you the truth. CNA G asked him again why he did that and he responded well honey, I was playing with her. She wheeled down to my room and told me to come back to her room, that no one had to know. It would be between us, so I followed her back to her room and then you saw us. CNA G said Resident #19 laughed while telling him/her what happened and as he rolled to dinner, he said ask her, she'll tell you the truth. Review of a statement written by RN H reiterated what CNA G wrote and added, Resident #63 is very confused and unable to make any choices for herself or protect herself. The DON was notified at approximately 8:00 P.M. and the ADON called the facility and spoke with RN H. Instructions were given to start one-on-one monitoring of Resident #19. The RPs for both resident's were notified along with the physician. Review of the progress note, dated [DATE] at 5:52 A.M., showed resident is alert and oriented to self and has no recollection of earlier events. Review of the care plan, dated [DATE] and last updated on [DATE], showed no updates regarding the incident on [DATE] or the new order for [MEDICATION NAME] daily. Review of the progress notes, dated [DATE], showed the following: -At 1:16 P.M., resident tearful at breakfast but easily directed; -At 1:16 P.M., due to extreme anxiety the physician was notified and obtained an order to administer [MEDICATION NAME] (anti-anxiety) 0.5 mg one tablet every morning; -At 6:23 P.M., no tearfulness or anxiety noted. Seems comfortable. During an interview on [DATE] at approximately 9:30 A.M., the SW said she followed up with the resident by stopping by to talk and comfort her. She also said that the nuns from a local order stopped by daily to visit and offer support. She said she was not aware that [MEDICATION NAME] had been started and agreed more non-pharmacological attempts should have been tried first. The SW and DON both said all interventions should have been listed on the care plan and there should have been more follow up after the start of [MEDICATION NAME]. The DON looked for and could not find any progress notes after [DATE] at 6:23 P.M. 3. Review of Resident #7 quarterly MDS, dated [DATE], showed the following: -BIMS score of 6, indicated severe cognitive impairment; -Tired with little energy and trouble concentrating half or more days; -Felt bad about self on several days; -Independent with most activities of daily living (ADLs); -Used a walker; -Diagnoses included [MEDICAL CONDITION], dementia, anxiety, depression and [MEDICAL CONDITION] disorder (brain disorder that causes extreme mood swings). Review of the resident's face sheet, showed additional diagnoses of counseling related to sexual attitude and high risk heterosexual behavior. Review of the resident's care plan, updated on [DATE], showed the following: -Problem: Needs reminders to come to activity programs, likes to socialize with a female resident and calls her his girlfriend, tendency to be obsessive about his girlfriend and may not understand when female resident does not want his attention or company; -Goal. Attendance in activities over the next 90 days and will exhibit proper social behavior over the next 90 days; -Approach: Monitor for socially unacceptable behaviors during activities, make sure girlfriend is consenting to his attention; -Problem: Mood, has history of [MEDICAL CONDITION] disorder and anxiety, has been delusional and thinks people are stealing from him; -Goal: Will exhibit decreased signs of depression and anxious moods over the next 90 days; -Interventions: Encourage resident to attend activities and sees the in-house psychiatric consultant; -Problem: Psychological, has [DIAGNOSES REDACTED]. -Goal: Will have decreased behaviors that would induce self harm; -Interventions: Monitor any problems with relationships with roommate, family, peers and staff, note responses of residents, monitor resident behavior all shifts, sees in-house psych consultant; -Update [DATE]: [MEDICATION NAME] (anti-psychotic medication) ordered, see Medication Administration Record, [REDACTED] -Problem: Mood, has history of [MEDICAL CONDITION] disorder and anxiety, has been delusional and thinks people are stealing from him; -Goal: Will exhibit decreased signs of depression and anxious moods over the next 90 days; -Interventions: Encourage resident to attend activities and sees the in-house psychiatric consultant. Review of Resident #16 annual MDS, dated [DATE], showed the following: -BIMS score of 3, which indicated severe cognitive impairment; -Tired with little energy and poor appetite half or more days; -Limited assistance of staff required for dressing, toilet use and personal hygiene; -Used a walker; -Occasionally incontinent of bladder; -Diagnoses included [MEDICAL CONDITION], dementia and depression. Review of the resident's care plan, updated [DATE], showed