Every finding on record at St Joe Manor

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 147.Review of the facility's policy titled, Code of Dress and Personal Appearance, dated 2011, showed:- All Dining Services employees will comply with printed and posted personal hygiene and sanitation practices of this facility;- Hairnets, hair restraints, and beard guards shall be worn.Review of the facility's policy titled, Cleaning Instructions, dated 2011, showed:- The range will be cleaned and sanitized after each use, spills and food particles will be wiped up as they occur;- Ice machine and equipment will be kept clean and sanitized, according to the manufacturer's procedures if available, wipe down exterior with detergent solution, clean underneath and around the machine;- Kitchen floors will be swept and cleaned after each meal. At least once a month, large appliances will be moved to clean behind and underneath them;- Ceilings and walls will be cleaned and sanitized on a regular basis;- Both handheld and electric can openers will be cleaned following each use;- Check the dishwashing machine for cleanliness at least once a day, cleaning it as necessary.Review of the facility's policy titled, Refrigerator/Freezer Temperatures, dated 2011, showed:- If the temperature is outside the acceptable temperature range for safe food handling, the refrigerator/freezer will be emptied and foodstuff transferred to another refrigerator/freezer or discarded with Dining Services Manager's approval.Review of the facility's policy titled, Instructions on Fundamentals of a Safe Food Service, dated 2011, showed:- Right temperatures, cold (under 40 degrees Fahrenheit ( F) stops bacteria from growing, heat (over 135 F) kills most bacteria, cold foods should be kept chilled, hot foods should be kept hot, foods should never be thawed on a counter or at room temperature.1. Observation on 05/17/26 at 12:23 P.M., of the kitchen showed:- Three unidentified dietary staff worked in food preparation areas without a hair restraint;- Dietary Aide (DA) S placed assorted deli style meats in storage bags without a hair restraint;- Seven approximately 10-pound plastic packages of pork loin thawed partially submerged in standing water in the three-compartment sink in the food prep area.During an interview on 05/17/26 at 12:25 P.M., DA S said the dietary workers were expected to follow the facility policy and should utilize hair nets. The other staff in the kitchen without hair restraints were part of the dietary department staff.During an interview on 05/17/26 at 12:29 P.M., the Dietary Supervisor said the frozen pork should have been placed in the walk-in refrigerator last night but wasn't done. It thawed today in the sink while the sink was plugged and filled with water. Staff did not leave the water running over the frozen food. The dietary workers should have worn hair restraints in the kitchen, and they were told to wear them.2. Observation on 05/17/26 at 12:27 P.M., and 05/19/26 at 2:23 P.M., of the kitchen showed:- The commercial dishwasher interior and exterior with flaky white grime (dirt ingrained on the surface of something) build-up;- The gas range with an oily grime build up and scattered food debris around each burner and on the floor beneath; - The ice machine with a white grime build-up on the exterior surfaces, ventilation louvers with a brown substance, a plastic drain line with black grime build-up, and scattered debris on the floor beneath;- One three quart dented can of spaghetti sauce, undated;- An approximate 5 foot (ft.) by 1 ft. section of ceramic flooring with white grime build-up below the three-compartment sink in the dishwashing area and the plastic drain pipes with a brown grime build up; - An approximate 2 ft. diameter section of damaged wallboard below the commercial dishwasher and a black grime build-up on the plastic drain pipes and floor below;- Two 4 inch (in.) x 4 in. ceramic tiles missing on the baseboard area wall sections in the dishwashing area near the exit door;- An approximate 4 ft. by 4 ft. section of the wall board peeled from the wall to the right of the dishwashing spray area near the corridor passageway;- Food debris and an oily film build-up on the floor beneath the range;- Three 2 ft. by 2 ft. ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers;- The commercial style can opener with a worn cutting edge, oily film, and a black grime build-up.2. Observation of the serving area meal preparation on 05/18/26 at 12:20 P.M., showed:- DA T loaded plates onto food trays without a proper restraint for facial hair;- DA U scooped food from the steam table onto plates without a hair restraint. 3. Observation on 05/19/26 at 2:23 P.M., of the serving area showed:- An eight-ounce single serving milk container, dated 05/31/26, from the right-side reach in refrigerator at 45 F;- Right side refrigerator at 58 F filled with one crate of single serving milk containers;- Room temperature at 83 F. Review of the facility's right side serving area Refrigeration/Freezer Temperature Log, dated May 2026, showed:- Evening refrigerator temperatures should range between 34 and 41 F. - Evening temperatures on 05/01/26 and 05/02/26 not recorded, 05/03/26 at 48 F, 05/04/26 at 48 F, 05/05/26 at 48 F, 05/06/26 at 38 F, 05/07/26 at 50 F, 05/08/26 at 46 F, 05/09/26 at 46 F, 05/10/26 at 40 F, 05/11/26 at 50 F, 05/12/26 at 50 F, 05/13/26 at 52 F, 05/14/26 at 48 F, 05/15/26 at 48 F, 05/16/26 at 50 F, 05/17/26 at 44 F, and 05/18/26 at 45 F.During an interview on 05/19/26 at 2:27 P.M., DA V said the serving area room was always hot and it was hard to keep the refrigerator cooled down. The refrigerator door was left open at times, the room was warm due to the air conditioning vents not working, and the steam table and plate warmer were used in the area and made the room warmer. During an interview on 05/20/26 at 3:03 P.M., the Administrator, Dietary Manager and Dietary Supervisor said the dietary staff should be wearing hair restraints when working in the kitchen. There should not be missing tiles, the ceiling vents and all appliances should be cleaned. There were issues with water leaks in the dishwashing area causing problems and wall damage, but the walls should be intact. The refrigerator did not stay cold enough near the steam table because the air conditioner was unplugged. There were plans to add a new electrical outlet so it could be used to keep the room temperature lower. The milk and the reach-in refrigerator should be kept colder, and frozen meat should not be thawed in standing water. During an interview on 05/20/26 at 4:00 P.M., the Maintenance Assistant said he/she knew there were some missing floor tiles in the kitchen, and they had been noticed during inspections. He/She wasn't aware of wall damage under the dishwasher, but the walls should be kept intact, and vents should be clean. During an interview on 05/20/26 at 4:33 P.M., the Maintenance Supervisor said the Dietary Manager had mentioned the dishwashing area having issues with the floor and wall, the walls and floor should be kept intact, but it was always wet in that area and there were some problems. There were plans to replace the sprayer gasket. There were some holes in the wall where ceramic tiles should be replaced. The ceiling vents should be cleaned routinely but they had some dirt and dust built up.

Based on interview and record review, the facility failed to demonstrate evidence of maintaining an ongoing effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. This had the potential to affect all residents residing in the facility. The facility's census was 147.Review of the facility's policy titled, QAPI Program, revised February 2020, showed:- This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents;- The objectives of the QAPI program are to provide a means to measure current and potential indicators for outcomes of care and quality of life, provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators, reinforce and build upon effective systems and processes related to the delivery of quality care and services, and establish systems through which to monitor and evaluate corrective actions;- The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program;- The governing board/owner evaluates the effectiveness of its QAPI program at least annually and presents findings to the QAPI committee;- The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements;- The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee;- The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed;- The committee meets monthly to review reports, evaluate data, and monitor QAPl-related activities and make adjustments to the plan;- The QAPI coordinator manages QAPI committee activities and changes to the QAPI plan;- The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan.Review of the facility's policy titled, QAPI Program - Design and Scope, revised August 2025, showed the facility QAPI program is ongoing, comprehensive, and addresses all care and services provided by the facility.Review of the facility's 2020 QAPI Plan, dated February 2020, showed:- Annual evaluation of the QAPI Plan by the administrator will ensure appropriate engagement of applicable QAPI practices;- The QAPI Committee will, on at least an annual basis, complete a plan to identify opportunities for improvement. The prioritization plan will consider factors such as high risk, high volume, problem prone areas that affect outcomes, and quality of care;- At a minimum, the executive leadership will report on the status of the current QAPI Plan, the proposed QAPI Plan, and goals for the coming year. This report will be made available to the corporate compliance committee, leadership, and staff;- No current QAPI Plan or goals.During an interview on 05/20/26 at 3:52 P.M., the Administrator said she hadn't updated the QAPI Plan annually, but she was trying to do better with the Performance Improvement Projects (PIPs). She had two open right now. The Medical Director wasn't usually at the quarterly meetings, but she would send him the meeting minutes after the meeting. Sometimes he would comment on it and sometimes not. During an interview on 05/20/26 at 6:08 P.M., the Administrator said she would expect the facility to have a current QAPI Plan.

