Every finding on record at St James Living Center

Based on observation, interview, and record review, facility staff failed to review and revise the care plan after falls for five residents (Resident #4, #5, #16, #20, and #42) out of 13 sampled residents. The facility census was 43.1. Review of the facility policy titled Care Plan Comprehensive, undated, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool. The interdisciplinary care plan team is responsible for the periodic review and updating of care plans, when a significant change in the resident's condition has occurred, at least quarterly, and when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #4's Annual MDS assessment, dated 06/13/25, showed staff assessed the resident as: -Severely cognitively impaired; -Used a wheelchair; -Required partial to moderate assist with all mobility; -Had not fallen since admission or prior assessment; -Diagnoses of arthritis, high blood pressure, heart disease, anxiety and depression. Review of the resident's medical record showed staff documented: -On 05/15/25 unwitnessed fall with bruising to right side face; -On 09/7/25 unwitnessed fall without injury. Review of the resident's care plan, dated 06/23/25, showed the care area for falls updated 06/28/24. The care plan did not contain documentation of the falls on 05/15/25 or 09/07/25 or updated interventions. 3. Review of Resident #5's Quarterly MDS assessment, dated 08/22/25, showed staff assessed the resident as: -Severely cognitively impaired; -Used a wheelchair; -Had upper extremity impairment on one side; -Dependent on staff for all mobility; -Had no falls since admission or prior assessment; -Diagnoses of hip fracture, other fracture, high blood pressure, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's medical record showed staff documented: -On 07/19/25 unwitnessed fall with left femur fracture; -On 09/22/25 unwitnessed fall with no injury. Review of the resident's care plan, dated 08/28/25, showed the care plan did not contain documentation of the falls on 07/19/25 or 09/22/25 or updated interventions. 4. Review of Resident #16's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Used a wheelchair; -Required supervision or touch assist with all mobility; -Diagnoses of non-traumatic brain dysfunction, cancer, and high blood pressure. Review of the resident's medical record showed staff documented: -On 08/03/25 unwitnessed fall without injury; -On 08/19/25 unwitnessed fall without injury; -On 09/03/25 unwitnessed fall without injury. Review of the resident's care plan, dated 07/25/25, showed the care area for falls updated on 07/25/25. The care plan did not contain documentation of the 08/03/25, 08/19/25 or 09/03/25 falls or updated interventions. 5. Review of Resident #20's Quarterly MDS assessment, dated 06/10/25, showed staff assessed the resident as: -Severely cognitively impaired; -Did not use mobility devices; -Required supervision or touch assist with walking; -Had fallen since admission or prior assessment; -Had two falls without injury; -Diagnoses of heart failure, high blood pressure, anxiety, dementia, and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's medical record showed documented: -On 05/14/25 witnessed fall, no injury; -On 08/12/25 unwitnessed fall with reopening of right elbow scab; -On 09/6/25 unwitnessed fall no apparent injury, sent to emergency room for evaluation, bruise to upper back; -On 09/11/25 witnessed fall, bruise on back of head. Review of the resident's care plan, dated 06/16/25, showed staff did not document the falls or updated interventions for the falls. 6. Review of Resident #42's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Used a walker and wheelchair; -Required partial to moderate assist with all mobility; -Had not fallen prior to admission; -Diagnoses of high blood pressure, diabetes, and Alzheimer's Disease. Review of the resident's medical record showed staff documented: -On 09/17/25 unwitnessed fall, no injury; -On 09/19/25 unwitnessed fall, bruising to left eye. Review of the resident's care plan, dated 08/19/25, showed staff did not document the falls or updated interventions for the falls. 7. During an interview on 09/25/25 at 9:32 A.M., Certified Medication Technician (CMT) A said care plans should have all fall interventions listed for the resident. During an interview on 09/25/25 at 9:36 A.M., Certified Nurse Aide (CNA) C said all fall interventions should be listed on the residents' care plans. During an interview on 09/25/25 at 10:16 A.M., Licensed Practical Nurse (LPN) E said all fall interventions should be on the care LPN E said he/she did not know if the nurses could update or edit care plans, usually the MDS Coordinator or Director of Nursing (DON) does it, or even the Social Services Director (SSD), but he/she has never edited a care plan. During an interview on 09/25/2025 at 12:31 P.M., the MDS Coordinator said he/she just started working at the facility on 09/03/25, and this is his/her first full week in his/her office. The MDS Coordinator said he/she has not been trained on care plans yet. He/she said care plans should be updated after every fall and with new interventions. The MDS Coordinator said everyone uses the care plan from CNAs to dietary staff, so they know how to care for the residents. During an interview on 09/25/25 at 1:00 P.M., the DON said care plans should be updated after every fall and should include new interventions. He/she did not know they were not updated; he/she has only been in this position for about one month. The DON said the MDS Coordinator is responsible for updating the care plan, but the nurses should be able to update the care plans as well, and he/she will have to train them. During an interview on 09/25/25 at 1:30 P.M., the administrator said care plans should be updated after every fall and with new interventions and the MDS Coordinator is responsible for updating them. The administrator said he/she would think that the nurses would be able to update them as well but is not sure what access they have in the system, and he/she did not know they were not being done.

Based on interview, and record review, facility staff failed to document the neurological assessments (an assessment completed to determine if the nervous system is impaired) for six residents (#4, #5, #8, #16, #20, and #42) out of 13 sampled residents. Facility staff failed to complete the event documentation for four residents (Resident #4, #8, #20 and #42) out of 13 sampled after falls. The facility census was 43. 1. Review of the facility policy titled Event Investigation, undated, showed the purpose is to investigate the cause of all injuries which have not been witnessed, and to identify any injuries after a resident sustains an event. Complete an event report form as soon as possible whenever there is an unusual, unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor. Examples of when a form should be completed include fracture/dislocation of unknown origin, bruise/skin tear of unknown origin, fall or person found on the floor. The charge nurse is responsible for completion of the Report of Event form and forwarding to the Director of Nursing (DON) as soon as possible. Review of the facilities observation report titled Neurological Checks 72-hour monitoring eight hour shifts, undated, showed neurological checks are required for 72 hours after an unwitnessed fall or head injury. The frequency for neurological checks is for the first hour every 15 minutes times four; for the second hour every 30 minutes times two; for the next two hours every one-hour times two; and for the next 72 hours every shift. 2. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/13/25, showed staff assessed the resident as: -Severely cognitively impaired; -Used a wheelchair; -Required partial to moderate assist with all mobility; -Had not fallen since admission or prior assessment. Review of the resident's progress notes showed staff documented: -On 05/15/25: Unwitnessed fall with bruising to right side of face. The medical record did not contain documentation of neurological checks completed;-On 09/07/25: Unwitnessed fall without injury. The medical record did not contain nine of 17 neurological checks. Review of the resident's medical record showed staff did not document a fall event report for 05/15/25 or 09/07/25. 3. Review of Resident #5's Quarterly MDS assessment, dated 08/22/25, showed staff assessed the resident as: -Severely cognitively impaired; -Used a wheelchair; -Had upper extremity impairment on one side; -Dependent on staff for all mobility; -Had no falls since admission or prior assessment. Review of the resident's progress notes showed staff documented: -On 08/18/25: Unwitnessed fall with skin tear. The medical record did not contain 11 of 17 neurological checks;-On 09/22/25: Fall with no injury. The medical record did not contain eight of 17 neurological checks. 4. Review of Resident #8's Quarterly MDS assessment, dated 08/22/25, showed staff assessed the resident as: -Moderate Cognitive impairment; -Used a wheelchair; -Required substantial/maximal assist from staff for all mobility; -Had not fallen since admission or prior assessment;-Diagnoses of non-traumatic brain dysfunction. Review of the resident's progress notes showed staff documented: -On 07/13/25: Unwitnessed fall. The medical record did not contain seven of 17 neurological checks;-On 09/20/25: Unwitnessed fall. The medical record did not contain completed neurological checks. Review of the resident's medical record showed staff did not document a fall event report for the 07/13/25 and 09/20/25 falls. 5. Review of Resident #16's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Used a wheelchair; -Required supervision or touch assist with all mobility; -Diagnoses of non-traumatic brain dysfunction, cancer, and high blood pressure. Review of the resident's progress notes showed staff documented: -On 08/03/25: Unwitnessed fall. The medical record did not contain 16 of 17 neurological checks;-On 08/19/25: Unwitnessed fall. The medical record did not contain completed neurological checks;-On 09/03/25: Unwitnessed fall. The medical record did not contain completed neurological checks. 6. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Did not use mobility devices; -Required supervision or touch assist with walking;-Had fallen since admission or prior assessment; -Had two falls without injury. Review of the resident's progress notes showed: -On 07/24/25: Unwitnessed fall with small skin tear to left elbow. The medical record did not contain documentation of neurological checks completed;-On 08/12/25: Unwitnessed fall with reopening of right elbow scab. The medical record did not contain documentation of neurological checks completed; -On 09/06/25: Unwitnessed fall with no apparent injury, sent to the emergency room (ER) for evaluation with a bruise to upper back on. The medical record did not contain five of 17 neurological checks;-On 09/11/25: Witnessed fall with small hematoma (bruise) on back of head. The medical record did not contain three of 17 neurological checks, and the completed 14 neurological checks consisted of only vital signs (blood pressure, heart rate, temperature, respiratory rate and oxygen saturation). Review of the resident's medical record showed staff did not document a fall event report for the falls. 7. Review of Resident #42's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Used a walker and wheelchair; -Required partial to moderate assist with all mobility; -Had not fallen prior to admission. Review of the resident's progress notes showed staff documented: -On 09/17/25: Unwitnessed fall with no injury. The medical record did not contain documentation of neurological checks completed;-On 09/19/25: Unwitnessed fall with bruising to the left eye. The medical record did not contain five of 17 neurological checks, and the completed 12 neurological checks consisted only of vital signs. Review of the resident's medical record showed staff did not document fall event report for the 09/19/25 fall. 8. During an interview on 09/25/25 at 10:16 A.M., Licensed Practical Nurse (LPN) E said if a resident has a fall and hits his/her head he/she will begin neurological checks, or if it was unwitnessed. LPN E said if the resident requires neurological checks, they should be completed every 15 minutes for the first hour, then every 30 minutes for two hours, then every hour for the remainder of the shift, then every shift for three days. LPN E said neurological checks are documented under the event or observation in the computer, and staff are supposed to fill out the event report, and typically the charge nurse at the time is supposed to open the event. LPN E said he/she did not know why the event reports were not being done consistently and was not sure why the neurological checks were not being done consistently. LPN E said he/she is not sure if the documentation is being followed through on, the facility has not had a consistent DON. LPN E said staff use a daily report form to document which residents had falls or need to have neurological checks completed. LPN E said he/she completes neurological checks to ensure there is no obvious head injury or something that could start hours after such as a head injury. LPN E said the DON is responsible for overseeing staff to ensure all documentation is completed, but without a consistent DON staff have gotten loose in their charting. During an interview on 09/25/25 at 1:00 P.M., the DON said neurological checks should be completed if a resident bumps their head or has an unwitnessed fall. He/she said neurological checks should be completed every 15 minutes times four, every four hours after that for 24 hours, then every shift for 72 hours. He/she said the neurological checks he/she has seen were done on paper, and he/she does not know why staff do not consistently complete them. The DON said he/she did not know what the frequency was for the checks in the computer, and he/she has only worked at the facility for about a month and is working on getting everything organized. He/She said the nurses are responsible for completing the neurological checks and event reports. The DON said it would be ideal for the staff to complete event reports as soon as the falls happens, and then start the neurological checks, and complete all assessments that need to be done, and this is what he/she expects them to do, because the assessments can detect brain bleeds or a concussion or any type of issue. During an interview on 09/25/25 at 1:30 P.M., the administrator said neurological checks should be completed for unwitnessed falls or witnessed falls with head involvement, and he/she was not sure of the frequency, but knows at least each shift should be doing something and it is for 72 hours. The administrator said it should be documented in the computer under observations, nurses should also do a follow up progress note in the computer, and an event report should be completed for unwitnessed falls and the charge nurse is responsible. He/she said it is important to complete neurological checks to make sure there are not any neurological deficits or a brain bleed, and if there are staff can get the resident sent out in a timely manner to prevent more injury or harm.