the following: -Problem: Resident has a [DIAGNOSES REDACTED]. -Goal: Frequency of depressed statements will be reduced over the next 90 days; -Interventions: Resident frequently enjoys the company of another resident, but can easily be irritated by his attention, staff to monitor and redirect as needed. Review of Resident #7's progress notes, showed the following: -[DATE] at 2:33 P.M., resident was seen touching a female resident at morning med pass. The CNA redirected Resident #7, as the female resident was very upset. Will keep residents separated and continue to monitor behavior, next shift made aware; -[DATE] at 8:18 A.M., resident has been showing aggression towards employees. Does not want to be cut off from his friend, told him that he does not need to be cut off, needs to not touch her. Agreed to no touching as long as they can still sit together in mass and talk in activities, will continue to observe this situation and possibly discuss medication issue with physician since aggression has come on suddenly; -[DATE] at 1:44 P.M., new verbal orders from physician, give [MEDICATION NAME] (acid reducer) 200 mg, twice daily for overactive sexual behaviors; -[DATE] at 2:11 P.M., pharmacy called stating the supplier is not able to get [MEDICATION NAME] 200 mg from the manufacturer, per physician, change to [MEDICATION NAME] (medication that lowers testosterone levels and sexual drive in men) 10 mg, one daily for overactive sexual behaviors. Review of the resident's psychological services progress notes, showed the following: -[DATE], Current risk factors: sexual acting out, none; -Patient's response to intervention, talked about maintaining appropriate boundaries with female resident friend; -[DATE], Current risk factors: sexual acting out, none; -Patient's response to intervention, talked again about maintaining appropriate boundaries with female resident friend, and he expressed understanding and willingness to do that. Review of the resident's clinical treatment plan review (plan of care), dated [DATE], showed the following: -Clinical assessment: Resident presents to have impulse control issues as indicated by the way he kisses other residents on the hands and sometimes on the face; -Patient specific long-term goals: Discontinue boundary violations with female residents; -Patient specific short-term goals and rating: Engage in positive relationships with other residents while maintaining appropriate boundaries, moderate progress made. Further review of the resident's progress notes, showed the following: -[DATE] at 3:08 P.M., resident was in the dining room sitting next to female resident and was continually telling her (Resident #16) You know I love you and I wouldn't hurt you. Other resident did not want to talk to him and tried to leave the dining room. As she walked down the hall, Resident #7 followed the female resident screaming her name and telling her to get back here. Resident #16 was very upset, blubbering type crying and shaking uncontrollably. Much reassurance given to female resident, was able to calm her down and redirect her to her room. Resident #7 shook a closed fist at CNAs, trying to hit them, threw coffee at staff when trying to redirect away from female resident, cussing at other residents and staff. Physician called and got order to send to hospital for psychiatric evaluation. Called 911 and police department showed up, but stated they could not take him due to he did not hit anyone and does not believe he is a threat. Stated emergency medical would not take him due to they would evaluate and send right back. Explained our protocol and keeping our residents and staff safe. Spoke with DON who stated she would talk to the ED and social worker tomorrow regarding the issue. Advised to keep resident away from Resident #16 and out of dining room since that gives him access to her wing. Female resident is on locked unit, but can be accessed by other door to dining room. Resident #7 has attempted two times to get to Resident #16 by sneaking into dining room; -[DATE] at 8:41 A.M., due to recent events, Resident #7 is not to sit with another specific resident due to aggressive behaviors. Resident #7 was found at dining table with other resident and this nurse spoke to resident reminding him he cannot be there. Resident began to yell at nurse, stating This is bullshit, what did I do? Resident was told that he had behaviors that could cause potential harm to others and we wanted to avoid that happening again. Resident stood up and moved out of dining room, stating This is bullshit, just bullshit repeatedly; -[DATE] at 11:43 A.M., received call back from psychiatric nurse practitioner (NP), discussed recent behaviors and given the following new orders; discontinue [MEDICATION NAME] (anti-depressant medication) and change to [MEDICATION NAME] (anti-depressant