Based on interview and record review, the facility failed to ensure two of three sampled Certified Nurse Aides (CNAs) received an annual performance review. The facility census was 147.Review of the facility's employee handbook, dated 12/08/23, showed:- Performance Improvement: The facility will make efforts to periodically review your work performance;- The performance improvement process will take place annually or as business needs dictate;- You may specifically request that your supervisor assist you in developing a performance improvement plan at any time.The facility did not provide a policy related to annual performance reviews.1. Review of CNA K's personnel file showed:- Hire date of 04/09/25;- No documentation of an annual performance review.2. Review of CNA L's personnel file showed:- Hire date of 05/08/25;- No documentation of an annual performance review.During an interview on 05/18/26 at 1:30 P.M., the Human Resources Director said the facility did not do performance reviews and if there was a write-up, then they would add those to their record.During an interview on 05/20/26 at 6:08 P.M., the Administrator and Director of Nursing (DON) said they would expect performance reviews for nurse aides to be completed at least once every 12 months. The DON also said they do performance education all year long.During an interview on 05/20/26 at 6:18 P.M., the DON said performance reviews had not been completed for CNA K or CNA L.

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for two residents (Residents #13 and Resident #83) out of two sampled residents. The facility failed to follow proper infection control practices during incontinent care for two residents (Residents #1 and #154) out of three sampled residents. The facility also failed to provide appropriate infection control measures during medication pass for three residents (Residents #11, #14, and #86) out of six sampled residents and glucometer (a machine used to check blood sugars) cleaning for two residents (Residents #11 and #86) out of three sampled residents who required glucose monitoring. The facility census was 147. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, showed: - EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents;- EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply;- Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: providing hygiene, changing briefs or assisting with toileting, device care or use (urinary catheter – a sterile tube inserted into the bladder to drain urine), and wound care. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: - Hand hygiene is indicated immediately before touching a resident, before performing an aseptic (environment that is free from contamination by harmful microorganisms such as bacteria, viruses and fungi) task, after contact with blood, body fluids or contaminated surfaces, after touching a resident or resident's environment, before moving from soiled body site to clean body site and immediately after glove removal; - Use an alcohol-based hand rub containing at least 60 percent alcohol for most clinical situations; - Wash hands with soap and water when hands are visibly soiled and after contact with resident with infectious diarrhea; - Single use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids, and when in contact with resident on contact precautions; - The use of gloves does not replace hand washing/hand hygiene. Review of the facility's policy titled, Perineal Care, revised February 2018, showed: - The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; - Steps in the Procedure: 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. Put on gloves. 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. 4. Fold the bedspread or blanket toward the foot of the bed. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 7. Put on gloves. 8. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly. Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, revised October 2011, showed: - Place the equipment on the bedside stand or overbed table, arrange the supplies so that they can be easily reached; - Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Single-resident use fingerstick devices (pen-like devices) should never be used by more than one resident; - Wear clean gloves; - Wash the selected fingertip, obtain a blood sample, place drop of blood on reagent strip (diagnostic tool made of a plastic or paper strip embedded with chemical pads), wipe fingertip with cotton ball, dispose of the lancet (tiny, sterile pricking device used to draw small blood samples) in the sharps container; - Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice; - Remove gloves and discard into designated container; - Wash hands. Review of the facility's policy titled, Administering Medications, revised April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed; - Staff follow established facility infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the Wipes Plus disinfecting wipes manufacturer's instructions, via www.wipesplus.com, revised 08/30/22, showed: - Use Wipes Plus disinfecting wipes to clean, sanitize, and disinfect commonly touched surfaces in one easy step. Kills 99.9% of bacteria and viruses, including the COVID 19 virus and cold and flu virus; - To disinfect - wipe surface and allow surface to remain wet for four minutes. 1. Observation on 05/18/26 at 6:15 P.M., of Resident #1's perineal care showed: - Nurse Aide (NA) D and Certified Nurse Aide (CNA) E entered the room and put on gloves without washing hands; - NA D placed two bags at the end of the bed and both staff pulled the resident up using bed pad. NA D raised the bed with controller; - NA D pulled the resident's pant bottoms down and CNA E removed the resident's brief; - NA D cleaned the resident's perineal area and placed soiled washcloth in bag; - With the same soiled gloves, the resident was rolled toward CNA E, NA D obtained a clean washcloth and cleaned fecal material from the resident's buttocks; - NA D removed gloves, did not wash hands, and left the room to get more washcloths. CNA E covered the resident with sheet while waiting; - NA D returned to room, placed washcloths under running water, and put gloves on without washing hands; - CNA E removed sheet, NA D cleaned the resident's buttocks and CNA E placed the soiled brief in a trash bag; - With the same soiled gloves, NA D placed a clean brief under the resident, straightened bed pad, adjusted brief, straightened pillows and raised head of bed with controller; - CNA E tied up bags and with the same soiled gloves, both staff pulled sheet and blanket over the resident and NA D placed call light on resident's blanket within reach; - NA D and CNA E touched clean supplies, clean linens, the bed controller, call light, and resident care items with contaminated gloves after contact with urine and/or fecal material; - Both staff removed gloves and left the room without washing or sanitizing hands. During an interview on 05/18/26 at 6:30 P.M., NA D and CNA E said they should have removed gloves and washed hands between dirty and clean care, and before touching the clean sheets, blanket, call light, and bed controller. NA D said he/she was allergic to the facility soap but could use the sanitizer. NA D thought he/she used sanitizer before leaving the room and when he/she entered after getting more washcloths. 2. Observation on 05/18/26 at 7:02 P.M., of Resident #83's urinary catheter care showed: - CNAs A and B did not put on a gown, performed hand hygiene, and put on gloves;- CNA B leaned over the resident without a protective barrier and touched the resident with his/her clothing to tuck the lift pad underneath the resident;- CNA B did not use disinfectant wash or soap to disinfect the catheter during cleaning;- CNA B used washcloths to clean fecal material from the resident's back peri area;- CNA B did not change gloves or perform hand hygiene before applying a clean brief;- CNAs A and B removed gloves and did not perform hand hygiene. During an interview on 05/20/26 at 3:15 P.M., CNA B said he/she just forgot to put a gown on when providing catheter care for Resident #83. Residents with wounds, catheters or any other opening were put on EBP. 3. Observation on 05/19/26 of the medication administration showed: - At 6:21 A.M., Certified Medication Technician (CMT) N did not perform hand hygiene prior to Resident #11's medication administration; - CMT N obtained medication from the cart, placed two tablets into a pill cup and administered the two tablets to Resident #11; - CMT N obtained two glucometers from the cart and laid them on top of the cart without a barrier; - CMT N, without performing hand hygiene, put on clean gloves and obtained a Wipes Plus disinfecting wipe from a container, wiped off both glucometers with the same wipe, did not wrap the glucometers so the surface remained wet for four minutes per the manufacturer's instructions, laid both glucometers back on the cart without a barrier, and removed gloves; - CMT N, without performing hand hygiene, put on clean gloves, obtained finger stick blood sugar (FSBS) and administered Resident #11's insulin; - CMT N obtained a disinfecting wipe, wiped off the glucometer, did not wrap the glucometer so the surface remained wet for four minutes per the manufacturer's instructions, and laid the glucometer back on the cart without a barrier; - CMT N used the same wipe on multiple glucometers, did not ensure the device remained visibly wet for the required four minute contact time, and returned the glucometer to service immediately after wiping. - CMT N did not perform hand hygiene after the medication administration; - At 7:00 A.M., CMT N did not perform hand hygiene prior to Resident #86's medication administration; - CMT N obtained 10 medications from the cart, placed them in a pill cup, obtained an inhaler from the cart, and administered the medications and inhaler to Resident #86; - CMT N, without performing hand hygiene, put on clean gloves, obtained a glucometer from the top of the cart, obtained a FSBS on Resident #86, removed gloves and washed hands; - CMT N obtained a disinfecting wipe, wiped off the glucometer, did not wrap the glucometer so the surface remained wet for four minutes per the manufacturer's instructions, lay the glucometer back on the cart without a barrier and did not perform hand hygiene; - At 7:01 A.M., CMT N did not perform hand hygiene prior to Resident #14's medication administration; - CMT N obtained 10 medications from the cart, placed them in a pill cup and administered the medications to Resident #14; - CMT N did not perform hand hygiene after the medication administration. During an interview on 05/19/26 at 7:15 A.M., CMT N said he/she should wash or sanitize his/her hands prior to and after medication administration. Glucometers should be disinfected per the Wipes Plus disinfecting wipes instructions. 