Based on observation, interview, and record review, facility staff failed to ensure safety in the shower room with an unsecured shower drain cover for one resident (Resident #9) out of 13 sampled residents. The facility census was 43. 1. Review of the facility's Preventative Maintenance List, undated, showed it contained a monthly review and checklist of the physical environment for each area of the facility, and did not contain the shower rooms as an area the maintenance staff checked for condition. Review of the policies provided by the facility showed the policies did not contain a policy for reporting maintenance concerns and repairs needed. 2. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Intact cognition; -Used a wheelchair; -Required moderate assist from staff members with bathing; -Had one non-injury fall. Review of the resident's medical record showed the record did not contain even documentation of the resident's shower chair wheel going in the drain. During an interview on 09/24/25 at 9:27 A.M., the resident said staff put him/her in a white plastic shower chair, propelled him/her forward, and the front wheel of the shower chair went in the open drain, which had been missing three screws on the drain cover. The resident said the drain cover flipped up and sent him/her forward in the chair, and he/she had to grab the bar on the shower wall to keep from falling out of the shower chair. The resident said staff pulled the shower chair backwards and told him/her to let go of the bar and he/she told the staff he/she couldn't, he/she would fall out of the shower chair and on to the floor. The resident said he/she is now afraid to go take a shower until it gets fixed. Observation on 09/24/2025 at 10:54 A.M., showed the shower room occupied by an unknown resident and staff. The metal shower drain cover has three missing screws used to secure the cover to the metal drain, and is flipped up on side, out of the drain. The plastic shower chair has its front left wheel down in the open drain. The shower chair tilted forward. Observation on 09/25/25 at 11:59 A.M., showed the shower room occupied by an unknown resident and staff. The metal shower drain cover has three missing screws used to secure the cover to the metal drain, and is flipped up on side, out of the drain. During an interview on 09/25/25 at 12:00 P.M., CNA M said he/she provides the residents shower, and he/she had noticed the drain cover does not have screws in it, and it never has. The CNA said he/she had a resident on a shower bed, and the wheel from the shower bed went down in the drain and broke off. The CNA said he/she hasn't told anyone the drain cover is not screwed down, because he/she didn't know it was supposed to be screwed down. The CNA said staff should put issues with environment, or equipment on a maintenance slip in the maintenance book. During an interview on 09/25/25 at 12:07 P.M., Licensed Practical Nurse (LPN) E said he/she wasn't aware the drain in the shower is broken, and typically a maintenance request should be filled out. The LPN said the shower drain cover popping up out of the drain could be a trip hazard, and a resident could get cut on it. The LPN said anyone can fill out a maintenance request form, it's on the Maintenance Supervisor's door. The LPN said nobody has reported a resident being propelled in a plastic shower chair, and it going in the drain. The LPN said staff should have informed him/her if a chair fell in the drain. The LPN said it would be a safety concern. During an interview on 09/25/25 at 12:32 P.M., CNA F said he/she has not reported the broken drain cover to the current Maintenance Supervisor. The CNA said he/she has pushed the shower chair with the resident in it, and the wheel fell into the drain. The CNA said he/she has pushed the resident into the drain, he/she can see how dangerous it is, but he/she can only tell maintenance so many times. The CNA said he/she should have told the current Maintenance Supervisor, it is the only Maintenance Supervisor, he/she hasn't told. During an interview on 09/25/25 at 12:39 P.M., the Maintenance Supervisor said he/she was not aware the shower drain is supposed to be screwed down. The Maintenance Supervisor said he/she hasn't ever had anyone report to him/her, any issues with the shower drain. The Maintenance Director said he/she would expect staff to report it, staff should have filled out a maintenance request on door. During an interview on 09/25/25 at 1:01 P.M., the DON said staff has reported issues with the shower drain to him/her. The DON said if the staff propelled a resident in the shower chair and it went into the drain, the staff should have reported it to the charge nurse, and an event form should have been filled out. The DON said the event forms are in the system, so he/she has access to go in and review the event forms. The DON said the staff should also notify maintenance and the administrator to get the drain cover fixed, because the next time a resident may not be able to catch themselves on an assist bar and fall in shower. During an interview on 09/25/25 at 1:25 P.M., the administrator said staff has not reported a broken shower drain to him/her. The administrator said staff has not reported a shower chair falling into the shower drain, with a resident in it. The administrator said there would be a risk for injury, by the resident being thrown out of the shower chair. The administrator said he/she would expect staff to stop using that shower until the drain is fixed, and to notify maintenance. The administrator said he/she would expect an event report completed. The administrator said the shower aides and Maintenance are responsible to make sure shower rooms are maintained. The administrator said he/she is responsible to make sure the building is maintained. The administrator said he/she is not aware the shower room is not on the monthly preventative maintenance list; it should be on the monthly maintenance list.

Based on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for three residents (Resident #7, #16, and #30) out 13 sampled residents. The facility census was 43.1. Review of the facility's policy titled Care Plan, Temporary, undated, showed a temporary care plan will be implemented to meet the new residents' immediate needs. To assure that the residents immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within twenty-four hours of admission. The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI), manual used to complete resident assessments, process. 2. Review of Resident #7's medical record showed staff documented the resident was admitted to the facility on [DATE]. Review of the record showed a baseline care plan completed on 12/20/24. 3. Review of Resident #16's medical record showed staff documented the resident was admitted to the facility on [DATE]. Review of the record showed a baseline care plan completed on 07/21/25. 4. Review of Resident #30's medical record showed staff documented the resident was admitted to the facility on [DATE]. Review of the record showed a baseline care plan completed on 7/08/25. 5. During an interview on 09/25/25 at 10:10 A.M., License Practical Nurse (LPN) E said there is an admission checklist at the nurse's station, and it shows the admitting charge nurse is to complete the baseline care plan within two hours of a resident being admitted . He/She said the baseline care plan is completed upon admission, so staff know the resident's normal day to day routines and how to care for the resident. He/She said if the baseline care plan is not completed then staff will not know how to care for the resident. During an interview on 09/25/25 at 12:31 P.M., the Care Plan Coordinator said he/she is very new to this role and facility, but he/she believes the admitting charge nurse is responsible for completing the baseline care plans. He/She said the baseline care plan should be completed 24-48 hours after admission. He/She said the importance of having a baseline care plan is so staff to know how to care for the resident. During an interview on 09/25/25 at 1:00 P.M., the Director of Nursing (DON) said baseline care plans should be completed upon admission by the admitting charge nurse. He/She said the baseline care plan should be completed as soon as possible but within 24 hours. He/She said the importance of baseline care plans is for staff to know how to care for the newly admitted resident. During an interview on 09/25/25 at 1:50 P.M., the administrator said baseline care plans should be completed upon admission. He/She said previously it was the Care Plan Coordinator who completed them. He/She said baseline care plans should be completed within 24 hours. He/She said the importance of completing a baseline care plan is, so staff know how to care for the resident.

Based on observation, interview and record review, facility staff failed to change one resident's (Resident #9's) of three sampled residents supra-pubic indwelling urinary catheter (flexible tube inserted through the abdomen directly into the bladder to drain urine) per physician's order and failed to provide catheter care. The facility census was 44.1. Review of the facility's policy titled Catheter Care, undated, showed catheter care is to be provided, to prevent infection and reduce irritation. 2. Review of Resident #9's face sheet showed staff documented a diagnosis of Neuromuscular dysfunction of bladder (Nerves that control bladder function are damaged, leading to problems with storing and releasing urine). Review of the resident's care plan, dated 07/03/25, showed staff documented the resident has an indwelling urinary catheter and catheter care should be provided every shift. Review of the resident's physician's order sheet (POS), dated September 2025, showed: -Order for catheter care every shift and to change catheter monthly on the 18th.-Cleanse area around suprapubic catheter, pat dry, place split gauze around catheter, secure with tape once a day. Review of the resident's Treatment Administration Record (TAR), dated September 2025, did not contain documentation staff provided catheter care on the evening shift for 09/03/25, 09/12/25, 09/15/25, 09/18/25, 09/19/25, and 09/23/25. Review showed staff did not document they changed the resident's catheter as ordered on 09/18/25. Observation on 09/22/2025 at 3:45 P.M., showed the resident in bed with his/her supra-pubic catheter tube secured to his/her leg and the catheter site with dried, reddish and black drainage around it. During an interview on 09/22/2025 at 3:45 P.M., the resident said it is probably time for staff to change his/her catheter. Observation on 09/24/25 at 8:58 A.M., showed the resident in bed with his/her catheter tubing secured to his/her leg. The catheter site had dried black and reddish drainage around it and on the catheter tubing. During an interview on 09/24/25 8:58 A.M., the resident said the staff does not always provide catheter care. He/She said the night shift and evening shift did not complete it, or place gauze at the catheter insertion site. The resident said he/she tries not to bother the staff, is appreciative of the care and never turns it down. Observation on 09/24/25 at 4:16 P.M. showed the Director of Nursing (DON) entered the resident's room and observed the resident's catheter site had dried black and reddish brown drainage around the tubing and did not have a split sponge in place. At this time, the DON explained to the resident they should have a split sponge at the catheter site, and he/she did not know why the resident did not. Observation showed the DON attempted to wipe the dried drainage from the tube. The DON explained to the resident staff are supposed to clean the catheter site. The resident explained to the DON staff are supposed to, but they don't and had not received catheter care and has not had the gauze around the tubing today, or yesterday. During an interview on 09/25/25 at 11:15 A.M., the DON said Registered Nurse (RN) L said he/she forgot to do the resident's catheter care the night before. The DON said by the looks of the resident's catheter tubing, it had not been changed on the 18th and if the TAR had not been signed by a nurse, he/she would say the catheter did not get changed. During an interview on 09/25/25 at 11:40 A.M., Licensed Practical Nurse (LPN) E said he/she has noticed some mornings the resident does not have a split bandage around the catheter site. The LPN said the resident is supposed to have his/her catheter changed once a month. The LPN said if a nurse comes on shift and a treatment has not been signed on the TAR, it should fall on the next shift nurse to get those treatments completed. The LPN said treatments not signed for is an error and should be brought to the DON. The LPN said he/she does not recall telling the DON when he/she came in the morning of the 19th that the resident's catheter had not been documented as changed. During an interview on 09/25/25 at 1:01 P.M., the DON said he/she is responsible to ensure the nurses complete treatments. The DON said he/she just got trained in the system and has not had the chance to look at the TARS. The DON said he/she had not been made aware of missing signatures on the resident's TAR. During an interview on 09/25/25 at 1:25 P.M., the administrator said when treatments are due, they pop up on the TARs the nurse is working on. The administrator said no one has told him/her about missing signatures on the resident's TAR, or the resident missing treatments. The administrator said he/she would expect the nurse who comes on shift after the missing treatments, to report the missing treatments to the DON and perform the treatments that needed to be performed. During an interview on 09/25/25 at 1:54 P.M., RN L said he/she ran out of time on his/her shift and that is why the resident's treatments were not done on the 23rd. The RN said he/she did not change the resident's catheter on the 18th, because it did not pop up for him/her to do it.