medication) 75 mg daily for five days then increase to [MEDICATION NAME] 50 mg twice daily. Add [MEDICATION NAME] (anti-depressant medication) 25 mg every six hours as needed (PRN) times 14 days and discontinue [MEDICATION NAME]; -[DATE] at 3:34 P.M., physician visit, order to increase [MEDICATION NAME] to 25 mg twice daily. Review of a psychological progress note, dated [DATE], showed the following: -Current risk factors: sexual acting out, none; -Patient's response to intervention: Patient again talked about the female patient he enjoys spending time with and how the staff want him to leave her alone, talked again with patient about how this has more to do with the other patient's anxiety and emotional issues than it has to do with him. Further review of the resident's progress notes, showed the following: -[DATE], late note, 2:30 P.M., resident was in activity room when Resident #16 was walking out. Resident #7 grabbed Resident #16's walker, put his leg between the legs of the rollator walker to prevent Resident #16 from leaving. He began to pat Resident #16's inner thigh. Resident #16 was confused and yelling incoherently, CNA redirected Resident #7 to leave the other resident alone and let her leave and moved Resident #7 to a table in activity room; -[DATE] at 5:00 P.M., Resident #7 went to sit with Resident #16 after being informed that he could no longer sit with her at meals because this caused Resident #16 distress and anxiety. Resident #7 was yelling at staff stating I never did anything but stick up for her because you make her cry. Resident #16 sat calmly at table, pleasantly confused; -[DATE] at 5:59 P.M., resident became physically threatening to CNA (I am going to stab her with a fork) when the CNA tried to separate him from another female resident. Escorted Resident #7 from dining room. PRN [MEDICATION NAME] given with good results; -[DATE] at 3:33 P.M., reported to this nurse by dietary staff that Resident #7 grabbed a female resident on upper part of body over clothing. Female resident told Resident #7 no and walked away. Review of a nurse practitioner's progress notes, showed the following: -[DATE], Resident continues to have episodes of inappropriate and sometimes forceful attention towards female resident. Staff able to redirect during these incidents; -[DATE], Resident continues to have episodes in which he directs unwanted attention towards another female resident. Staff report no physical harm has been caused to the other resident. Further review of Resident #7's progress notes, showed the following; -[DATE] at 2:28 P.M., resident attends mass and group activities only. Reads the newspaper daily and sits by the front door to read, has a love for dogs and enjoys the visits from all outside dogs that visit, at times can be moody and will rest in his room, has a female resident that lives here that he spends a lot of time with. Review of Resi (TRUNCATED)

Based on observation, interview, and record review, facility staff failed to prevent an avoidable accident for one of six sampled residents (Resident #1). The resident had a [DIAGNOSES REDACTED]. Staff reported they informed the nurses the resident repeatedly slid to the side of the mattress and had to be frequently repositioned away from the side rail. On [DATE], staff observed the resident lying on the floor with his/her face between the mattress and the side rail. The resident was deceased . The census was 91. 1. Review of Resident #1's face sheet, showed an admission date of [DATE]. Additionally, staff documented the resident was at risk for falls. Review of the resident's side rail and assist bar evaluation, dated [DATE] and verified by the Director of Nursing (DON) as the most recent assessment completed, showed: -Brief interview of mental status (BIMS) score of 4 out of a possible score of 15; -A BIMS score of ,[DATE] shows rarely or never understood; -Half rails on the left and the right side; -Interventions and care plans have been implemented. Review of the resident's fall risk evaluation, dated [DATE] and verified by the DON as the most recent assessment completed, showed staff assessed the resident as high risk for falls. Review of the facility's fall risk reduction policy, last revised [DATE], showed: -Purpose, to identify residents at risk for falls and implement interventions to reduce risk and to insure appropriate and prompt follow up of resident falls; -Protocol, residents will be assessed for fall risk quarterly; -Strategies for fall risk reduction, maintain non-skid surfaces and a low bed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -BIMS score of 7 out of a possible score of 15; -Extensive assistance of one staff person required for bed mobility. Review of the resident's care plan, last updated on [DATE], showed: -The resident required maximum assistance with activities