4. Observation on 05/19/26 at 6:31 A.M., of Resident #154's peri care showed: - CNA G washed his/her hands in the resident's restroom, left the room to get a basin and washcloths, filled the basin with water, placed it on the resident's bedside table, lay a trash bag on the floor, and without performing hand hygiene, put on clean gloves; - NA H, without performing hand hygiene, pulled gloves from his/her pocket and put them on after moving the resident's wheelchair from between the resident's bed and wall; - CNA G cleaned the resident's front peri area with a washcloth and placed in a trash bag on the floor; - With the same soiled gloves, CNA G turned the resident toward himself/herself and, touched the resident's back, held the resident in place as NA H wiped fecal material from the resident's buttocks, then NA H removed gloves; - CNA G told NA H that he/she needed to wash his/her hands. NA H threw gloves in trash and washed hands in the resident's restroom; - CNA G removed gloves, left the room to retrieve a box of gloves and, without performing hand hygiene, put on clean gloves, then NA H put on clean gloves; - NA H put a new bed pad on the bed, rolling it under the dirty pads. Both CNA G and NA H rolled the resident toward NA H as CNA G pulled the dirty bed pads out and placed them in the trash bag on the floor and rolled the clean bed pad out under the resident; - With the same soiled gloves, CNA G obtained a clean washcloth from the basin and washed the resident's buttocks again; - Both staff removed gloves and left the room, with CNA G carrying the bag of dirty linens to the cart in hall. During an interview on 05/19/26 at 6:51 A.M., NA H said he/she did not wash his/her hands prior to starting, but he/she should wash before, between dirty and clean care, and after care. CNA G agreed and said he/she should not have cleaned the resident and then touched the resident with the same dirty gloves. 5. Observation on 05/19/26 at 8:00 A.M., of Resident #13's gastrostomy tube (g-tube – a tube surgically inserted into the stomach to provide hydration, nutrition, and medications) medication administration showed: - EBP signage on the resident's door; - Licensed Practical Nurse (LPN) M entered the resident's room and washed his/her hands, then exited the room; - LPN M obtained a medication tablet from the medication cart, placed it into a plastic sleeve, crushed the medication in the sleeve, placed his/her bare finger into the plastic sleeve to open it and dumped the medication into a small plastic cup; - LPN M entered the resident's room, did not put on a gown for EBP, washed hands, put on clean gloves, and filled the plastic cup containing the medication with water; - LPN M filled a graduated cylinder (container used to measure liquid) with 550 milliliters (ml) of water and placed it, along with the plastic cup containing the medication, on the bedside table, - LPN M obtained a syringe from the package, connected it to the g-tube, removed the plunger from the syringe and administered the crushed medication mixed with water to gravity flow; - LPN M flushed the g-tube with 550 ml of water to gravity flow and closed the g-tube stopper; - LPN M removed gloves and washed his/her hands; - LPN M poured the enteral feeding into the bag, primed the tubing and connected the tubing to the resident's g-tube, started the feeding tube pump and washed hands. During an interview on 05/19/26 at 8:15 A.M., LPN M said he/she should wear a gown and gloves for EBP. During an interview on 05/20/26 at 6:08 P.M., the Administrator and Director of Nursing (DON) said they would expect staff to wash/sanitize their hands prior to and after medication administration, for glucometers to be cleaned/sanitized per manufacturer's directions and for staff to wear a gown and gloves if needed for g-tube medication.

Based on interview and record review, the facility failed to ensure communication forms that reflected ongoing coordination and collaboration between facility staff and the dialysis (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed) staff were sent with two residents (Residents #11 and #62) out of two sampled dialysis residents on all dialysis days and failed to ensure one resident (Resident #11) had an order for dialysis. The facility's census was 147. Review of the facility's policy titled, Dialysis, dated 03/25/20, showed: - Effective immediately: Anyone going to dialysis will bring a dialysis communication form with them that has the most recent vital signs or order changes for the patient on it as well as any concerns you may have; - The sheet is to come back with the patient after dialysis, and it should have any concerns or instructions from the dialysis center; - Please remember to send this each time the patient goes to dialysis. Check it upon return for any orders or concerns and place on the patient's chart; - Any patient on dialysis must have a dialysis order and treatment orders to check shunt (a small surgically implanted tube that diverts the flow of blood from one part of the body to another) or ports (a surgically created site that allows blood to be removed from the body). 1. Review of Resident #11's medical record showed: - admission date of 10/21/25; - Diagnoses of end stage renal disease (ESRD – the final, permanent stage of chronic kidney disease), muscle weakness, and dependence on renal dialysis. Review of the resident's Physician Order Sheet (POS), dated 05/20/26, showed: - An order to send Velphoro (a phosphate binder) 500 milligrams (mg) with the resident to dialysis on dialysis days in the morning every Monday, Wednesday, and Friday for phosphorus binder, dated 01/22/26; - No other orders related to dialysis. Review of the resident's care plan, revised 12/04/25, showed: - Dependence on renal dialysis related to renal failure; - Receiving dialysis three times weekly on Monday, Wednesday, and Friday; - Check and change dressing daily at dialysis access site; - Monitor the resident's vital signs as ordered by a physician or per facility policy; - Monitor/Assess for signs and symptoms of infection, renal insufficiency, steal syndrome (complication where an arteriovenous (AV) fistula or graft steals blood away from the hand), edema (swelling), bruit (whooshing) and thrill (vibration). Review of the resident's progress notes showed: - On 01/26/26, dialysis was canceled; - On 02/09/26, the resident did not go to dialysis. Review of the resident's Dialysis Communication Forms, dated 01/01/26 through 05/20/26, showed forms not completed for a total of 56 out of 58 opportunities. During an interview on 05/20/26 at 1:10 P.M., Resident #11 said no one checked his/her shunt. When he/she got back from dialysis, staff didn't do anything. They just let him/her sleep. He/She sometimes got a communication form when going to dialysis. During an interview on 05/20/26 at 2:52 P.M., Licensed Practical Nurse (LPN) F said he/she did not do the dialysis communication form for Resident #11 this morning because he/she was late, but they should complete them and send them to dialysis with the residents. 2. Review of Resident #62's medical record showed: - admission date of 03/06/26; - Diagnoses of ESRD, granulomatosis with polyangiitis (a rare autoimmune disease that caused inflammation of the blood vessels, forming inflamed tissue masses) with kidney involvement, and dependence on renal dialysis. Review of the resident's POS, dated 05/20/26, showed: - Attends dialysis on Tuesday, Thursday and Saturday, assure breakfast prior to leaving; - Monitor signs and symptoms of steal syndrome every shift, report signs and symptoms to dialysis unit or physician; - Assess, monitor and report concerns to primary care physician (PCP) and dialysis center such as bruit, thrill, collateral vein distention (vein in access arm becoming larger), bruising, hematoma (collection of clotted blood that pools outside of a blood vessel), significant changes when compared to opposite extremity, every shift; - No blood pressure taken in the right arm; - Nurse to fill out the dialysis communication form and send to dialysis with the resident. Review of the resident's care plan, revised 03/06/26, showed: - Assess and monitor before and after dialysis treatments; - Assess for bruit and thrill at access site; - Resident prefers to eat meals at facility before and after dialysis treatments; - Monitor for signs and symptoms of infection; - Monitor for signs and symptoms of steal syndrome; - No blood pressure to limb with access site; - Monitor weight daily. Review of the resident's progress notes showed no documentation of dialysis refusal. Review of the resident's Dialysis Communication Forms, dated 03/09/26 through 05/19/26, showed forms not completed for a total of 13 out of 32 opportunities. During an interview on 05/20/26 at 2:45 P.M., Registered Nurse (RN) I said the resident received breakfast before he/she left and a sack lunch; however, the resident normally would just eat here when he/she returned, about 11:45 A.M. RN I was not sure why the forms had not been filled out completely and why there were some missing. During an interview on 05/20/26 at 6:08 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect dialysis communication forms to be filled out completely and on every dialysis day and for a resident who received dialysis to have orders for dialysis.