Based on interview and record review, facility staff failed to notify one resident (Resident #1's) physician, when staff assessed the resident with a significant change in condition and administered Narcan for suspected overdose. The facility census was 45. 1.Review of the facility's Charting and Documentation policy, undated, showed staff are to document any time the physician is called about the resident as well as their response. 2. Review of Resident #1's Baseline care plan, dated 8/4/25, showed staff assessed the resident alert and cognitively intact, experienced seizures. Review showed staff are to monitor medications, provide safe environment, monitor condition and report changes to Director of Nursing (DON) and Physician.Review of the resident's nurse's notes, dated 08/11/2025, showed staff documented the resident was lethargic, with pinpointed pupils, and unresponsive to name. Narcan nasal spray administered, resident unresponsive. Called 911. Resident began breathing more deeply after administration. Resident transferred to local hospital for evaluation. The record did contain notification of the physician. Review of the resident's rapid drug screen, dated 8/11/25, showed the resident positive for Opiates and Benzodiazepines. 3. During an interview on 8/13/25 at 9:11 A.M., the administrator said the physician was not notified and orders have not been changed since this incident. He/She said he/she would expect the physician to be notified and is unsure why it was not done. He/She said the charge nurse, Registered Nurse (RN) A was in charge to notify the physician.During an interview on 8/13/25 at 9:30 A.M., the DON said the physician should have been notified and he/she does not know why the physician was not notified. He/She said the charge nurse is responsible for all notifications. During an interview on 12:48 P.M., the physician said he/she was not notified and there is no documentation in the chart that his/her office was notified via telephone or fax. He/She said he/she expects to be notified of changes in a resident condition. He/She said he/she was not aware of the resident's overdose and therefore has not adjusted his/her medications which needs to be done. During an interview on 8/25/25 at 8:48 A.M., Registered Nurse (RN) A said he/she entered the resident's room to pass medications, resident was hard to arouse, resident was in and out of it. He/She administered the resident nasal Narcan per his/her orders. After administering Narcan, the resident was sent to the emergency room. He/She said he/she faxed the nonemergent fax line around 10:00 P.M., but did not call the physician because the family wanted the resident sent to the hospital for evaluation. He/She did not get a faxed confirmation because he/she was busy that evening. Complaint #2587617

Based on interview and record review, facility staff failed to complete an investigation when one resident (Resident #1) overdosed on a Benzodiazepine (a class of central nervous system (CNS) depressants that produce sedation, reduce anxiety, and relax muscles) and administered Narcan (a medication that can rapidly reverse the effects of an opioid overdose. The facility census was 45.1. Review of the facility's Investigation policy, undated, showed facility staff are directed to promptly and thoroughly investigate and try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. When an incident or suspected incident is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: -Who was involved;-Resident statements;-Resident roommate statements;-Interviews obtained from three to four residents who received care from alleged staff (if applicable);-Interviews obtained from three to four different department staff (if applicable);-Involved staff and witness statements of events;-Description of the resident's behavior and environment at the time of the incident;-Injuries present including a resident assessment;- Observation of resident and staff behaviors during the investigation;-Environmental considerations. 2. Review of Resident #1's Baseline care plan, dated 8/4/25, showed staff assessed the resident alert and cognitively intact, experienced seizures. Review showed staff are to monitor medications, provide safe environment, monitor condition and report changes to Director of Nursing (DON) and Physician.Review of the resident's medical records showed the medical record did not contain an investigation. Review of the resident's nurse's notes, dated 08/11/2025, showed staff documented the resident lethargic, with pinpoint pupils, and unresponsive to name. Narcan nasal spray administered, resident unresponsive. Staff called 911. Resident began breathing more deeply after administration. Resident transferred to local hospital for evaluation. Review of the resident's hospital records, dated 08/11/25, showed the resident admitted through the emergency room after an accidental overdose. Resident is on chronic opiate therapy for management of cancer related pain. Review of the resident's rapid drug screen, dated 8/11/25, showed the resident positive for Opiates and Benzodiazepines. 3. During an interview on 8/13/25 at 9:11 A.M., the Administrator said he/she was notified by the charge nurse, Registered Nurse (RN) A the resident was sent out because he/she was not stable. He/She said he/she later heard the resident was administered Narcan but was unsure if it was at the facility or at the hospital. He/She said he/she and the Director od Nursing (DON) should have been notified when Narcan was administered for a possible drug overdose at the facility and an investigation should have been started. He/She said he/she did not start an investigation because he/she was unaware of the full incident. During an interview on 8/13/25 at 9:30 A.M., the DON said he/she was not aware of any incident with the resident. He/She said he/she expects to be notified and in this case an investigation should have been started to rule out any medication errors, if medications need to be adjusted or if there was any abuse. Complaint #2587617

Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from accidents when facility staff failed to remove his/her oxygen and supervise him/her while smoking to ensure his/her safety. On 7/6/25, the resident failed to remove his/her oxygen while smoking in the courtyard and caught fire to his/her nasal cannula which resulted in severe burns to his/her nares and the right side of his/her head. The facility census was 45.The administrator was notified on 7/8/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 7/6/25. Upon discovery, the administrator conducted an investigation, notified appropriate parties, and educated Housekeeper A. Facility staff reviewed the smoking policy, audited the care plans and smoke assessments for all residents who smoke, placed signs on the courtyard door to remind staff and residents to take off oxygen, placed a oxygen rack outside the door to enter the facility, placed a fire blanket in the courtyard, and in-serviced all employees on smoking safety. The IJ was corrected on 7/8/25.1. Review of the facility's Smoking Policy for Residents, dated 02/26/24, showed staff were directed as follows:-Smoking privileges for residents must be evaluated by the Social Service Director (SSD);-Residents are not permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession. -Every resident must pass the smoking evaluation to be an independent smoker, this assessment will be completed annually.Review of the facility's investigation, dated 07/07/25, showed staff documented on 07/06/25 Resident #1 smoked with oxygen on and received a burn to the right side of his/her face and nares.Review of Resident #1's Entry Minimum Data Set (MDS), a federally mandated assessment tool, showed the resident admitted on [DATE].Review of the resident's physician order sheet (POS), dated 07/03/25 to 7/8/25, showed an order for two liters of oxygen per minute per nasal canula as needed to keep oxygen saturation (measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) at or above 92%.Review of the resident's nurse's notes, dated 7/6/25, showed Licensed practical Nurse (LPN) B was notified by a housekeeper, at approximately 3:30 P.M. the resident caught himself/herself on fire. LPN B ran to smoking area and found the resident in his/her wheelchair with his/her nasal canula hanging on the ground with the nose piece burnt/melted. The cigarette on the ground by the nasal canula started to burn again. The nurse stomped on the sparks, turned off the oxygen and removed the tubing from the tank. The nurse brought the resident inside the building and assessed him/her. The nurse documented the resident's mouth was darkened with soot in the back of his/her throat, burned hair on the back of the resident's shirt, and a half dollar sized burn to the side of his/her head. The nurse called the administrator, nurse on call and physician. Staff sent the resident to the emergency department. Review of the resident's progress notes, date 7/6/25, showed the resident returned from the hospital with burns to his/her nasal cavity and the right side of his/her head. New orders to apply bacitracin to his/her nasal cavities and right head. Nose is red, and uncomfortable. Denies pain to his/her right head.Review of the resident's baseline care plan, dated 7/8/25, showed staff did not assess the resident's cognition, oxygen use, or smoking ability.Review showed the resident's medical record did not contain documentation staff completed the resident's smoking assessment or interventions to ensure the resident's safety while smoking. During an interview on 7/8/25 at 1:10 P.M., the SSD said he/she was responsible for ensuring smoking assessments and smoking policies were done when a resident is admitted . He/She is supposed to have the smoking assessments and signed policy done within five days of admission, but tries to have them done as soon as possible. He/She did not have the resident's smoking assessment or policy done when he/she admitted , because the SSD also had three discharges done the same day and it got overlooked. He/She was told that on 7/7/25 the resident was outside smoking with oxygen on when the housekeeper came out to do the other residents supervised smoke break. He/She said the resident caught on fire and the housekeeper got the nurse as soon as it happened. Observation on 7/8/25 at 1:23 P.M., showed the resident with a burn to the right side of his/her head, burns to his/her nasal passages, and singed eyebrows.During an interview on 7/8/25 at 2:26 P.M., Housekeeper A said Resident #1 was already outside on Sunday (7/6) around 3:30 P.M., when he/she came out with the residents who required supervision when smoking. He/She turned toward the resident and saw flames coming from the resident's nasal cannula. The resident had ripped out the nasal cannula as he/she ran to help him/her. Sparks were coming from the cannula on the ground, so he/she stomped on it to put it out and then ran for a nurse to help. He/She had been educated on how to assist the residents during smoke breaks, but had never been told they were not allowed to use oxygen when smoking. He/She had seen the resident smoking outside several times during the day, so he/she thought the resident was an independent smoker. During an interview on 7/8/25 at 2:10 P.M., Resident #5 said Resident #1 was outside smoking when he/she and the housekeeper came out for the supervised smoke break. Housekeeper A was helping him/her when he/she saw the resident caught fire from across the courtyard. He/She yelled and Housekeeper A ran to Resident #1 and helped Resident #1 put out the fire. After the fire was put out Housekeeper A ran to get help from the nurse. He/She heard the housekeeper tell the nurse he/she was not aware the resident could not smoke with oxygen on. During an interview on 7/8/25 at 1:52 P.M., LPN B said he/she was the nurse who responded to the incident. The resident was outside smoking independently when Housekeeper A came out with the other dependent residents. Housekeeper A told him/her the resident was smoking with oxygen on when he/she brought the other residents out to smoke. The housekeeper told LPN B that he/she had his/her back to the resident when the resident caught fire. Housekeeper A came in the building yelling for help when he/she responded. The resident was sitting in his/her wheelchair, had burns to his/her nares and the right side of his/her head. The resident should have had a smoking assessment completed on admission to guide staff, but one was not completed. He/she said it is the responsibility of the SSD to complete the smoking assessment upon admission. The resident should not have been smoking with oxygen on.During an interview on 7/8/25 at 2:04 P.M., Resident #1 said he/she arrived at the facility last week. Staff were aware he/she smoked and when he/she was at this facility a couple years ago he/she was allowed to smoke independently. He/She was told not to smoke with oxygen by the administrator, but he/she had done it at home without issue and didn't think it was a big deal. He/She said residents and staff were outside when he/she went to smoke. He/She was already smoking when it blew up in his/her face. Housekeeper A ran to him/her to help him/her put it out and then the housekeeper got him/her help form the nurse.During an interview on 7/8/25 at 2:14 P.M., Certified Medication Technician (CMT) D said when the facility gets residents who smoke, staff are made aware if they are supervised or independent by looking at the resident's smoking assessment. Assessments are done on admission. During an interview on 7/8/25 at 2:17 P.M., the administrator said he/she picked the resident up last week on Thursday (7/3). The resident asked to smoke when he/she arrived at the facility, education was done at that time about not smoking with oxygen on and a policy was signed by the resident. The administrator said Resident #1 received and signed the smoking policy on 7/3/25 initially. He/She was notified on Sunday (7/6), Resident #1 was outside smoking when Housekeeper A came out for the supervised smoke break. The resident was already smoking when his/her nasal canula caught fire. He/She was told the housekeeper assisted the resident and then got help from LPN B. He/She is not sure how the resident obtained the cigarettes and lighter. Smoking assessments were to be done by the SSD upon admission, quarterly, and with a change in condition. He/She does not know why it was not done. Typically after the assessment is done the resident is placed on the smokers list under supervised or unsupervised.Complaint #1612565