of daily living (ADL's; bathing, toileting, dressing etc.); -At risk for falls due to a contracture of the left hand (the care plan did not address any strategies for fall risk reduction); -Side rails not listed on the care plan as an intervention used. Review of the resident's physician order [REDACTED]. -Diagnoses of dementia, osteoporosis (bones become extremely porous and are subject to fracture and slow healing), iron deficiency anemia (low red blood count caused by low levels of iron in the blood) and difficulty hearing; -No diagnoses for heart disease, high blood pressure, high cholesterol or any other cardiac diagnoses listed as an active diagnosis; -No order for medication to treat heart disease, high blood pressure, high cholesterol or any other cardiac diagnosis; -May have half siderails up for positioning. Review of the resident's nurses notes, dated [DATE] at 2:00 P.M., showed a new order received for a hospice consult. Review of the resident's hospice medical record, showed: -A comprehensive nursing assessment dated [DATE], showed: -Teaching provided to facility staff, Nurse Supervisor R; -Teaching included the use of equipment; -Caregiver expresses confidence in providing care; -Verbalized understanding; -Initial orders and plan of care dated [DATE], showed: -A terminal diagnoses of Alzheimer's (form of dementia) and a related condition of dementia; -Immediate plan of care problems include functional ability, difficulty swallowing, impaired skin integrity and facility coordination; -Low air loss mattress (a mattress that provides a constant flow of air); -A clinical nursing note, dated [DATE], showed: -Increased weakness, the resident is total care and unable to reposition him/herself; -Summary, no concerns per the skilled nursing facility staff; -A death event record, dated [DATE] at 8:30 A.M., showed the resident expired on [DATE] at 6:55 A.M. The facility called hospice to inform that the resident passed and the hospice nurse attended. During an interview on [DATE] at 9:19 A.M., the DON verified that the resident's side rail assessment and fall risk evaluation were the most recent completed. The DON said the assessments were not done appropriately. They should be completed quarterly. The DON said staff did not complete them when residents received new mattresses. Review of the facility's physical restraint, devices, and side rails policy, last updated [DATE], showed: -Purpose, to insure each resident is free from physical restraints. Physical restraints, devices, and side rails shall only be applied if it enables and promotes greater functional independence for the resident; -No physical restraint, device, or side rail will be placed until the resident has been evaluated; -The continued need for the restraint, device, or side rail will be reviewed periodically. Review of the resident's nurse's notes, dated [DATE] (no time noted), showed: late entry, night shift, certified nursing assistant (CNA) requested the nurse to come to the resident's room STAT (immediately). The night shift nurse quickly responded to the resident's room and found the resident lying on the floor on his/her right side with his/her face between the mattress and side rail. Vital signs quickly obtained. No pulse present, unable to obtain vital signs. Resident code status, do not resuscitate (DNR). No further rescue measures taken. Resident pronounced dead at 6:55 A.M. Resident removed from the floor and placed into bed. The nursing supervisor is aware of resident's condition. The DON was notified of the resident's condition. Call placed to hospice to notify of resident's death. Staff notified the family, physician, and medical examiner of the death. During an interview on [DATE] at 12:58 P.M., CNA E said he/she was the CNA responsible for the resident the night he/she expired. CNA E said the previous shift passed on information that the resident's mattress was slippery and the bed would not lower to the floor. Staff had to pull the resident out of the railing several times because he/she slid off the mattress. The mattress seemed to be over inflated. CNA E said when he/she entered the resident's room the morning of [DATE], the resident's head was stuck between the side rail and the mattress, and he/she was dead. His/her neck was twisted at an abnormal angle and his/her face was towards the floor. The resident's shoulders were off the bed and one was closer to the ground. CNA E was unsure which shoulder was closer to the floor. Both of the resident's legs were on the ground. The resident was in an unusual position; the resident's hips were off the ground. Review of CNA B's attestation (statement) form, dated [DATE], showed he/she walked by the resident's room, as CNA E went to see what the resident's roommate needed. That is when he/she noticed the resident. CNA E said Oh my God, this