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and failed to provide a copy of the bed-hold policy with the daily rate amount upon transfer to the hospital for six residents (Residents #1, #2, #4, #11, #114, and #123) out of 29 sampled residents. The facility's census was 147. Review of the facility's policy titled, Bed Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours); - The written bed-hold notices provided to the residents/representatives explain in detail: the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed hold period (for Medicaid residents}; and the facility return policy. Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, revised October 2022, showed: - The resident and representative are notified in writing of the following information: The specific reason for the transfer or discharge, including the basis under 483.lS(c)(l)(i}(A}-(F}; the effective date of the transfer or discharge; the specific location (such as the name of the new provider or description and/or address of the location) to which the resident is being transferred or discharged ; an explanation of the resident's rights to appeal the transfer or discharge to the state, including the name, address, email and telephone number of the entity which receives such appeal hearing requests; information about how to obtain an appeal form; and how to get assistance in completing and submitting the appeal hearing request; the Notice of Facility Bed-Hold and policies; the name, address, and telephone number of the Office of the State Long-term Care Ombudsman; the name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); the name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and the name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices; - Notice of Transfer or Discharge (Emergent or Therapeutic Leave): When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the resident's return is generally expected; - Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; the resident's health improves sufficiently to allow a more immediate transfer or discharge; an immediate transfer or discharge is required by the resident's urgent medical needs; or a resident has not resided in the facility for 30 days; - Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable; - Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 1. Review of Resident #1's medical record showed:- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];- No documentation the written notification of the transfer or a copy of the bed-hold policy, including the daily rate amount, was provided to the resident and/or the resident's representative at the time of the transfer. 2. Review of Resident #2's medical record showed:- The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident was transferred to the hospital on [DATE], and returned to the facility on [DATE];- No documentation the written notification of the transfer or a copy of the bed-hold policy, including the daily rate amount, was provided to the resident and/or the resident's representative at the time of the transfer. 3. Review of Resident #4's medical record showed:- The resident transferred to the hospital on [DATE], and returned to the facility the same day;- No documentation the written notification of the transfer or a copy of the bed-hold policy, including the daily rate amount, was provided to the resident and/or the resident's representative at the time of the transfer. 4. Review of Resident #11's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility the same day; - No documentation the written notification of the transfer or a copy of the bed-hold policy, including the daily rate amount, was provided to the resident and/or the resident's representative at the time of the transfer; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on the same day; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility the same day; - The resident transferred to the hospital on [DATE], and returned to the facility the same day; - No documentation of the daily rate amount on the bed hold policies; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the written notification of the transfer or a copy of the bed-hold policy, including the daily rate amount, was provided to the resident and/or the resident's representative at the time of the transfer. 5. Review of Resident #114's medical record showed:- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];- No documentation the written notification of the transfer or a copy of the bed-hold policy, including the daily rate amount, was provided to the resident and/or the resident's representative at the time of the transfer. 6. Review of Resident #123's medical record showed:- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];- No documentation the written notification of the transfer or a copy of the bed-hold policy, including the daily rate amount, was provided to the resident and/or the resident's representative at the time of the transfer. During an interview on 05/20/26 at 3:00 P.M., the Director of Nursing (DON) said staff were supposed to do a progress note when someone went out to the hospital. They notified the family and gave the bed-hold policy. They sent it to the family or personal representative (PR) if the resident couldn't understand. They did a discharge assessment form. They printed two copies of the discharge record to send with Emergency Medical Services (EMS) and to give to the hospital. They should do the transfer/discharge notice for everyone who went out, even if it was just to the ER and they would likely come back soon. In looking at Resident #11's chart, it looked like some were missed. During an interview on 05/20/26 at 6:08 P.M., the Administrator, DON, Assistant Director of Nursing, and Social Services Director said they would expect written notification of transfers to be completed with transfers and discharges, including ER visits, and the bed-hold rate amount to be included. It would be the private pay rate, but it was not included on the bed-hold policy. The rate was included on the admission paperwork.

Based on observation, interview, and record review, the facility failed to ensure treatment decisions, including hospice election and code status decisions, were made by the resident or a legally authorized representative. This failure affected one resident (Resident #7) out of 29 sampled residents. The facility census was 147.Review of the facility policy titled, Advanced Directives, revised September 2022, showed:- The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment, advanced directives are honored in accordance with state law and facility policy;- Prior to or upon admission of a resident, the social services director (SSD), or designee inquires of the resident, his/her family members, and/or his or her legal representative about the existence of any written, advanced directives; - If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced directive, the information may be provided to the resident's legal representative; - Upon admission, the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision making capacity; - The interdisciplinary team conducts ongoing review of the resident's decision-making capacity, and invokes the resident's representative or healthcare agent if the resident is determined not to have decision-making capacity, changes are documented in the care plan and medical record;- The plan of care for each resident is consistent with his or her documented treatment, preferences, and/or advanced directive. Review of Resident #7's medical record showed:- admission date of 03/12/20;- Diagnoses of moderate protein calorie malnutrition (inadequate intake or malabsorption of protein and calories), high blood pressure, mood affective disorder (a mental health condition that primarily disrupts emotional state), Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), major depressive disorder (a severe mental health condition characterized by a persistent, overwhelming low mood, sadness, and a complete loss of interest in activities), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and dementia with mood disturbance (emotional, psychological, and personality changes that commonly occur alongside a decline in memory and thinking skills). Review of the resident's care plan, revised 05/18/26, showed:- The resident has no contact with family or has no family involvement, initiated 12/13/21;- Impaired cognitive function/dementia, impaired thought processes, disorganized thinking, inattention, and delusions related to dementia, initiated 04/28/20;- Resident has a psychosocial well-being problem and has no contact with family and there are no family members on file, has one friend down as a contact but has very little contact with this individual related to no family involvement, lack of family, initiated 12/13/21;- Resident receives hospice care related to stage four lung cancer, initiated 04/30/26;- Resident would like his/her code status to remain a full code, initiated on 11/02/21, and revised on 03/26/25. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), showed:- admission MDS, dated [DATE], resident had a severely impaired cognition;- Significant change MDS, dated [DATE], resident had a severely impaired cognition. Review of the resident's Emergency Healthcare Directive, signed on 07/09/25, showed the resident gave a verbal response to remain a full code. Review of the Hospice Informed Consent Electing Hospice Care, dated 04/30/26, showed the form was signed by the Administrator. Review of the Do Not Resuscitate (DNR) request, dated 04/30/26, showed the form signed by the Administrator. Review of a Notarized Written Deposition, dated 11/20/25, showed the resident's physician indicated in the best interest of this person that a guardian be appointed to protect his/her person, and/or a conservator be appointed to manage his/her property. Observation of the resident on 05/17/26 at 2:46 P.M., showed the resident lay in bed with eyes opened and did not respond when spoken to.During an interview on 05/19/26 at 12:50 P.M., the SSD said the prior SSD instructed the staff to obtain a written deposition to appoint a guardian for the resident. After this was completed, the staff found out the facility would have to pay for it and so this was not followed through with. During an interview on 05/19/26 at 1:45 P.M., the Administrator said she did not usually act as a resident's representative, in this case, after discussing the resident's condition with the resident's physician, the hospital, and the interdisciplinary team, she acted as the resident's representative by signing the code status form and the hospice form. She said corporate told her residents with a Brief Interview for Mental Status (BIMS, 13-15: no or very little cognitive impairment, 8-12: moderate cognitive impairment, and 0-7: severe cognitive impairment) score of less than 13 needed a Power of Attorney or a guardianship but she felt a resident had no rights after being assigned a guardian. During an interview on 05/20/26 at 2:35 P.M., Registered Nurse (RN) I said the resident could feed self and talk previously but could not recall a time when the resident was orientated but did feel the resident could understand things depending on the situation in the past. RN I said the resident only had a friend listed as a contact and he/she had previously expressed he/she did not feel comfortable making decisions on the resident's behalf. During an interview on 05/20/26 at 4:22 P.M., the Assistant Director of Nursing (ADON) said residents with severely impaired cognition should not sign consent forms. The responsible party should be contacted, if the resident did not have a next responsible party, then the hope would be that a guardian or another person would be assigned to make decisions for the resident. During an interview on 05/20/26 at 4:24 P.M., the Director of Nursing (DON) said when the resident was discharged from the hospital, the hospital ethics committee told the Administrator she could sign for the hospice care, and the resident left the hospital with an order for hospice. During a phone interview on 06/02/26 2:35 P.M., the resident's Physician P said the resident did meet the qualifications for hospice, would have to look more into the specifics of this situation to say for sure but would typically expect the resident, their guardian, or their Power of Attorney to sign documents on the resident's behalf, and was not aware the guardianship was not followed through.During a phone interview on 06/02/26 3:33 P.M., the hospice Office Administrator said when the Do Not Resuscitate request came into the office, he/she had an available physician sign the document and neither physician would necessarily know who signed as the resident's representative as these documents came to the office already signed.During a phone interview on 06/03/26 at 7:48 A.M., the Patient Safety and Quality Specialist for the hospital said they did not say the Facility Administrator could sign on the resident's behalf, they were told by the facility that they would use a two-physician authorization.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for three residents (Residents #52, #96, and #154) out of 29 sampled residents with side rails. The facility's census was 147. Review of the facility's policy titled, Bed Safety and Bed Rail, revised September 2025, showed: - The resident's sleeping environment is evaluated by the interdisciplinary team; - Consideration is given to the resident's safety. Medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; - Bed frames, mattresses, and bed rails are checked for compatibility and size prior to use; - Bed dimensions are appropriate for the resident's size; - Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail, and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within safety dimensions established by the Food and Drug Administration (FDA - a federal public health agency that promotes public health by ensuring safety, efficacy, and security of human, veterinary drugs, biological products, medical devices and the nation's food supply); - Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks; - The maintenance department provides a copy of inspections to the Administrator and reports results to the Quality Assurance Performance Improvement (QAPI) committee for appropriate action; - Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer's specifications; - Bed rails are properly installed and used according to the manufacturer's instructions, specifications, and other pertinent safety guidance to ensure proper fit; - Additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment; - The facility's education and training activities will include instruction about risk factors for resident injury due to beds and strategies for reducing risk factors for injury, including entrapment. 1. Review of Resident #52's medical record showed:- An order for quarter upper side rail bilateral (both sides) for repositioning and transfers, dated 11/14/25;- A side rail consent, signed 03/25/26;- Bed Rail Measurement assessment, completed 03/25/26;- Side Rail Resident assessment, completed 03/25/26;- Side rail use addressed on the care plan, revised 03/25/25. Observation on 05/17/26 at 3:26 P.M., showed the resident used the right side rail to assist himself/herself to stand and the rail moved with minimal effort from the resident. During an interview on 05/17/26 at 3:26 P.M., the resident said he/she used the side rails on the bed to help with transfers from the bed and from the chair. The resident said the right rail had been loose for a while. The resident said he/she couldn't remember if any staff were notified that the rail was loose. 2. Review of Resident #96's medical record showed:- An order for one quarter, right, upper side rail for repositioning and transfers, dated 07/14/25;- A side rail consent, signed 04/09/26;- Bed Rail Measurement assessment, completed 04/09/26;- Side Rail Resident assessment, completed 04/16/26;- Side rail use addressed on the care plan, revised 05/06/26. Observations showed: - On 05/17/26 at 3:15 P.M., the resident lay in bed with his/her eyes closed and the one quarter rail up on right side of the bed; - On 05/19/26 at 2:50 P.M., the one quarter rail was up on the right side of the bed while the resident was out of the room. The rail was able to be moved with minimal effort. 3. Review of Resident #154's medical record showed:- An order for one quarter upper side rail bilateral for repositioning and transfers, dated 04/27/2026;- A side rail consent, signed 01/26/26;- Bed Rail Measurement assessment, completed 02/26/26;- Side Rail Resident assessment, completed 04/27/26;- Side rails addressed on the care plan, revised 03/20/26. Observation on 05/19/26 at 6:31 A.M., showed the resident turned toward Certified Nurse Aide (CNA) G during peri-care and grabbed the bed rail. The bed rail moved with minimal effort and tilted in toward the bed as the resident held it. During an interview on 05/20/26 at 10:45 A.M., the resident said the right side rail was broken. He/She didn't know when the staff came around to check the side rails. He/She used the bed rails to help turn over in bed and when staff changed him/her. During an interview on 05/20/26 at 9:20 A.M., the Maintenance Supervisor said the Quality Assurance (QA) Nurse and the Housekeeping Supervisor did the side rail assessments. They checked for the correct size, fit, and tightened the side rails. During an interview on 05/20/26 at 9:22 A.M., the Housekeeping Supervisor said the QA Nurse will see if bed rails were a good fit for the resident and would give him/her a work order. He/She would then put rails on and tighten them. He/She said they were tightened twice a month. During an interview on 05/20/26 at 9:25 A.M., the QA Nurse said he/she would write work orders for side rails and assess them for tightness when the checks were completed, which were every three months. Staff were not allowed to put on or take off bed rails. He/She would assess for those who need it and, if they were no longer needed, the rails were taken off. Some bed rails didn't fit very well. If they were found to be loose, then a work order would be put in, and they would get tightened, but some seemed to get loose again. During an interview on 05/20/26 at 6:08 P.M., the Administrator, Director of Nursing, Assistant Director of Nursing, and the Social Service Director said they would expect bed rails to be tight and secure. Maintenance or Housekeeping would tighten the rails after staff filled out a maintenance request.