Based on interview and record review, facility staff failed to prevent the misappropriation of medications for two residents (Residents #1 and #2) out of four sampled residents, without the consent of the resident or the resident's representative. The facility census was 50. The administrator was notified on 05/09/25 of past Non-Compliance which occurred on 04/25/25. Staff immediately suspended CMT A, conducted an investigation, and notified the required parties and agencies. The administrator immediately in-serviced staff on the facility's policy regarding counting narcotics and abuse, neglect and misappropriation. Staff terminated CMT A on 04/28/25. The deficiency was corrected on 04/25/25. 1. Review of the facility's Abuse Prohibition Protocol Manual, undated, showed staff are directed as follows: - The purpose of training is to prohibit and prevent all forms of abuse, neglect, exploitation, and misappropriation of resident property; - Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/14/25, showed staff assessed the resident as moderately impaired for cognitive skills of daily decision making. Review showed staff documented the resident without anxiety, and not currently taking antianxiety medication. Review of the resident's physician order sheet (POS), dated 04/01/25 to 04/30/25, showed an order for Lorazepam 0.5 milligrams (mg) one-half (1/2) tablet daily for anxiety. Review showed the physician discontinued the order on 04/09/25. Review of the resident's medication administration record, dated 04/01/25 through 04/28/25, showed CMT A signed he/she administered Lorazepam .5 mg to the resident on 04/08/25 and 04/09/25 between 6:00 P.M. and 10:00 P.M. Review of the resident's Controlled Drug Receipt/Record/Disposition Form, dated 04/03/25, showed the pharmacy delivered 30 tablets of Lorazepam 0.5 mg on the evening shift. Review showed CMT A signed he/she administered Lorazepam 0.5 mg to the resident, one tablet on 04/09/25, 04/10/25, 04/11/25, 04/14/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/21/25, 04/22/25, and 04/23/25, and 1/2 tablet on 04/24/25 and 04/25/25. 3. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/25, showed staff assessed the resident as cognitively intact, and currently taking antianxiety medication. Review of the resident's face sheet, undated, showed the resident with a diagnosis of a history of restlessness and agitation. Review of the resident's physician order sheet (POS), dated 04/01/25 to 04/30/25, showed an order for Lorazepam 1 mg one tablet three times daily. Review of the resident's medication administration record, dated 04/01/25 through 04/30/25, showed CMT A signed he/she administered Lorazepam 1 mg to the resident on 04/01/25, 04/02/25, 04/03/25, 04/04/25, 04/08/25, 04/09/25, 04/10/25, 04/14/25, 04/15/25, 04/17/25, 04/18/25, 04/21/25, 04/22/25, 04/23/25, and 04/24/25. Review of the resident's Controlled Drug Receipt/Record/Disposition Form, dated 04/14/25, showed the pharmacy delivered 30 tablets of Lorazepam 1 mg on the 04/14/25. Review showed CMT A signed he/she administered Lorazepam 1 mg to the resident on 04/25/25 at 6:00 P.M. Review of the facility's investigation, dated 04/25/25, showed staff documented the Business Office Manager (BOM) contacted the administrator in regards to a phone-in report from Certified Nurse Aide (CNA) C in which CNA C reported he/she had evidence CMT A had been stealing medications. Review showed the DON conducted a narcotics count on 04/25/25 at 5:15 P.M., which showed CMT A pre-popped all medications to pass that shift. Staff documented CMT A signed out Resident #2's Lorazepam 1 mg, but the medication was not present in the medication cup labeled with the resident's name. CMT A signed he/she administered the medication at 6:00 P.M. on 04/25/05. Review showed the physician discontinued Resident #1's Lorazepam on 04/09/25. Review showed CMT A signed out Lorazepam .25 mg for a total of 11 doses from 04/09/25 to 04/25.25. Review showed staff terminated CMT A on 04/28/25 for for patient abuse or neglect, theft or attempted theft of facility property, resident property, another employees' property, or visitor's property, and falsification of records. During an interview on 05/09/25 at 11:00 A.M., the BOM said CNA C called the facility and reported he/she had information regarding CMT A stealing resident's medications. During an interview on 05/09/25, at 12:35 P.M., the DON said when the administrator notified him/her of the allegation regarding CMT A stealing medications, he/she immediately conducted a narcotics count of the medication cart CMT A controlled that afternoon. He/She said CMT signed out Resident #2's Lorazepam, but the Lorazepam was not in the medication cup with the resident's name. During an interview, on 05/09/25 at 1:45 P.M., the administrator said the BOM contacted him/her to notify him/her CNA C called the BOM, and alleged CMT A was stealing medications. He/She said he/she reviewed the information, suspended CMT A, notified the police and the state agency, and the DON conducted a narcotics count on the medication cart under CMT A's control. He/She said review showed he/she misappropriated a minimum of one Lorazepam 1 mg, and a minimum of 11 Lorazepam 0.5 mg. The administrator said he/she terminated CMT A on 04/28/25 for multiple offenses, including misappropriation and falsification of records. MO00253320

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to use Enhanced Barrier Precautions ((EBP), an infection control method that involves wearing gowns and gloves during high-contact resident care activities) for one resident (Resident #19) and perform appropriate hand hygiene, and glove changes during care for two residents (Resident #35 and #47) of 23 sampled residents. Staff failed to ensure the first step of the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was administered and read prior to the hire date, in accordance with their policy for seven employees (Certified nursing assistant (CNA) P, Dietary Aide (DA) Q, Certified Medication Technician (CMT) J, Maintenance Director, Laundry Aide S, Director of Nursing (DON), and Housekeeper V). The facility census was 48. 1. Review of the facility policy titled, Enhanced Barrier Precautions to Infection Control Guidance, dated March 2024, showed; -The purpose is to prevent broader transmission of Multidrug Resistant Organisms (MDRO), and to help protect patients with chronic wounds and indwelling devices; -EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed; -Residents with an indwelling medical device, including urinary catheter, should be on EBP; -EBP should be used with high-contact resident care activities such as providing hygiene and caring for or using an indwelling medical device. -Required equipment is gown and gloves to be donned prior to care 2. Review of Resident #19's Quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident had an indwelling urinary catheter. Review of the resident's care plan, dated 07/09/24, showed staff assessed resident as follows: -Indwelling urinary catheter due to Benign Prostatic Hyperplasia ((BPH) enlargement of the prostate gland) and neurogenic bladder; -Perform catheter care every shift; -Empty catheter bag every shift and as needed. Review of the resident's medical record showed the resident had been treated for a urinary tract infection (UTI) from 04/20/24-04/20/24, 06/10/24-06/18/24, and 06/23/24-06/27/24. Observation on 07/14/24 at 9:48 A.M., showed Certified Nursing Aide (CNA) E entered the resident's room, performed hand hygiene, applied clean gloves and provided catheter care. CNA E did not wear a gown during catheter care for the resident. During an interview on 07/15/24 at 9:52 A.M., CNA E said he/she did not know about EBP. The CNA said he/she did not know what the signs on the door or the cart outside the door was for. The CNA said he/she knew the resident was on precautions but forgot what it means. During an interview on 07/17/24 at 9:48 A.M., the MDS Coordinator said EBP is for anyone who has a catheter, open wound with infection from a drug resistant organism, tracheostomy, or anytime staff could come in contact with bodily fluids. The MDS coordinator said EBP means staff must wear a gown and gloves when providing care. The MDS Coordinator said a gown and gloves should be worn when providing catheter care. If EBP are not followed this could lead to a staff member being exposed to bodily fluids and increased risk of infection to the resident. During an interview on 07/17/24 at 10:02 A.M., the Director of Nursing (DON) said EBP is another level of infection control and prevention for residents with open wounds, tracheostomies, or catheters. The DON said staff should wear a gown and gloves every time they enter these residents' rooms. The DON said if staff are not following EBP this could lead to the spread of infections. 3. Observation on 07/17/24 at 8:30 A.M., showed CNA M and CNA F entered Resident #35's room, performed hand hygiene, and applied gloves. CNA F removed the resident's soiled brief, and reached in his/her pocket, grabbed trash bags, removed one trash bag, and placed the rest of the trash bags back in to his/her pocket. CNA F continued to wear the same soiled gloves and wiped the resident's front perineal area. CNA F removed his/her soiled gloves and applied clean gloves without performing hand hygiene between glove changes. CNA F and CNA M moved the resident toward CNA M. CNA F wiped the resident's backside. CNA F continued to wear the same soiled gloves, applied barrier cream and placed a clean brief on the resident. During an interview on 07/17/24 at 8:45 A.M., CNA F said hand hygiene should be performed with all gloves changes. The CNA said he/she knew he/she should have washed his/her hands more. The CNA said there is no access to hand sanitizer in the resident rooms and soap and water hand hygiene should be performed. During an interview on 07/17/24 at 8:45 A.M., CNA M said hand hygiene should be performed when moving from dirty to clean tasks, so multiple times during care. The CNA said hand sanitizer should be kept in their pockets for performing hand hygiene during care. 4. Observation on 07/15/24 at 1:28 P.M., showed CNA E and CNA F entered Resident #47's room, applied gloves, and did not perform hand hygiene. CNA E and CNA F transferred the resident with the hydraulic lift from his/her recliner to the bed. CNA F removed the resident's soiled brief and provided perineal care. With the same soiled gloves, CNA F handed the resident's barrier cream and wipes to CNA E and moved the resident toward CNA F. CNA F wiped the residents' backside. CNA E and CNA F removed their soiled gloves, applied clean gloves and did not perform hand hygiene. CNA E applied barrier cream to the resident and wiped the excess cream off their glove on to the clean brief and put the brief on the resident. With the same soiled gloves, CNA F and CNA E transferred the resident back to his/her chair. During an interview on 07/15/24 at 1:36 P.M., CNA E said hand hygiene should be done before and after care and with all gloves changes to prevent cross contamination and infection. The CNA said a clean wipe should be used for each area during perineal care. The CNA did not say why he/she did not use a clean portion of the wipe with each swipe. The CNA said incontinence care should be performed at the beginning of your shift and at least once before the end of your shift. During an interview on 07/15/24 at 1:27 P.M., CNA F said a clean wipe should be used for each area during perineal care. During an interview on 07/17/24 at 9:48 A.M., the MDS coordinator said gloves should be changed and hand hygiene should be completed when moving from a dirty to clean task The MDS Coordinator said during perineal the resident should be wiped with a clean wipe or clean area of the wipe every time, and if not there is an increased risk of infection to the resident. During an interview on 07/17/24 at 10:02 A.M., the DON said staff should perform hand hygiene with all gloves changes, and should change their gloves when soiled or when moving from dirty to clean tasks. The DON said staff can use hand sanitizer for hand hygiene when their hands are not visibly soiled, and staff have access to small bottles they can keep in their pocket, as well as on the carts and in the hallways. 5. Review of the facility's, Tuberculosis Control policy, undated, showed once the decision has been made to employ an individual, the individual will be asked for documentation of a prior PPD. If the employee does not have documentation of a prior PPD, the first step PPD will be administered by the nursing department, documented on the Employee's Immunization record, and must be read prior to or no later than start date. 6. Review of CNA P's employee file showed: -Hire date of 07/10/24; -First step PPD on 07/11/24 and read on 07/13/24 -Review showed the employee file did not contain a documented PPD prior to the employee's start date. 7. Review of DA Q's employee file showed: -Hire date of 06/11/24; -First step PPD on 06/26/24 and read on 06/28/24; -Review showed the employee file did not contain a documented PPD prior to the employee's start date. 8. Review of CMT J's employee file showed: -Hire date of 05/30/24; -First step PPD on 05/30/24 and read on 06/01/24; -Review showed the employee file did not contain a documented PPD prior to the employee's start date. 9. Review of the Maintenance Director's employee file showed: -Hire date of 02/19/24; -First step PPD on 02/19/24 and read on 02/21/24; -Review showed the employee file did not contain a documented PPD prior to the employee's start date. 10. Review of Laundry Aide S's employee file showed: -Hire date of 01/22/24; -First step PPD on 05/07/24 and read on 05/10/24; -Review showed the employee file did not contain a documented PPD prior to the employee's start date. 11. Review of the DON 's employee file showed: -Hire date of 01/20/24; -First step PPD on 01/20/24 and read on 01/22/24; -Review showed the employee file did not contain a documented PPD prior to the employee's start date. 12. Review of Housekeeper V's employee file showed: -Hire date of 04/18/24; -First step PPD on 04/18/24 and read on 04/21/24; -Review showed the employee file did not contain a documented PPD prior to the employee's start date. During an interview on 07/16/24 at 3:29 P.M., the DON said the Assistant Director of Nursing (ADON) who no longer works at the facility, did the TB screening for staff. The DON said staff's first TB test should be read before the staff starts, otherwise that defeats the purpose of doing the TB. The DON said he/she is also the Infection Preventionist and it is his/her expectation the TB be read before the staff can even start. The DON said the listed hire date is the actual day the staff started working at the facility. During an interview on 07/17/24 at 11:07 A.M., the administrator said staff's first step of TB screening should be done during the hiring process. The administrator said the first step of the TB screening for staff, should be administered and read prior to the staff starting. The administrator said the DON is now responsible, but the ADON was responsible for the TB screening, until the ADON quit three weeks ago. The administrator said the staff's hire date is the date they started working at the facility and the staff should have had the 1st step TB read before the hire date. 50361