resident is on the floor. CNA B went in and saw the resident hanging down on the side of the bed. His/her feet were on the floor and his/her head was stuck between the mattress and bed rail. His/her face was not against the mattress, it was facing out towards the door. His/her chin was caught in the rail. His/her neck was not against the rail. It seemed like he/she rolled over off the bed and his/her chin caught the rail and that is how he/she stayed until both night nurses and CNA E pushed the mattress away to release him/her and then lowered him/her to the floor. Nursing Supervisor H came in after they lowered the resident. A few minutes later the four staff lifted the resident onto the bed. During an interview on [DATE] at 6:46 A.M., CNA B said he/she worked the morning of the incident. He/she had no information to give because all he/she knew was that the resident's roommate was yelling for help and when CNA E entered the room, he/she found the resident on the floor. The resident had the mattress for only a few days and he/she kept rolling around in it and his/her feet would slide off the bed. On [DATE] at 7:34 A.M., after being asked about the discrepancies between the interview obtained on [DATE] and the attestation form provided by the facility, CNA B added the following information. He/she worked that morning. He/she did go into the resident's room after being informed by staff that the resident was on the floor. When he/she saw the resident, his/her feet were on the floor. His/her head was between the side rail and mattress. The resident faced towards the door. It looked like he/she rolled off the bed and his/her chin got caught in the side rail. The resident's shoulders were off the side of the bed. His/her hips were hanging off the bed. The bed was in a high position. Night shift said the bed was broken and would not go all the way down. During an interview on [DATE] at 8:26 A.M., Licensed Practical Nurse (LPN) D said he/she was the nurse responsible to care for the resident the night he/she died . CNA B and CNA E were the two staff who found the resident. Earlier in the morning, CNA B and CNA E dressed the resident. It had only been approximately 45 minutes since they dressed the resident when they found the resident. LPN D said when he/she entered the room, the resident was on the floor on his/her back with his/her body tilted to the side. The resident's chest was tilted at about a 30 degree angle, facing upward and towards the mattress. The resident's chin was in between the bed rail and the mattress. The resident's face was tilted towards the door. He/she could see the resident's face and both eyes as he/she entered the room. The resident's shoulders were off the bed. The right shoulder touched the mattress and the left shoulder was angled away. The resident's legs were on the floor. His/her right hip was on the floor and the left hip was suspended and tilted towards the mattress. The resident was dead. The resident was on hospice and was a no code. LPN D was the person who called the family, hospice, physician, and the medical director. LPN D said he/she told everyone how the resident was found. The physician gave the [DIAGNOSES REDACTED]. Prior to the incident, LPN D had concerns about the mattress. The mattress had no traction and was very slippery. The mattress was too thick and it gave the potential for the resident to slide off. The bed could not be in the lowest position with that mattress. The bed was at the height of a normal bedside table. He/she told management in the past about concerns with that type of mattress. He/she told one of the supervisors and they said that they complained about it to the hospice company. LPN D was not sure the name of the supervisor he/she told. He/she interviewed the resident's roommate who said he/she heard Resident #1 take two gasps and fall over. During an interview on [DATE] at 1:37 P.M., LPN F said he/she worked the night the resident expired, but he/she was not responsible for the resident. The nurse from the other side of the building came over and got him/her. When they entered the room, the resident's neck and head were wedged between the bed rail and mattress. The resident's body was on the floor on the side of the bed closest to the room door. The resident's face was up and angled towards the opposite corner of the head of the bed. The resident's shoulders were lower than his/her head. His/her neck was at an abnormal angle. The resident's knees and legs touched the floor, and his/her hips were suspended in the air. The resident was almost in a kneeling position. His/her chest was angled towards the bed and slightly arched. It took three staff to get the resident's head unstuck from the side rail. The resident was already dead when he/she entered the room. It looked as if the bed was higher than normal. The