Based on observation, interview, and record review, the facility failed to obtain urinary catheter (a sterile tube inserted into the bladder to drain urine) orders for one resident (Resident #15) out of three sampled residents with a urinary catheter and failed to follow physician's orders for one resident (Resident #13) out of 29 sampled residents. The facility census was 147. Review of the facility policy titled, Catheter Care, Urinary, revised August 2022, showed: - Empty the collection bag at least every eight hours; - Review and document the clinical indications for catheter use prior to inserting; - Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place; - Remove the catheter as soon as it is no longer needed. The facility did not provide a policy regarding gastrostomy tube (G-tube - a thin flexible tube surgically inserted through the abdomen into the stomach to provide fluids, nutrition and medications) orders. 1. Review of Resident #13's medical record showed: - admission date of 02/13/20; - Diagnoses of multiple sclerosis (MS - a chronic autoimmune disease of the central nervous system), gastrostomy status, protein calorie malnutrition (an inadequate intake of protein and calories for the body's needs) and dysphagia (difficulty swallowing). Review of the resident's physician order sheet (POS), dated 05/19/26, showed: - An order for nothing per mouth (NPO) diet, dated 08/31/25; - An order to check the G-tube placement four times a day prior to use by aspiration (medical procedure of removing fluids by suction), tube length 32 centimeters (cm) from stomach, or checking potential of hydrogen (pH - a measurement that indicates how acidic or basic a substance is) of gastric contents, dated 09/01/25; - An order for Baclofen (muscle relaxant) 10 milligrams (mg), one tablet crushed per G-tube three times a day, dated 02/14/26; - An order for Jevity (a brand of medical liquid nutrition) 1.5, 300 cubic centimeters (cc) at 110-150 milliliters (ml) per hour, three times a day as resident tolerates, hold for residual (volume of fluid and formula remaining in the stomach) greater than 150 ml, three times a day per G-tube, dated 04/22/26; - An order for 550 ml water flush four times a day per G-tube, dated 04/22/26. Observation on 05/19/26 at 8:00 A.M., showed Licensed Practical Nurse (LPN) M did not obtain gastric contents during aspiration, did not measure the tube length, and did not check the pH level prior to administering Baclofen or before administering a 550 ml water flush or enteral (placed directly into the gastrointestinal (GI) tract) feeding. During an interview on 05/19/26 at 8:15 A.M., LPN M said if there was no residual and no gastric contents obtained with aspiration, he/she should check the G-tube placement by using a stethoscope (a medical device used to listen to internal sounds within the body). During an interview on 05/20/26 at 6:08 P.M., the Director of Nursing (DON) said she would expect staff to check placement of a G-tube before medication administration, especially if no gastric contents were aspirated. The facility just received litmus paper (specialized filter paper treated with a natural dye that acts as a pH indicator) and just recently educated staff on the need to check G-tube placement prior to using it. 2. Review of Resident #15's medical record showed: - admission date of 04/23/26; - Diagnoses of left tibia (larger, stronger, and inner bone of the lower leg) fracture, right tibia fracture, left fibula (long, slender bone located on the outer side of the lower leg) fracture, right fibula fracture, muscle weakness, cognitive communication deficit, history of falling, and stroke; - No order for a urinary catheter; - No order for urinary catheter care. Review of the resident's care plan, revised 04/30/26, showed the resident had an indwelling urinary catheter. Observation of the resident on 05/17/26 at 2:17 P.M., showed the resident lay in bed with a urinary drainage bag hanging on the side of the bed in a dignity bag. During an interview on 05/17/26 at 2:18 P.M., the resident's representative said the resident came from the hospital with the catheter and believed he/she had it because he/she couldn't get out of bed. During an interview on 05/20/26 at 2:35 P.M., Registered Nurse (RN) I said residents with urinary catheters should have an order for the catheter with the diagnosis for the catheter, and an order for catheter care. If no order was available, the physician would be contacted and either the catheter would be discontinued, or an order and diagnosis would be obtained. During an interview on 05/20/26 at 3:30 P.M., the Director of Nursing (DON) said residents with catheters should have an order for the catheter and catheter care. During an interview on 05/20/26 at 6:08 P.M., the Administrator said residents with catheters should have an order for the catheter.

Based on observation, interview, and record review, the facility failed to include the actual hours, and total hours worked per shift for licensed and unlicensed staff responsible for resident care and failed to include the daily census for four of the four observed days. The facility census was 147.Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, showed:- Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents;- Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following:a. The name of the facility;b. The current date;c. The resident census for the beginning of the shift for which the information is posted;d. Twenty-four-hour shift schedule operated by the facility;e. The shift for which the information is posted;f. Type (Registered Nurse (RN), Licensed Vocational Nurse (LVN), Certified Nurse Aide (CNA)) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff);g. The actual time worked during that shift for each category and type of nursing staff and;h. Total number of licensed and non-licensed nursing staff working for the posted shift.Observations of the staffing sheet taped to the window between the 500 and 600 Halls showed:- On 05/17/26 at 4:37 P.M., 05/18/26 at 3:00 P.M., 05/19/26 at 7:30 A.M., and 05/20/26 at 8:45 A.M., staffing data posted did not include actual and total hours worked per shift for licensed and unlicensed staff or the census.During an interview on 05/20/26 at 8:50 A.M., Employee J said he/she made and posted the daily staffing data sheets, and they should probably have the total and actual hours worked per shift for licensed and unlicensed staff and they should include the daily census. He/She was told in the past that there was no need to include the actual and total hours worked.During an interview on 05/20/26 at 6:08 P.M., the Administrator and Director of Nursing (DON) said they would expect the daily staffing data posting to include the total and actual hours worked per shift for licensed and unlicensed staff and for the posting to include the census.

Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for four residents (Resident #18, #34, #44, and #53) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy titled, Bed Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. Review of Resident #18's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 07/09/24; - The resident transferred to the hospital on [DATE] and returned to the facility 08/13/24; - The resident transferred to the hospital on [DATE] and returned to the facility 09/24/24; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #34's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/23/24; - The resident transferred to the hospital on [DATE] and returned to the facility 10/25/24; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 3. Review of Resident #44's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 4. Review of Resident #53's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 08/05/24; - The resident transferred to the hospital on [DATE] and returned to the facility 12/31/24; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 02/13/25 at 1:42 P.M., the Social Services Designee said the floor nurses send out the bed hold policies upon resident discharge, and then the bed holds are scanned into the system. During an interview on 02/13/25 at 1:50 P.M., Registered Nurse (RN) C said the nurse that sends a resident out is responsible for sending the face sheet, medication list, code status, Durable Power of Attorney (DPOA-legal document that allows someone to make decisions for another person), bed hold policy, and Situation/Background/Assessment/Recommendation (SBAR-a structured way to send information between people). During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing collectively said they would expect residents and/or resident's representatives to be made aware of bed holds in writing.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #41 and #131) out of 28 sampled residents and two residents (Resident #40 and #138) outside the sample. The facility's census was 139. The facility did not provide a policy regarding MDS accuracy. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section J1400 should be coded yes if the resident is receiving hospice services; - Section N0300 should state the number of days during the 7-day look-back period that any type of injection was received; - Section N0350A should state the number of days during the 7-day look-back period that insulin injections were received. 