37131 Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when the staff failed to maintain walls, floors, windows, showers and equipment in resident rooms clean and in good repair. Facility staff failed to provide an environment free of pests. The facility census was 48. 1. Review of the facility's policy's showed the facility did not provide a policy for staff to report environmental concerns. 2. Observation on 07/14/24 at 10:00 A.M., showed the water station in front of the nurse's station between the memory care unit and 400 hall contained a dried orange/brown spot on the wall behind and above the trash can. 3. Observation on 07/14/24 at 10:01 A.M., showed the shared bathroom in occupied resident rooms [ROOM NUMBERS] contained yellow stained toilet seat with two cracks in the back side at the hinges. Observation showed a bed pan and a dirty toilet riser on the floor on either side of the toilet between the wall. The bathroom walls dirty and contained black and brown smudges. The inside of the door to room [ROOM NUMBER] contained a large area of chipped paint with exposed green paint underneath and black marks along the lower portion of the door. 4. Observation on 07/14/24 at 10:02 A.M., showed occupied resident room [ROOM NUMBER] with multiple areas of the floor peeled up and three pieces of duct tape used to hold the floor together. 5. Observation on 07/14/24 at 11:00 A.M., showed occupied resident room [ROOM NUMBER] had three gouges in the floor next to the bed by the door. The inside of the bedroom door and inside of the bathroom door had chipped paint which exposed green paint underneath. During an interview on 07/14/24 at 11:00 A.M., Resident #35 said he/she had asked someone in administration for the doors to be painted but was told the request wouldn't make it through corporate. 6. Observation on 07/14/24 at 2:45 P.M. showed occupied resident room [ROOM NUMBER] contained missing drywall and paint behind the headboard of bed b, and drywall debris hanging from the wall, electric outlet, and on the floor. Observation showed half of the room had not been painted. During an interview on 07/14/24 at 2:45 P.M., Resident #1 said staff started repainting the room, but did not finish the front half and they only painted around the edges. The resident said it looks bad, and he/she is not happy that is has been over two months since it was initially started. The resident said the maintenance guy quit and no one had finished the room. 7. Observation on 07/15/24 at 8:23 A.M., showed occupied resident room [ROOM NUMBER]'s air conditioning (AC) unit without a cover and the AC line exposed. Observation showed the toilet seat had chipped paint. Observation showed the sanitizer pump was broken, with the front of the pump open and hanging down, with two pieces of tape used to hold it closed. 8. Observation on 07/15/24 at 9:24 A.M., showed occupied resident room [ROOM NUMBER] with trim peeled off the wall in front of the cabinet by the windwn. The inside of the bathroom door and the resident room door had paint gone and gouges and black marks along the bottom. 9. Observation on 07/15/24 at 9:38 A.M., showed occupied resident room [ROOM NUMBER]'s bathroom door had chipped paint. Both interior doors and door frames had scratches and paint was gone. 10. Observation on 07/15/24 at 9:47 A.M., showed occupied resident room [ROOM NUMBER]'s shower with duct tape on the tiles and over the shower handles. 11. Observations on 07/17/24 during the facility tour, showed: -Sections of missing paint and drywall on the walls by the beds in resident rooms 303, 304, 309, 406 and in the 300 hall conference room; -The cove base (a trim piece used in the transition space between a wall and floor) peeled away from the walls by the windows in resident rooms 308, 404, 506, and 509 and away from the walls in the activity room; -A hole in the 400 shower wall and an unidentifiable black speckled substance lined the area between the shower wall and floor. During an interview on 07/17/24 at 2:30 P.M., the maintenance director said he/she is responsible for maintenance of the facility's physical environment. The maintenance director said when he/she became the maintenance director in April 2024, the facility did not have a maintenance director for a period of time and there was a backlog of multiple things that needed repaired or replaced. The maintenance director said if there is something that needs repaired or replaced, staff are supposed to fill out a work order and give it to him/her so that he/she knows about the issues. The maintenance director said he/she had not received any work orders for the paint gouges, peeling cove base or 400 hall shower room and did not know about those issues. During an interview on 07/17/24 at 2:45 P.M., the administrator said the facility did not have a written policy for facility maintenance, but staff are expected to comply with state and federal guidelines. The administrator said prior to his/her employment, the facility did not have a maintenance director for a period of time and they found that the former maintenance director had not been fulfilling his/her job duties so there were a lot of things that needed attention. The administrator said if there is something that needs repaired or replaced, staff are supposed to fill out a work order and give it to maintenance director so that he/she knows about the issues and can prioritize his/her work. During an interview on 07/22/24 at 3:28 P.M., Certified Nurse Aide (CNA) U said staff fill out a work order for maintenance to fix issues. The CNA said he/she had noticed some missing paint on doors and room walls and did not report it because he/she figured maintenance already knew about it. The CNA said he/she never noticed any issues with the floors and has not noticed duct tape on floors of the rooms. The CNA said he/she has not noticed damage to toilet seats or paint. During an interview on 07/22/24 at 3:35 P.M., the Minimum Data Set (MDS) Coordinator said staff have a form to fill out and put in the maintenance door box and maintenance checks the box every day he/she is here. The MDS Coordinator said staff have not brought missing paint on the doors and walls to his/her attention and no one has told him/her of any damage on the residents' walls. The MDS Coordinator said staff have not told him/her about missing paint on toilet seats. The MDS Coordinator said he/she does recall seeing duct tape on the floor and he/she did not report it to maintenance. During an interview on 07/22/24 at 3:41 P.M., the Administrator said he/she expects staff to put work orders in with maintenance and maintenance to prioritize the issues based on severity and safety concern. The administrator said he/she is aware of the missing paint on the resident doors, but has not had the time to go in all of the rooms. The administrator said staff has not reported any issues with toilet seats. During an interview on 07/22/24 at 3:49 P.M., the Maintenance Director said staff should fill out a work order and put it in a box on the maintenance door. There has been no work orders in regard to paint on the doors or walls. The maintenance director said he/she has noticed the scratched paint on doors and walls of resident rooms. There has been no work orders in regard to pain on the toilet seats, but he/she does get a lot of work orders about broken toilet seats. He/She has not seen and is not aware of duct tape on the floor of resident rooms and staff has not reported it. 12. Observations on 07/17/24 during the facility tour showed the windows in resident rooms 101, 102, 103, 105, 106, 107, 109, 202, 203, 205, 208, 210, 403, 404, 405, 407, 408, 409, 410, 501, 502, 503, 504, 506, 507, 508, 509 sealed and did not open. During an interview on 07/17/24 at 10:10 A.M., the resident who occupied room [ROOM NUMBER] said his/her window did not open and he/she would like to be able to open it. During an interview on 07/17/24 at 10:50 A.M., the resident who occupied room [ROOM NUMBER] said his/her window did not open and he/she would like to be able to open it. During an interview on 07/17/24 at the maintenance director said he/she knew the windows in the resident rooms did not open and when he/she questioned facility management about the windows, the management told him/her that they were sealed closed during the pandemic and were okay to remain that way. During an interview on 07/17/24 at 2:45 P.M., the administrator said the facility did not have a written policy for the maintenance of windows, but staff are expected to comply with state and federal guidelines. The administrator said the maintenance director is responsible to inspect the windown monthly and make repairs as needed. The administrator said the windows in resident rooms should open and he/she did not know that they were sealed shut. 13. Observation on 07/14/24 at 10:00 A.M., showed Resident #12 in bed with several flies around the room and on the resident. Observation on 07/14/24 at 12:40 P.M., showed the resident sat on the side of his/her bed as he/she ate. Five flies flew around the resident and landed on the resident's food. The resident swatted at the flies on his/her food. Observation on 07/15/24 at 10:24 A.M., showed three flies on the resident as he/she laid in his/her bed. During an interview on 07/15/24 at 10:33 A.M., the resident said he/she complained about the flies several months ago and staff did not do anything about it. Observation on 07/15/24 at 10:45 A.M., showed six flies sat around the resident's feet, and one dead fly on the bed sheet beside the resident's feet. Observation on 07/16/24 at 8:34 A.M., showed two flies on the door frame at the entrance to the resident's room. Multiple flies flew around the resident's room and landed on the resident's breakfast, which sat on the bedside table. 14. Observation on 07/14/24 at 10:06 A.M., showed Resident #36 not in his/her room. Observation showed the sheet contained a large brown stain on the sheet. Flies were observed crawling around on the stains on the sheet and flew around the room. 15. Observation on 07/14/24 at 12:10 P.M., showed Resident #26 sat in a chair in a community area of the facility. Multiple flies landed on the resident's arms and legs. The resident slapped at the flies as they landed on him/her. Observation on 07/15/24 at 9:38 A.M., showed the resident entered his/her room and flies landed on the resident. During an interview on 07/15/24 at 9:40 A.M., the resident said he/she doesn't notice the flies. 16. Observation on 07/14/24 at 12:34 P.M., showed Resident #30 sat in a recliner in his/her room. The resident had a bedside table in front of him/her, with his/her lunch on it and a fly swatter. The resident swatted at flies that landed on his/her food. During an interview on 07/14/24 at 12:23 P.M., the resident said he/she has a problem with all the flies. Observation on 07/15/24 at 10:08 A.M., showed the resident swatted at flies in his/her room with a fly swatter. During an interview 07/15/24 at 10:08 A.M., the resident said he/she has to swat at the flies with the fly swatter to keep them off of his.her food. They're terrible. 17. Observation on 07/15/24 at 9:47 A.M., showed Resident #8 laid on his/her bed in his/her room. Three flies flew around the room. During an interview on 07/15/24 at 9:47 A.M., the resident said he/she notices the flies, and they bother him/her. 18. Observation on 07/15/24 at 3:25 P.M., showed Resident #2 in his/her bed. Flies flew around the room and landed on the resident. During an interview on 07/22/24 at 3:28 P.M., CNA U said he/she has noticed the flies in the facility and resident rooms and brought it to maintenance and the administrators attention. The CNA said maintenance said they had to call somebody to get it treated. The CNA said he/she is not aware of anyone coming in to treat for flies. The CNA said he/she is still seeing flies in the facility. During an interview on 07/22/24 at 3:35 P.M., the MDS Coordinator said he/she did notice residents with more odors had flies in their rooms. The MDS Coordinator said he/she reported the flies to maintenance and is not sure what maintenance did about the flies. During an interview on 07/22/24 at 3:41 P.M., the administrator said no one has reported an issue with flies. The administrator said he/she has seen the flies around the offices, but has not really been in rooms to witness it himself/herself. The administrator said he/she is sure if the flies are in building, the flies are in the rooms. The administrator said he/she has contacted pest control about the flies and the pest control company said there is nothing they can do. During an interview on 07/22/24 at 3:49 P.M., the Maintenance Director said he/she has not had any reports of flies in resident rooms or hallways. He/She has seen flies in the halls but not in resident rooms. 45489 50361