mattress was over inflated. It was huge. It took a while to get the resident's head out of the side rail because the mattress was too full. Staff had to push on the mattress to release his/her head. During an observation and interview on [DATE] at 6:07 A.M., CNA C said he/she worked the night of the resident's death. He/she heard staff talking about how the resident kept sliding out of the bed. Everyone kept saying the bed was too high, and it was. CNA C held his/her hand at just below chest level to indicate the height of the bed. The bed was also slick. He/she went in the resident's room a couple times that night. He/she told the nurse and the CNA assigned to care for the resident that they needed to get the resident up because he/she was sliding. At around 6:00 A.M., staff ran to the room. When he/she entered the room, the resident's head and jaw were in the side rail with his/her feet on the floor. His/her head faced out, and he/she was no longer alive. Review of Nursing Supervisor H's attestation form, dated [DATE], showed: -The report was made regarding a fall and death; -He/she last saw the resident on [DATE] on the 7:00 A.M. through 3:00 P.M. shift; -Upon entering the building on the morning of [DATE], LPN D told this nurse he/she needed help in the resident's room, the resident fell , was on the floor, and deceased . Upon entering the room, the resident was lying face down on the floor next to the bed without respirations or heartbeat. This nurse notified the DON and instructed LPN D to get the resident into bed and begin the process of reporting the death. Staff called hospice, the physician, family, coroner, and funeral home. During an interview on [DATE] at 7:47 A.M., Nursing Supervisor H said he/she was the supervisor that weekend and worked day shift. As soon as he/she walked in the building, LPN D said he/she needed him/her right away. Nursing Supervisor H went into the resident's room and the resident was face down on the floor next to the bed on the side closest to the door. The CNA's (he/she could not remember who they were) said the resident was restless so they got the resident dressed and left the room to get a mechanical lift. When they returned, the resident had fallen out of bed. The roommate told him/her that he/she heard Resident #1 gasp and a bunch of noise. Nursing Supervisor H left the room to call the DON. Nursing Supervisor H told the DON what staff said and the DON said to go ahead and call hospice to come in. Staff then assisted the resident back onto the bed. On [DATE] at 1:10 P.M., Nursing Supervisor H said he/she would not consider this a suspicious death. He/she said a suspicious death would be if there was evidence of blue discoloration, obvious injury to the neck, or broken bones. He/she was not aware of any staff having concerns about the resident's mattress. Review of Nurse Supervisor R's attestation form, dated [DATE], showed he/she witnessed a conversation between the DON and LPN D regarding the death of the resident. He/she recalled LPN D reporting that the resident did not appear to be restless through the shift until the morning. He/she also recalled LPN D reporting the resident was found face down on the floor. During an interview on [DATE] at 6:35 A.M., CNA A said he/she did not work on [DATE] but had cared for the resident the night before. The resident had a blow up mattress. He/she kept sliding off the mattress. He/she seemed to always slide to the side of the bed towards the door. During an interview on [DATE] at 11:57 A.M., CNA G said he/she worked the evening prior to the day the resident expired. He/she heard staff talking about the resident's mattress being too slick. During an interview on [DATE] at 7:21 A.M., the DON said Nursing Supervisor H called and said the resident was restless that morning and staff dressed him/her. They left the room to get the mechanical lift to get the resident up. When they returned, the resident was on the floor. The nurse working said staff found the resident on the floor with his/her head by the side rail. The DON said she talked to the roommate who reported he/she heard Resident #1 take two gasps when the incident occurred. The DON said she knew residents have a tendency to slide off of air mattresses. On [DATE] at 9:55 A.M., the DON said she investigated the death by reading the nurses notes and talking to the nurse and the resident's roommate. The nurse on duty said the resident did fine through the night and it was in the morning when he/she became restless. The resident was on a low air loss mattress with bolsters (raised edges on a mattress, used to define the parameters of the bed). The DON said staff did not verbalize any concerns regarding the mattress to her. She expects staff notify her if they have concerns with the safety of a mattress. The investigation did not include