1. Review of Resident #40's medical record showed: - An admitted [DATE]; - Diagnoses of type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being), and hypertension (a condition where the blood pressure in the arteries is consistently elevated above normal levels); - An order for Humalog Injection Solution (an insulin used to lower blood sugar) 100 units per milliliter (ml), inject eight units subcutaneously (beneath the skin) one time only, dated for 12/31/24 and completed on 12/31/24; - An order for Ozempic Subcutaneous Solution (anti-diabetic medication used for the treatment of type 2 diabetes) two milligrams (mg) per three ml, inject 0.25 mg subcutaneously every Friday, dated 01/10/25, discontinued 01/16/25; - Medication Administration Record (MAR), dated January 2025, showed the resident received an injection of Ozempic on 01/10/25 and did not receive insulin in the seven day look back period; - A quarterly MDS assessment, dated 01/14/25, with Section N0350A coded as receiving one injection of insulin in the seven day look back period. 2. Review of Resident #41's medical record showed: - An admitted [DATE]; - Diagnoses of obstructive sleep apnea (a sleep disorder that occurs when your upper airway becomes blocked during sleep), shortness of breath, respiratory failure (a condition making it difficult to breathe on your own), chronic kidney disease (kidneys do not filter waste and fluid like they should), heart failure (the heart does not pump blood as well as it should), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and COPD; - An order for Ozempic Subcutaneous Solution Pen-injector two mg per three ml. Inject 0.5 mg subcutaneously one time a day every Thursday, dated 10/09/24; - MAR, dated December 2024, showed the resident received an injection of Ozempic on 12/12/24 and did not receive insulin in the seven day look back period; - A significant change MDS assessment, dated 12/13/24, showed Section N0350A coded as receiving one injection of insulin in the seven day look back period. 3. Review of Resident #131's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and altered mental status; - An order for Haloperidol Lactate Injection Solution (antipsychotic medication) five milligrams (mg) per milliliter (ml), inject 10 mg intramuscularly every eight hours as needed for agitation and aggression for 14 days. Alternate with Ativan (anxiety medication) two mg intramuscularly every eight hours as needed, dated 10/09/24 and discontinued 10/23/24; - MAR, dated October 2024, with Haldol 10 mg intramuscularly administered on 10/15/24 and 10/17/24; - An admission MDS assessment, dated 10/18/24, showed Section N0300 marked zero for injections received in the seven day look-back period. 4. Review of Resident #138's medical record showed: - An admitted [DATE]; - Diagnoses of COPD, dementia, and muscle weakness; - admitted to hospice on 12/20/24; - A significant change MDS assessment, dated 12/23/24, with Section J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? marked no. During an interview on 02/20/25 at 8:17 A.M., the MDS Coordinator said he/she would expect the MDS to accurately reflect the residents' condition at the time of the assessment. During an interview on 02/13/2025 at 2:18 P.M., the Administrator, DON, and ADON said they would expect the MDS assessments to accurately reflect the current condition of the resident. 47678 49999

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #31, #41, #55 and #111) out of 28 sampled residents. The facility's census was 139. Review of the facility's Comprehensive Person-Centered Care Plan Policy, last revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan includes measurable objectives and time frames, describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being; - When possible, interventions address the underlying sources of the problems, not just symptoms or triggers; - Assessment of residents are on-going and care plans are revised as information about residents and residents' conditions change; - The IDT reviews and updates the care plans when there has been a significant change, when desired outcome has not been met, when resident has been readmitted from a hospital stay and at least quarterly. 1. Review of Resident #31's medical record showed: - admitted [DATE]; - Diagnoses of paraplegia (inability to voluntarily move lower parts of the body), rheumatoid arthritis (a chronic inflammation affecting small joints in hands and feet), morbid obesity, muscle weakness and lack of coordination; - Bed assessment and consent, dated 01/18/24; - Side rail assessment, dated 07/18/24; - Physician's Order Sheet (POS), dated February 2025, with an order for one quarter (1/4) upper side rails, bilaterally, for mobility. Observations of Resident #31 showed: - On 02/10/25 at 1:00 P.M., Resident #31 resting in bed with quarter rails up on both sides; - On 02/11/25 at 12:21 P.M., Resident #31 resting in bed with quarter rails up on both sides; - On 02/13/25 at 9:30 A.M., Resident #31 resting in bed with quarter rails up on both sides. During an interview on 02/11/25 at 12:21 P.M., Resident #31 said he/she uses the side rails to grab onto during care and mobility. Review of Resident #31's care plan, last revised 01/08/25, did not address side rails. 2. Review of Resident #41's medical record showed: - admitted [DATE]; - Diagnoses of obstructive sleep apnea (a sleep disorder that occurs when the upper airway becomes blocked during sleep), shortness of breath, respiratory failure (a condition making it difficult to breathe on your own), chronic kidney disease (kidneys do not filter waste and fluid like they should), heart failure (the heart does not pump blood as well as it should), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems); - An order for BIPAP at bedtime, dated 10/02/24. Review of the resident's significant change MDS assessment, dated 12/13/24, showed: - Oxygen therapy in Section O (O0100C) coded as being in use in the seven-day look back period; - Non invasive mechanical ventilator (BIPAP) in Section O (O0100C) coded as being in use in the seven-day look back period. Observations of the resident showed: - On 02/10/25 at 12:46 P.M., the resident sat in a recliner with oxygen via nasal cannula (NC - a flexible tube inserted into the nose to administer supplemental oxygen) at 3.5 liters per minute (LPM), and a BIPAP at bedside; - On 02/11/25 at 9:28 A.M., the resident lay in bed with oxygen via NC at 3.5 LPM; - On 02/12/25 at 12:36 P.M., the resident lay in bed with oxygen via NC at 3.5 LPM. During an interview on 02/10/25 at 12:47 P.M., the resident said he/she always uses oxygen and has for quite some time and wears a BIPAP at bedtime. Review of the resident's care plan, last revised 02/10/25, showed it did not address use of BIPAP or oxygen. 3. Review of Resident #55's medical record showed: - admitted [DATE]; - Diagnoses of shortness of breath, COPD, and atrial fibrillation (abnormal heart beat); - An order for oxygen at two liters per minute via nasal cannula as needed, dated 07/29/24. Review of the resident's quarterly MDS assessment, dated 02/05/25, showed Section O (O0100C) coded as oxygen therapy being used in the seven-day look back period. Observations of the resident showed: - On 02/11/25 at 08:24 A.M., the resident sat in a recliner with oxygen via NC at 2LPM; - On 02/12/25 at 12:37 P.M., the resident sat in a recliner with oxygen via NC at 2LPM. During an interview on 02/12/25 at 12:38 P.M., the resident said he/she wears oxygen all the time. Review of the resident's care plan, last revised 02/07/25, did not address the use of oxygen. 4. Review of Resident #111's medical record showed: - admitted [DATE]; - Diagnoses of COPD, Type II diabetes, heart failure, urinary tract infection (UTI), over active bladder and mixed incontinence; - Nurses note, dated 02/07/25, showed that Resident #111 had a bladder mesh placement years ago (per family member) and it was later found to be damaging, causing frequent UTIs. Review of the resident's POS, dated February 2025, showed: - An order on 02/06/25, for Azo tablets (phenazopyridine-medication that soothes urinary tract infection pain), one tablet by mouth, daily for chronic UTI; - An order on 02/11/25, for macrobid (antibiotic), 100 milligrams (mg), one capsule, by mouth twice daily for 5 days for UTI. During an interview on 02/10/25 at 1:00 P.M., Resident #111 said he/she had a UTI and was taking antibiotics. He/She hoped to feel better soon. Review of the resident's care plan, last revised 02/10/25, showed it did not address chronic UTIs. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing, collectively said they would expect care plans to be updated and to include the current condition of residents. 47678 49999

Based on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for five residents (Resident #1, #6, #18, #34, and #126) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) assessment. 1. Review of Resident #1's medical record showed: - admitted [DATE]; - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), vitamin B-12 deficiency anemia (a condition where the body lacks enough healthy red blood cells due to a deficiency of vitamin B12), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), gastroesophageal reflux disease (GERD-a digestive disease in which stomach acid of bile irritates the food pipe lining), and shortness of breath; - Physician's Order Sheet (POS), last order review date of 01/14/25, showed no medication orders. - Review of Resident #1's care plan, initiated 06/15/22, next review date 02/26/25, showed: - GERD - give medications as ordered; - Antidepressant - administer antidepressant as ordered; - Anemia - give medication as ordered; - Risk for infection - administer antibiotic therapy as prescribed; - Urinary tract infection (UTI-an infection of any part of the urinary tract, the system of organs that make urine) - administer antibiotic therapy as prescribed; - Behavioral problems - administer medications as ordered, monitor/document for side effects and effectiveness; - Potentially physically and verbally aggressive - administer medications as ordered and monitor/document for side effects and effectiveness; - Cognitive impairment - administer medications as ordered and monitor/document for side effects and effectiveness. - Smoker, may smoke unsupervised; - Did not address the use of vapes. Observations of the resident showed: - On 02/12/25 at 2:15 P.M., a vape in the resident's room. - On 02/13/25 at 2:00 P.M., a vape on the resident's lap, while in his/her room. During an interview on 02/12/25 at 2:15 P.M., Resident #1 said he/she doesn't take any medications. 