Based on observation, interview, and record review, facility staff failed to ensure the comprehensive care plans were updated for oxygen use for two residents (Resident #2, and #41), depression for one resident (Resident #8), behaviors for one resident (Resident #34), wandering for one resident (Resident #36), weight loss for one resident (Resident #41), and for Activities of Daily Living (ADLs) for one resident (Resident #45) out of 23 sampled. The facility census was 48. 1. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed staff were directed as follows: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: -When a significant change in the resident's condition has occurred; -At least quarterly; -When changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident received oxygen. Review of the resident's care plan, dated 06/17/24, showed the care plan did not address the resident's oxygen use. Review of the resident's Physician Order Sheet (POS), dated 07/01/24, showed an order for oxygen two to four Liters Per Minute (LPM) through nasal cannula continuously, to maintain oxygen saturation above 92%, on every shift, with a start date of 05/30/24. Observation on 07/15/24 at 3:27 P.M., showed the resident with his/her oxygen on per nasal nasal cannula. During an interview on 07/17/24 at 1:31 P.M., the MDS Coordinator said oxygen should be care planned. The MDS coordinator said he/she overlooked the oxygen. During an interview on 07/17/24 at 2:45 P.M., the Director of Nursing (DON) said if a resident uses oxygen it should be on the care plan. 3. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident had a new diagnosis of depression and received antidepressant medication seven out of seven days in the look back period. Review of the resident's care plan, dated 06/27/24, showed the care plan did not contain information related to the resident's diagnoses of depression or antidepressant medication use. Review showed the care plan did not contain symptoms for staff to monitor for or non-pharmacological interventions to use. The care plan did not show the side affects of the antidepressant the staff should monitor the resident for. Review of the resident's POS, dated 07/01/24, showed the physician order for Zoloft (antidepressant medication) 50 milligram (mg) daily for a diagnosis of depression, with a start date of 06/22/24. During an interview on 07/17/24 at 1:34 P.M., the MDS Coordinator said a diagnosis of depression and antidepressant use should be care planned. The MDS coordinator said it was overlooked. The MDS Coordinator said he/she is supposed to revise the care plans quarterly, and he/she sometimes forgets to revise the care plan. During an interview on 07/17/24 at 2:45 P.M., the DON said a diagnosis of depression, and antidepressant use should be care planned, as well as non-pharmacological interventions staff should use. The DON said he/she does not know why it was not done, it is the responsibility of the MDS coordinator to ensure it is updated. 4. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Had hallucinations and delusions; -Rejected care one to three days out of the seven day look back period; -Verbal behaviors occurred one to three days out of the seven day look back period; -Diagnosis of major depressive disorder. Review of resident's care plan, dated 04/24/24, showed the care plan did not address the resident's physical and verbal behavioral care needs with appropriate interventions. Review of the resident's nurses notes showed staff documented the resident had aggressive physical and verbal behaviors toward staff on 07/13/24, 07/08/24, 06/10/24, 5/29/24, 5/23/24, and 5/23/24. During an interview on 07/17/24 at 1:34 P.M., the MDS Coordinator said he/she is aware of the resident's aggressive behaviors and the behaviors should have been care planned but he/she overlooked it. The MDS Coordinator said he/she is supposed to revise the care plans quarterly, and he/she sometimes forgets to revise the care plan. During an interview on 07/17/24 at 2:45 P.M., the Director of Nursing (DON) said the resident's aggressive behaviors should be on the care plan, and the care plans should be reviewed with significant changes, changes in care, and based on triggers for the annual and quarterly assessments. The DON said he/she does not know why it was not done. 5. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitive assessment unable to be completed; -Rarely/never understood; -Wanders daily; -Diagnoses of non-traumatic brain dysfunction, cerebral palsy (a group of conditions that affect movement and posture), seizures, anxiety, and depression. Review of the resident's Elopement Assessment, dated 07/02/24, showed the resident scored at high risk for elopement/wandering. The interventions listed are frequent monitoring and care plan. Review of the resident's care plan, dated 07/10/24, did not address the resident's wandering or elopement risks. Observation on 07/14/24 at 11:50 A.M. showed the resident wandered near the dining rooms and front entrance area. Observation on 07/15/24 at 8:40 A.M. showed the resident wandered near the dining rooms and front entrance area. Observation on 07/16/24 at 9:20 A.M. showed the resident wandered near the dining rooms and front entrance area. Obseravtion on 07/17/24 at 10:40 A.M. showed the resident wandered near the dining rooms and front entrance area. During an interview on 07/17/24 at 1:34 P.M., the MDS Coordinator said he/she is aware of the resident's wandering and thought that he/she had it care planned. He/She said wandering should be care planned. The MDS Coordinator said he/she is supposed to revise the care plans quarterly, and he/she sometimes forgets to revise the care plan. During an interview on 07/17/24 at 2:45 P.M., the DON said the resident's wandering should be on the care plan and care plans should be reviewed with a significant change, change in care, and based on triggers for the annual and quarterly assessments. 6. Review of the Resident #41's quarterly MDS, dated ,d+[DATE] 24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required maximal assistance from staff for eating; -Dependent on staff for oral hygiene, toilet hygiene, bathing, dressing, personal hygiene, bed mobility and transfers; -Always incontinent of bowel and bladder; -Two or more non-injury falls; -Significant weight loss; -Did not require oxygen. Review of the resident's care plan, dated 05/22/24, showed it did not contain the resident's significant weight loss, interventions put in place for the weight loss, use of mechanical lift or the resident's oxygen use. Review of the resident's POS, dated 07/01/24, showed staff should apply oxygen at two LPM for shortness of breath, with a start date of 05/02/24. Observation on 07/15/24 at 8:34 A.M., showed Certified Nurse Aide (CNA) E and CNA F used a mechanical lift to transfer the resident from his/her chair to his/her bed. The resident did not provide any assistance with the transfer. Observation showed the resident received continuous oxygen. During an interview on 07/17/24 at 1:31 P.M., the MDS Coordinator said oxygen should be on the resident's MDS and it should be care planned. The MDS coordinator said he/she overlooked the oxygen. The MDS Coordinator said weight loss should be care planned. The MDS Coordinator said he/she is supposed to revise care plans quarterly, but sometimes he/she forgets to revise the care plans. During an interview on 07/17/24 at 2:45 P.M., DON said if a resident uses oxygen, it should be on the care plan. The DON said a significant weight loss and interventions should be care planned. 7. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Required substantial/maximal assist to shower/bathe self; -Required partial/moderate assist for upper/lower body dressing, and putting on/taking off footwear; - Diagnoses of non-traumatic brain dysfunction, cognitive communication deficit, dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety. Review of the resident's care plan, dated 07/01/24, showed it did not address the resident's Activities of Daily Living (ADL) needs and assistance levels. Observation on 07/14/24 at 3:20 P.M., showed the resident wore a gray cardigan, dark teal pants, and light blue T-shirt with flowers. Observation on 07/15/24 at 8:25 A.M. showed the resident wore the same gray cardigan, dark teal pants, and light blue T-shirt with flowers. During an interview on 07/17/24 at 1:34 P.M., the MDS Coordinator said the resident's ADL needs and assistance level should be care planned. The MDS Coordinator said he/she is supposed to revise the care plan quarterly, and he/she sometimes forgets to revise the care plan. During an interview on 07/17/24 at 2:45 P.M., the DON said the resident's care plan should have what ADL assistance they need. Care plans should be reviewed with a significant change, change in care, and based on triggers for the annual and quarterly assessments. The care plans should be updated or it would not reflect where the resident is now. 45489

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 48. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. Review of the Payroll Based Journal (PBJ), a method to collect auditable and verifiable staffing data from nursing facilities, report for Fiscal Year 2024, Quarter 2 (January 1 through March 31) showed triggers for no RN hours for 01/22/24, 02/10/24, 02/11/24, 03/03/24, 03/16/24, 03/17/24, and 03/24/24. 2. Review of the facility's payroll staff hours, dated January 2024, showed the facility did not have an RN in the building for eight consecutive hours on 01/09/24 and 01/14/24. 3. Review of the facility's payroll staff hours, dated February 2024, showed the facility did not have an RN in the building for eight consecutive hours on: -Saturday 02/10/24; -Sunday 02/11/24; -Sunday 02/18/24; -Sunday 02/25/24. 4. Review of the facility's payroll staff hours, dated March 2024, showed the facility did not have an RN in the building for eight consecutive hours on: -Friday 03/01/24 -Sunday 03/03/24; -Saturday 03/09/24 -Saturday 03/16/24; -Sunday 03/17/24; -Sunday 03/24/24. 5. During an interview on 07/17/24 at 2:14 P.M., the Director of Nursing (DON) said there should be an RN daily for 8 hours. The DON said he/she started in February as DON, and until the end of February and part of March he/she had one RN on nights, but then he/she was the only RN. The DON said they are offering sign on bonuses, going to job fairs and sending out postcards for recruiting. The DON said the facility does not use agency nursing staff, they do have two RN's who work for corporate that will try to help when needed. The DON said he/she did not know there were days of no RN coverage during that time, and took over the DON position in mid-February, and had been working doubles on the weekend. The DON said if there was not an RN, he/she would be the one to come in if needed for changing a Peripherally Inserted Central Catheter ((PICC), a long flexible tube that's inserted into a vein in the upper arm and threaded into a large vein near the heart, line dressing or intravenous infusions). During an interview on 07/17/24 at 2:29 P.M., the administrator said he/she started May 1st and did not know of the missing coverage for that quarter. The facility struggles to get RN's hired and we are doing a job fair tomorrow. The administrator said the facility would not be able to meet the residents care needs if they did not have an RN.