talking to the CNA's who found the resident. The DON said what staff told her gave her no suspicions. She was under the impression that the resident's head rested on the outside of the side rail and not in it. On [DATE] at 11:39 A.M., the DON said staff reported to her that the resident had no injuries that resulted from the fall. There was no bruising or marks and no petechiae (small red bumps on the skin, associated with strangulation). The DON said she read the nurses notes the following Monday, which that showed the documentation that the resident's head was in the side rail. On [DATE] at 1:07 P.M., the DON said staff do not complete new side rail assessments when residents get new mattresses. The mattress supply company does not give the facility a user manual for the beds and they do not have one on site. She is not sure if staff would assess the appropriateness of a mattress once a resident received a new one. The facility does not have a policy regarding the use of equipment acquired from an outside source. When the mattress supply company delivers a new mattress, they explain to staff how to use it properly. During an observation and interview on [DATE] at 9:01 A.M., Resident #2, who was the roommate of Resident #1, said he/she saw a horrible thing. Resident #2 pointed to the empty bed next to him/her and said is/her roommate died right there. He/she heard a noise and looked over. His/her roommate was on the floor. He/she could not see what position the resident was in but it sounded like loud gasping and a bang. The resident said he/she did not want to talk anymore as he/she covered his/her head with a blanket and started sobbing. During an interview on [DATE] at 9:20 A.M., Physician J said staff called him/her the morning of the resident's death. They told him/her the resident was found on the floor with no signs of distress and unresponsive. He/she was told that the resident's head was stuck in the side rail. Physician J said he/she thought this sounded like the resident had a heart attack. During an interview on [DATE] at 10:49 A.M., Hospice Nurse K said he/she visited the resident on [DATE]. The resident was not able to talk but was alert and responsive. He/she could blink his/her eyes to answer yes and no questions. He/she had no concerns about the resident's condition and staff reported no concerns regarding the resident's mattress. During an interview on [DATE] at 10:51 A.M., Hospice nurse O said he/she admitted the resident to hospice on [DATE]. The resident was up in a chair. He/she was alert and vital signs were fine. During an interview on [DATE] at 11:22 A.M., Hospice Nurse P said he/she was the nurse who came into the facility the morning the resident expired. The resident was in bed and covered with a blanket. Staff said the resident died comfortably. Staff did not inform him/her that the resident was found on the floor with his/her head in the side rail. If staff would have told him/her this information he/she would have called his/her supervisor. Residents on hospice are supposed to die of a natural death and falling with his/her head in the side rail is an unusual circumstance. During an interview on [DATE] at 11:33 A.M., Hospice Administrator N said he/she expected the facility to let his/her staff know if a resident expired in an unusual manor. On [DATE] at 9:05 A.M., Hospice Administer N said hospice will order a specialty mattress for a resident if it is requested. The mattress supply company brings the bed to the facility, not hospice. Hospice does not visit a facility just because a mattress has arrived. Once the resident is on the new mattress, it is the responsibility of the facility to make sure the mattress is appropriate and safe for the resident. During an interview on [DATE] at 9:04 A.M., Medical Examiner Q said when a facility calls in a death, they are asked about the surrounding circumstances. They are asked if there have been any falls and if the facility says yes, further questions are asked. They would be asked if there was any possible significant trauma, this includes head injury and fractures. If the facility would have informed the medical examiner's office that the resident was found on the floor with his/her head between the mattress and side rail, the medical examiner would go out and conduct an investigation. This could include going to the scene, possible recreation of the incident and then bringing the resident in for examination. Depending on the findings, the forensic investigator would determine what further tests would need to be conducted. Review of the resident's apparent natural death form (the form completed by facility staff and provided to the medical examiner's office to show the circumstances surrounding a resident's death), showed: -The resident was last seen on [DATE] at 5:45 A.M., -The resident was found at 