Based on observation, record review, and interview, facility staff failed to provide safe hydraulic lift (a mechnical lift used to assist with transferring a resident) transfers for two (Resident #41 and #47) of 23 sampled residents when staff did not ensure the base of the lift was open and stabalized. The facility census was 48. 1. Review of the facility policy titled Hydraulic lift, undated, showed, -The purpose of the policy is to enable one individual to lift and move a resident safely; -The fist step in operating the hydraulic lift is to open lift to the widest point and set the brakes. Review of the facility's hydraulic lift user manual, undated, showed: -When using an adjustable base lift, the legs must be in the maximum opened/ locked position before lifting the patient; -During transfer, with resident suspended in a sling attached to the lift, do not roll [NAME] base over uneven surfaces that could cause the patient lift to tip over; -The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. 2. Observation on 07/15/24 at 8:34 A.M., showed Certified Nurse Aide (CNA) E and CNA F entered resident #41's room with the hydraulic lift. CNA E opened the legs to the hydraulic lift, propelled it forward around the resident's wheelchair. CNA E and CNA F connected the resident's sling straps to the hydraulic lift. CNA E lifted the resident from the wheelchair, and as he/she backed the lift up he/she closed the legs of the lift. CNA F backed the resident's wheelchair up and did not guide the resident in the sling when CNA E turned the lift towards the resident's bed. Observation showed the resident swayed side to side while in the hydraulic lift sling. CNA E reached around the lift and grabbed a strap on the resident's sling, and pulled the lift towards the resident's bed which resulted in the resident to sway forwards and backwards. CNA F came around the resident's chair and grabbed the resident's legs to stabilize the resident. CNA E tried to push the legs to the hydraulic lift under the bed where a mat was placed and the resident swayed back and forth in the lift sling several times until CNA E pushed the legs of the lift over the mat. CNA E and and CNA F lowered the resident to his/her bed. Staff did not transfer the resident with the base of the lift in the maximum open position. During an interview on 07/15/24 at 1:24 P.M., CNA E said staff should go in the resident's room with the mechanical lift, open the legs of the mechanical lift, strap resident in and take resident to bed. The CNA said staff should close the legs on the mechanical lift, when the resident is in air, or staff could trip over the legs of the mechanical lift and get hurt. CNA E said the resident rocked in the mechanical lift, because the resident was slanted in the sling. He/She grabbed the resident to try and prevent the resident from falling out of the sling. CNA E said he/she should have pulled the mat out from under the bed, but he/she forgot it was under there and the mechanical lift got stuck on the mat. CNA E said he/she did not know the lift legs should be kept open to help with balance. The CNA said he/she had never been trained to keep the legs of the mechanical lift open during transfers. 3. Observation on 07/15/24 at 1:28 P.M., showed CNA E and CNA F entered resident #47's room to provide care. CNA E and CNA F opened the base of the hydraulic lift and moved it in front of the resident. The CNA's attached the sling to the lift, CNA E lifted the resident, pulled the lift away from the chair and closed the legs of the lift. CNA E moved the lift over the resident's bed and lowered the resident in to his/her bed. Staff provided care and raised the resident in the hydraulic lift with the base of the lift closed and the resident held on to the cross bar of the lift. CNA opened the legs of the lift to position the resident over his/her wheelchair. Staff did not transfer the resident with the base of the lift in the maximum open position, and did not ensure the resident did not touch the lift when in use. During an interview on 07/15/24 at 1:36 P.M., CNA E said the legs of the lift are only to be opened when it is needed to get around furniture, such as a chair. The CNA said staff should close the legs of the lift all the way when the resident is in the air to prevent a tripping hazard for staff during the transfer. During an interview on 07/15/24 at 1:37 P.M., CNA F said the legs of the lift are to stay open while transporting the resident in the lift. 4. During an interview on 07/17/24 at 9:48 A.M., Minimum Data Set (MDS) coordinator said the legs of the lift should be open during the entire transfer to keep the lift stable. During an interview on 07/17/24 at 10:04 A.M., the Director of Nursing (DON) said during a hydraulic lift transfer he/she would expect staff to have the legs of the lift open. The DON said this is to create a wide base and spread out the gravity of the resident so they do not tip. 50361

Based on observation, interview, and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment tool, when staff did not accurately code weight loss for one resident (Resident #8), restraints for one resident (Resident #34), and anticoagulant and hypnotic medication use for one resident (Resident #16) out of 23 sampled residents. The facility census was 48. 1. Review of the facility's policy titled, MDS and Care Planning Guidelines, dated 10/01/2015, showed it is the policy of the facility to use the most current Centers for Medicare and Medicaid (CMS) MDS Resident Assessment Instrument (RAI) manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, Care Area Assessments (CAAs), and resident care planning. 2. Review of Resident #8's Admission MDS, dated [DATE], showed staff assessed the resident weight as 254 pounds. Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident weight as 228 pounds. Staff did not document this weight loss as significant. During an interview on 07/17/24 at 1:34 P.M., the MDS Coordinator said if a resident has a significant weight loss, it should be coded on the MDS. The MDS Coordinator said the resident had a significant weight loss and he/she must have overlooked it. During an interview on 07/17/24 at 2:45 P.M., the Director of Nursing (DON) said the resident should have a significant weight loss on his/her MDS. The DON said the MDS Coordinator is responsible to add the information to the MDS an ensure it is accurate. 3. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Limb restraints used less than daily. Review of the resident's medical record showed medical record did not contain an order for restraint use. Observation on 7/14/24 at 12:10 P.M. showed the resident did not have limb restraints. Observation on 7/15/24 at 1:24 P.M. showed resident did not have limb restraints. Observation on 7/16/24 at 3:13 P.M. showed the resident did not have limb restraints. During an interview on 07/16/24 at 4:38 P.M., Certified Medication Technician (CMT) N said he/she was not aware of restraints ever being used on the resident. During an interview on 07/16/24 at 4:40 P.M., Certified Nurse Aide (CNA) O said he/she has worked at the facility for over a year and has never seen the resident use restraints, and has never seen a limb restraint on the resident. During an interview on 07/16/24 at 4:45 P.M., the MDS Coordinator said the resident has never had restraints and does not use them. During an interview on 07/17/24 at 1:34 P.M., the MDS Coordinator said he/she coded restraints for the resident due to bed rail use, and it was done in error. The MDS Coordinator said he/she has been in this position since November 2023 and was not fully trained, but is signed up for training in August 2024. During an interview on 07/17/24 at 2:45 P.M., the Director of Nursing (DON) said the resident does not use restraints and it should not be on the MDS. 4. Review of Resident #16's MDS, 05/28/24, showed staff assessed the resident received hypnotic (a medication used to induce or prolong sleep) and an anticoagulant (a medication used to thin the blood). Review of residents medical record showed the medical record did not contain an order for hypnotic or anticoagulant medication. During an interview on 07/17/24 at 2:00 P.M., MDS coordinator says he/she coded the resident as taking a hypnotic due to the use of amitriptyline, and he/she is unaware that it is not a hypnotic medication. The MDS coordinator said he/she coded the resident as taking an anticoagulant due to the use of Aspirin, and said he/ she is unaware it is not an anticoagulant medication. The MDS Coordinator said he/she is responsible to ensure the MDS is coded correctly. 45489 50361

Based on interview and record review, facility staff failed to complete a Significant change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, for three residents (Resident #2, #8 and #41) out of 23 sampled residents. The facility census was 48. 1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/23, shows a significant change is a major decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision of the care plan. 2. Review of Resident #2's SCSA MDS, dated [DATE], showed staff assessed the resident as: -Independent with eating, oral hygiene and bed mobility; -Required setup assistance from staff for toilet hygiene, dressing, personal hygiene and transfers; -Required supervision from staff for bathing; -Did not fall; -Did not have ulcers or wounds. Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Required setup assistance from staff for eating; -Required maximal assistance from staff for oral hygiene, dressing, personal hygiene, bed mobility and transfers; -Dependent on staff for toilet hygiene and bathing; -Fall with injury; -Open lesion on foot. Review showed facility staff did not complete a SCSA for a decline in two or more areas of function. 3. Review of Resident #8's Admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Rejected care one to three days out of the seven day look back period (period of time used to complete the assessment); -Required set up assistance from staff for eating and oral hygiene; -Required maximal assistance from staff for dressing, personal hygiene, transfers and to propel wheelchair 150 feet; -Required moderate assistance from staff for bed mobility; -Weighed 254 pounds; -Had one stage 2 pressure injury and one unstageable pressure injury; -Did not have a diagnosis of Depression; -Did not receive an antidepressant. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Rejected care four to six out of seven days during the look back period; -Independent with oral hygiene, transfers, bed mobility and to propel wheelchair 150 feet; -Required setup assistance only from staff for dressing and personal hygiene; -Weighed 228 pounds, a significant weight loss; -Two stage 2 pressure injuries; -New diagnosis of Depression; -Received antidepressant medication seven of the seven days in the look back period. Review showed facility staff did not complete a SCSA for multiple declines and improvements in two or more areas of function. 4. Review of Resident #41's SCSA, dated 02/28/24, showed staff assessed the resident as follows: -Had verbal behaviors directed towards others one to three days during the seven day look back period; -Had other behaviors not directed at others one to three days during the seven day look back period; -Wandered four to six days during the seven day look back period; -Required supervision from staff for eating; -Required moderate assistance from staff for oral hygiene; -Required maximal assistance from staff for toilet hygiene, bathing, dressing, personal, hygiene, bed mobility and transfers; -Frequently incontinent of bowel and bladder; -Did not fall; -Weighed 130 pounds. Review of the resident's quarterly MDS, dated ,d+[DATE] 24, showed staff assessed the resident as follows: -Did not exhibit behaviors; -Did not wander; -Required maximal assistance from staff for eating; -Dependent on staff for oral hygiene, toilet hygiene, bathing, dressing, personal hygiene, bed mobility and transfers; -Always incontinent of bowel and bladder; -Two or more non-injury falls; -Weighed 118, a significant weight loss. Review showed facility staff did not complete a SCSA for multiple declines and improvements in two or more areas of function. 5. During an interview on 07/17/24 at 1:34 P.M. the MDS Coordinator said he/she is responsible for completing all significant change MDS assessments, and a significant change should be completed if a resident is admitted to hospice care. The MDS coordinator said he/she does not know what the RAI manual says about significant changes and when a significant change assessment is required. The MDS coordinator said he/she works the floor as a charge nurse at times, and resident #2, #8, and #41 had a significant change in status, but he/she did not know an assessment should be completed. The MDS coordinator said he/she has signed up for MDS training. During an interview on 07/17/24 at 2:45 P.M., the Director of Nursing (DON) said he/she does not know how many areas of care have to change, to trigger a significant change MDS.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy prior to transfer for four (Residents #2, #8, #19 and #41) of 23 sampled residents. The facility census was 48. 1. Review of the facilities policy titled Discharge/Transfer of Resident, undated, showed: -The purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; -Explain and give copy of bed hold form to the resident and/or representative. 2. Review of Resident #2's medical record showed staff documented the resident had been transferred to the hospital on 05/09/24 and returned to the facility on [DATE]. The resident's medical record did not contain documentation which showed staff notified the resident and/or the representative of the facility's bed hold policy at time of the resident's transfer. 3. Review of Resident #8's medical record showed staff documented the resident had been transferred to the hospital on 03/23/24 and returned to the facility on [DATE], transferred to the hospital again on 04/17/24 and returned to the facility on [DATE]. The resident's medical record did not contain documentation which showed staff notified the resident and/or the representative of the facility's bed hold policy at time of the resident's transfer. 4. Review of Resident #19's medical record showed staff documented the resident had been transferred to the hospital on 04/10/2024 and returned on 04/13/2024, transferred on 05/3/2024 and returned on 05/3/2024, transferred on 06/23/2024 and returned on 06/23/2024, and transferred on 06/24/2024 and returned on 06/27/2024. The residents medical record did not contain documentation staff notified the resident and/or representative of the facilities bed hold policy at the time of either transfer. 5. Review of Resident #41's medical record showed staff documented the resident had been transferred to the hospital on 01/04/24 and returned to the facility on [DATE]. The resident's medical record did not contain documentation which showed staff notified the resident and/or the representative of the facility's bed hold policy at time of the resident's transfer. 6. During an interview on 07/16/224 at 2:20 P.M., the business office manger (BOM) said the nursing staff is responsible for providing bed hold information upon resident transfer. The BOM said there is a bed hold policy in the admission packet, but he/she does not do anything further with bed holds. During an interview on 07/16/24 at 3:30 P.M., the Director of Nursing (DON) said he/she took over the position in late February and prior to this staff were unaware of what a bed hold was. The DON said the nurses are responsible for providing the bed holds and having the residents sign before transfer. The DON said social services may have some of the bed holds. During an interview on 07/16/24 at 3:43 P.M., the activities director (AD) and former social services director said he/she does not have the signed bed holds. During an interview on 07/16/24 at 4:20 P.M., the administrator said he/she had been uploading the bed holds to the facility's software program. The administrator said the nursing staff had not been giving him/her bed holds, probably because they haven't been providing the beds holds to the residents on transfer. 45489 [NAME], [NAME]

Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 48. 1. Review of the facility's policies showed the facility did not have a policy for Daily Nurse staff posting. Review of the facility's records showed the facility did not retain completed nurse staff posting for 4/13/23 through 4/16/23, 6/1/23 through 6/14/23, 6/17/23, 6/18/23, 7/5/23 through 7/16/23. Review showed nurse staff form not available for 4/1/23, 6/12/23, 6/30/23, 11/10/23 through 12/31/23. Review of the facility's records showed the facility did not retain completed nurse staff posting 1/13/24, 1/14/24, 1/21/24, 2/2/24, 2/4/24, 2/13/24, 2/24/24, 4/13/24, 5/25/24; 6/13/24, and 7/8/24. Review showed nurse staff form not available 01/22/24 through 1/31/24 and 5/22/24. During an interview on 07/17/24 at 2:39 P.M, the DON said the daily nurse staff posting should be kept for a couple of years. During an interview on 07/17/24 at 2:39 P.M., the administrator said he/she did not know the appropriate amount of time keep the nurse staff posting. Observation on 07/14/24 at 11:46 A.M. showed the daily nurse staff post, dated 07/11/24, did not contain the current daily nurse staff posting until 3:17 P.M. Observation on 07/15/24 at 8:22 A.M. showed the nurse staff post did not contain the required day shift nurse staffing information. Observation on 07/16/24 at 8:17 A.M. showed the daily nurse staff post did not include evening and night shift staff and hours, and did not contain Certified Nurse Aide (CNA) hours for the day shift. Observation on 07/17/24 at 8:37 A.M. showed the nurse staff post did not contain the required day shift nurse staffing information. During an interview on 07/17/24 at 2:39 P.M., the Director of Nursing (DON) said the day shift charge nurse should be posting the nurse staff posting every morning. The DON said he/she pulls it to make sure it is correct, and the Assistant Director of Nursing (ADON) was the one in charge, but he/she took it over when the ADON quit a month ago. The DON said he/she started as DON mid-February, and has been busy trying to get everything else done and did not know they were not accurate or being saved. During an interview on 07/17/24 at 2:39 P.M., the administrator said he/she did not know the daily nurse staff postings were not being completed correctly. He/She has only been administrator here for two months and he/she is working to get processes fixed and in place.

Based on interview and record review, facility staff failed to ensure oncoming and off-going staff members verified and reconciled the narcotic count as accurate at each shift change. The facility census was 53. 1. Review of the facility's Narcotic Count Policy, undated, showed staff are directed as follows: -Controlled substances are available only to Licensed Practical Nurses (LPN's), Registered Nurses (RN's), pharmacists, and certified medical technicians (CMT's); -One RN, LPN, CMT going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift; -After the supply is counted and justified, the nurses/CMT records the date and his/her signature, verifying the count is correct. 2. Review of the Narcotic Inventory Sheet, dated October 2023, showed staff did not document or record a signature to signify the count had been completed as follows: -10/1/23 all shifts (day 6-2, evening 2-10, and night 10-6); -10/2/23 day shift; -10/3/23 day shift; -10/4/23 day shift; -10/5/23 day and night shift; -10/6/23 evening and night shift; -10/7/23 all three shifts; -10/8/223 all three shifts; -10/9/23 day shift; -10/10/23 day shift; -10/11/23 day shift; -10/12/23 day shift; -10/13/23 day and night shifts; -10/14/23 evening and night shift; -10/15/23 all three shifts; -10/16/23 evening shift; -10/17/23 evening shift; -10/18/23 night shift; -10/19/23 night shift; -10/20/23 evening and night shifts; -10/21/23 evening and night shifts; -10/22/23 evening and night shifts; -10/23/23 day and night shifts; -10/24/23 day and night shifts; -10/25/23 night shift; -10/26/23 day and night shift; -10/28/23 all three shifts; -10/29/23 all three shifts; -10/30/23 night shift; -10/31/23 night shift. During an interview on 11/3/23 at 12::00 P.M., the Assistant Director of Nurses (DON) said staff are expected to count narcotics with two nurses every shift. During an interview on 11/3/23 at 1:15 P.M., LPN H said one coming on duty and the one going off duty are supposed to count the narcotics and sign the narcotic count sheet. During and interview on 11/3/23 at 2:00 P.M., The Administrator and Director of Nurses (DON) said they expect nurses to sign together when coming on and leaving shift and they should be signing the count sheet as completed. The DON said the nurses have the bad habit of completing the count but they don't sign the book. He/She that is one thing that he/she plans to start some in-services with the licensed staff about to assure the counts are getting completed and signed. MO00226478

Based on interview and record review, facility staff failed to prevent the misappropriation of one resident's (Resident #1's) narcotic medications when Certified Nurse Assistant (CNA) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 53. 1. Review of the facility's Abuse Prohibition Policy, dated November 2017, showed the policy defined misappropriation of resident's property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/17/2023, showed staff assessed the resident as follows: -Cognitively Intact; -Diagnosis of pain in the right hip, and hypertrophic osteoarthropathy (a syndrome that is characterized by a periosteal reaction of the long bones without an underlying bone lesion; -Received scheduled pain management; -Received as needed pain medication. Review of the resident's Physician's Order Sheets (POSs), dated November 2023, showed an order for Oxycodone (narcotic pain medication) 10 milligrams (mg) take one half tablet by mouth every four hours. Review of the resident's Controlled Substance Log, dated 10/17/2023, showed the residentt received a medication card of 30 oxycodone 10 mg pills from the pharmacy. Review showed staff documented the total card count for the cart. Review of the resident's Controlled Drug Receipt form, dated 10/17/2023, showed the card of 30 oxycodone 10 mg had been entered on the form and none of the pills had been signed out as given. Review of the facility's investigation, dated 10/27/23, showed Licensed Practical Nurse (LPN) B notified the Assistant Director of Nursing (ADON) CNA A had accessed the medication cart and administered Resident #1's narcotic pain medication. The facility identified when the medication was counted Resident #1's entire 30 count card was unaccounted for. The ADON notified the Administrator and the investigation started. The staff notified the police department, the resident's primary care physician (PCP), the appropriate state agency, and the resident's responsible party of the misappropriation. The Administrator terminated CNA B on 10/28/23 for misappropriation of resident's narcotic medication. During an interview on 11/3/23 at 11:30 A.M., LPN B said one of the techs came to him/her and reported CNA A had been in the medication cart. He/She said, I immediately counted the card and realized there was a full card of 30 oxycodone 10 mg missing for Resident #1. LPN B said he/she then went to CNA A and confronted him/her and he/she said Resident #1 had asked for a pain pill so he/she got the keys and gave it. When he/she asked where the card was and he/she could not produce it. He/She said He/she went into the office and contacted the ADON to report it. LPN B said the ADON arrived within ten minutes and the next thing he/she knew CNA A had bolted out the front door. The police arrived shortly after he/she had left and they never found the card of missing narcotics. During an interview on 11/3/23 at 12:00 P.M., the ADON said he/she was called by LPN B around 1:00 A.M. who reported CNA A had gotten into the medication cart and given a resident a pain medication. ADON said he/she decided to just head there since he/she is only a few minutes away. Upon arrival he/she was informed CNA A had fled out of the facility through the field and there was a missing card of oxycodone 10 mg for Resident #1. During an interview on 11/3/23 at 2:00 P.M., The Administrator and Director of Nursing (DON) said the nurses have in the past left the keys in a drawer at the nurses station and they would expect them to keep them on their person even when they are on a break as long as they are not leaving the facility. CNA A got the keys and got into the cart and passed an oxycodone 10 mg pill to Resident #1 and had reported to staff that he/she was a CMT. When the keys were returned to LPN B he/she found the entire card of oxycodone 10 mg was missing from the cart. The police were notified, Primary Care Physician notified, Investigation was started, and CNA A was terminated. During an interview on 11/9/23 at 8:40 A.M., CNA C said he/she had answered a call light and when he/she returned to the nurse's station CNA A asked what the resident wanted and he/she told him/her the resident was requesting a pain pill. CNA C said CNA A then got into the medication cart and was signing something in the book. CNA C said he/she got up and went to the other side where a different CNA was working to ask if CNA A was a Certified Medication Technician (CMT) because he/she did not believe he/she was but he/she did not know how to look it up. CNA C said he/she did not go to the nurse first because he/she was on break. CNA C said another nurse LPN E had come to the facility and so LPN B asked LPN E what he/she should do because he/she was fairly new to the facility. CNA A began acting strange at that point he/she had his/her bag and was clutching it under his/her arm as he/she walked around going in and out of bathrooms from one to the other. When the two LPN's went into the office they watched CNA A, first he/she tried to exit out a side door, then when he/she couldn't get out that door he/she walked down the other hall and the next thing he/she knew the front door alarm was sounding. CNA C said by the time he/she got to the front door CNA A was running through the field and was out of sight. During an interview on 11/9/23 at 9:33 A.M., LPN E said he/she had come to the facility to bring lunch and the staff was questioning him/her about whether CNA A was a CMT or not because he/she had reported passing Resident #1's narcotic pain pill. He/She said, I advised them to contact the ADON because I did not think he/she was a CMT. LPN B had also reported the entire card of 30 oxycodone 10 mg was missing. LPN B then contacted the ADON, and the police. LPN E said during this time CNA A had exited out the front door before the police could arrive. During an interview on 11/9/23 at 12:30 P.M., CNA F said he/she was working the hall with CNA A the night the police were called because he/she had gotten into the medication cart and gave Resident #1 a pain pill. He/She said this was maybe the third or fourth time he/she had worked with CNA A and he/she seemed nice. CNA F said this night however he/she was acting bizarre like going from one bathroom to another and would stay in there for like 15 minutes or so and then go to another one. He/She said at one point CNA A even disappeared for like 20 minutes and no one could find him/her. CNA F said there was also an incident earlier in the shift where a resident who is very alert and oriented began to scream and when he/she entered his/her room the resident reported that CNA A had tried to take his/her tray with his/her medications on it. CNA F said shortly before CNA A left the facility he/she had heard the medication drawer slam and he/she thought that is odd because the nurse had gone on break and when he/she got to the nurse's station CNA A was in the med cart. CNA F said he/she went to the nurse and reported it. When LPN B confronted CNA A he/she reported that he/she was a CMT. During an interview on 11/20/23 at 10:45 A.M., CNA A said he/she was told by LPN B to give the resident a pain pill and the keys were on top of the medication cart. He/She said the pill he/she gave was the last one in the card so he/she placed it at the nurse's station once given and he/she is unaware of where the other 29 pills went or why no one had signed any as given. He/She said yes he/she was aware that he/she was unlicensed to pass the medication to residents. CNA A said he/she could not explain why other staff reported that he/she got into the cart without permission and could not find the card of oxycodone after he/she got the keys back from him/her and counted the cart. MO00226478