6:50 A.M., -Any recent complaints: left blank; -Any history of accidents/falls/fractures: left blank; -Any injuries present: left blank; -Anything suspicious at scene: left blank; -The facility failed to document the resident was found on the floor with his/her face between the mattress and side rail. Review of the medical examiner report, dated [DATE] at 7:40 A.M., showed: -Notifying call received from LPN D; -The resident expired on [DATE] at 6:55 A.M.; -Physician J listed as the certifying physician; -deceased was last seen alive by staff as they helped the deceased get dressed. They came back into the room to take him/her to breakfast when they found him/her unresponsive on the floor. No injuries. No reportable falls. Review of the medical examiner policies and procedures for reportable deaths, last revised [DATE], showed: -Reporting of deaths assures that appropriate deaths will be assessed by the medical examiner's office and evaluated as to whether investigation by the medical examiner is warranted; -Cases about which there is any question of reporting should be reported to allow evaluation by the medical examiner; -Deaths in the following circumstances and categories should be reported to the medical examiner: -Death in persons who die suddenly when in apparent good health and without medical treatment for [REDACTED]. -Deaths caused by or contributed to by unnatural means: -All deaths related to trauma, regardless of the interval before death, e.g. falls including hip and other fractures in the elderly; -Blows and other forms of mechanical violence; -Deaths related to asphyxia including strangulation either internal or external; -Collapse of structures; -Positioning of body to restrict airway; -Hanging; -Exclusion of oxygen; -Suffocation and smothering; -The chief medical examiner is a board certified forensic pathologist appointed to investigate sudden, unexpected, suspicious, unnatural or violent deaths; -Any person having knowledge of such a death shall immediately notify the office of the medical examiner of the know facts concerning the time, place, manner and circumstances of the death; -Any institution or individual reporting a death should understand that providing information to the medical examiner's office is to comply with the law and that failure to do so would place them in jeopardy of prosecution. During an interview on [DATE] at 11:42 A.M., a representative for the company who supplied the resident's mattress said they received no complaints from the facility about the bed they provided. Review of the product manual for the low air loss mattress provided to the resident, showed: -This manual must be given to the user of the product; -Before using this product, read this manual and save for future reference; -Warning: Patient entrapment with bed side rails may cause injury or death. Mattress must fit bed frame and side rails snugly to prevent patient entrapment. Follow the manufacturer's instruction. Monitor patient frequently. Read and understand the owner's manual prior to using this equipment; -Warning: Do not use this product or any available optional equipment without first completely reading and understanding these instructions. Injury or damage may occur; -Installation Warning: Health care professionals assigned to each case should make the final determination whether side or assist rails are warranted after assessing patient risks of entrapment and falls in accordance with state patients restraint legislation; -Warning: patient entrapment with bed side rails may cause injury or death. Mattress must fit bed frame and side rails snugly to prevent patient entrapment. Proper patient assessment and monitoring, and prior maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions and mattress thickness, size or density could increase the risk for entrapment; -Installing the side rails: Warning, patient entrapment with bed side rails may cause injury or death. Note: At the time of the abbreviated survey, the violation was determined to be at an immediate and serious jeopardy level. Based on observation, interview, and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction that included the following: in-services to direct care staff regarding communication, addressing concerns and following policies. The facility planned to re-assess all residents with a low air loss mattress and siderails. At the time of the exit, the facility still needed to complete in-services to the remaining staff and determine how they will implement their plan of correction on a long-term basis and keep their systems in place. 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 theD level. This statement does not denote that the facility has complied with State law (Section 198.026 RSMo) requiring prompt remedial action to be taken to address Class I violations. MO 070