2. Review of Resident #6's medical record showed: - admitted [DATE]; - Code status of DNR (Do Not Resuscitate); - An order to admit resident to hospice with diagnosis of senile degeneration of the brain (a progressive decline in cognitive function that occurs with aging), dated 07/28/24; - Care plan, last revised on 01/21/25, showed the resident as a full code, dated 01/17/22. 3. Review of Resident #18's medical record showed: - An admitted [DATE]; - Resident is own responsible party; - No documentation resident was informed of upcoming care plan meetings. During an interview on 02/10/25 at 1:14 P.M., the resident said he/she is not informed about upcoming care plan meetings. The resident said he/she would like to attend the meetings. During an interview on 02/13/25 at 11:02 A.M., Registered Nurse (RN) S said he/she does not document when he/she talks to residents about their upcoming care plan meetings. RN S could not recall if he/she informed Resident #18 about upcoming care plan meetings. 4. Review of Resident #34's medical record showed: - An admitted [DATE]; - Diagnosis of displaced fracture (occurs when the broken bone pieces move out of alignment, creating a gap or overlap between them) of right humerus (upper arm bone), epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures), dementia (a group of diseases and illnesses that affect your thinking, memory, reasoning, personality, mood and behavior), generalized anxiety disorder (constant worry that cannot be controlled), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs); - Twelve unwitnessed falls dated 08/29/24, 09/17/24, 10/09/24, 12/22/24, 01/09/25, 01/16/25, 01/21/25, 01/28/25, 01/30/25, 01/31/25, 02/03/25, and 02/04/25. Review of the resident's significant change MDS assessment, dated 02/05/25, showed: - Severe cognitive impairment; - Two or more falls with injury (except major); - One fall with major injury. Review of the resident's care plan, last reviewed on 02/10/25, showed: - Resident is at risk for falls; - Interventions for fall risk last updated on 08/01/23. The facility failed to put interventions in place after twelve falls. 5. Review of Resident #126's medical record showed: - admitted [DATE]; - Diagnoses of bipolar disorder, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), need for assistance for personal care, cognitive communication deficit (a communication difficulty due to an impairment in the cognitive processes), paraplegia (chronic condition that causes partial or complete paralysis of the lower body, including the legs and sometimes the abdomen), cannabis abuse (marijuana addition), alcohol dependence, stimulant abuse, psychoactive substance abuse (a patterned use of a drug in which the user consumes the substance in amounts or methods which are harmful to themselves or others), hallucinogen dependence (abuse of using psychoactive drugs that cause changes in mood, thought and perception); - An order for Apixaban (a blood thinner). Review of Resident #126's care plan, intitiated 10/02/24, next review date 04/14/25, showed: -Smoker, does use tobacco at times and vapes, unsupervised smoker. The care plan did not address smoking marijuana; -The care plan failed to address bleeding precautions, side effects, interactions and what to avoid while taking an anticoagulant. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect care plans to be updated to reflect the current condition of the residents. 49754 49879 49999

Based on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for two residents (Resident #24 and #55) out of three sampled residents. The facility's census was 139. The facility did not provide a facility regarding shower frequency. 1. Review of Resident #24's medical record showed: - An admitted [DATE]; - Diagnoses of arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), spinal stenosis (spaces inside the bones of the spine get too small), chronic obstructive pulmonary disease (COPD, disease that makes breathing difficult), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), heart failure (the heart does not pump blood as well as it should), morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), and severe chronic kidney disease (kidneys slowly get damaged and can't do important jobs like removing waste and keeping blood pressure normal). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 11/27/24, showed: - Cognitive status intact; - Partial or moderate assistance for dressing; - Partial or moderate assistance for toileting; - Supervision or touching assistance for personal hygiene; - Partial or moderate assistance for bathing. Review of the resident's care plan, dated 02/04/25, showed: - The resident with an ADL self-care performance deficit due to morbid obesity, arthritis, spinal stenosis and dialysis that makes him/her weaker than normal; - Needs assist of one staff for toileting, transfers, and hygiene. Observation on 02/11/25 at 2:50 P.M. showed the resident lay in bed with unkempt, one quarter inch facial hair on chin. During an interview on 02/11/25 at 2:51 P.M., the resident said he/she may get a shower once every two weeks. He/She would like to have one at least twice per week, feels dirty not having a shower, and doesn't like to be seen with facial hair. Review of the shower schedule, last updated 02/05/25, showed the resident's showers were scheduled for Thursdays and Sundays on day shift. Review of the resident's shower sheets dated, December 2024 through January 2025, showed: - In December 2024, three showers documented as given or refused out of nine opportunities, a total of six opportunities for showers missed; - In January 2025, five showers documented as given or refused out of nine opportunities, a total of six opportunities for showers missed. 2. Review of Resident #55's medical record showed: - admitted [DATE]; - Diagnoses of Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), pain in thoracic spine, shortness of breath, fatigue, need for assistance with personal care, muscle weakness, COPD, and heart failure. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status intact; - Partial or moderate assistance for dressing; - Partial or moderate assistance for toileting; - Supervision or touching assistance for personal hygiene; - Partial or moderate assistance for bathing. Review of the resident's care plan, revised 07/29/20, showed: - The resident with limited physical mobility related to disease process and pain; - Needs assist of one staff for toileting and dressing. During an interview on 02/11/25 at 08:23 A.M., the resident said it has been two weeks since he/she has had a shower, and often only gets one a month, and is nervous he/she has an odor. Review of the shower schedule, last updated 02/05/25, showed the resident's showers were scheduled for Tuesdays and Fridays on day shift. Review of the resident's shower sheets, dated December 2024 through January 2025, showed: - In December 2024, two showers documented out of nine opportunities, a total of seven opportunities for showers missed; - In January 2025, one shower documented out of nine opportunities, a total of eight opportunities for showers missed. During an interview on 02/13/25 at 9:47 A.M., Certified Nursing Assistant (CNA) Q said there is a shower schedule. There are shower aides and showers are assigned for the hall aide. Some residents have scheduled appointments that they work around, and shower sheets are filled out and marked refused if the resident refuses. During an interview on 02/13/25 at 10:08 A.M., Registered Nurse (RN) C said residents should receive two showers per week, and they are given based on the shower schedule. During an interview on 02/13/25 at 10:10 A.M., the Assistant Director of Nursing (ADON) said residents should receive two showers per week unless they refuse, and the staff have to complete 33 showers per day in order to get them all completed. During an interview on 02/13/25 at 2:18 P.M., the Director on Nursing (DON) and the Administrator said residents should receive two showers per week.

Based on observation, interview, and record review, the facility failed to obtain an order for oxygen administration and failed to ensure a physician's order for bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) included settings. This affected one resident (Resident #41) out of two sampled residents. The facility's census was 139. Review of the facility's policy titled, CPAP (continuous positive airway pressure)/BIPAP Support, revised March 2015, showed in preparation for BIPAP, review the physician's order to determine the oxygen concentration and flow, and the PEEP (positive end-expiratory pressure, settings) pressure for the machine. Review of Resident #41's medical record showed: - admitted [DATE]; - Diagnoses of obstructive sleep apnea (a sleep disorder that occurs when the upper airway becomes blocked during sleep), shortness of breath, respiratory failure (a condition making it difficult to breathe on your own), chronic kidney disease (kidneys do not filter waste and fluid like they should), heart failure (the heart does not pump blood as well as it should), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems). Review of the resident's Physician's Order Sheet (POS), dated February 2025, showed: - An order for BIPAP at bedtime, dated 10/02/24; - No order for BIPAP settings; - No order for oxygen. Observations of the resident showed: - On 02/10/25 at 12:46 P.M., the resident sat in the recliner with oxygen via nasal cannula (NC - a flexible tube inserted into the nose to administer supplemental oxygen) at 3.5 liters per minute (LPM), and a BIPAP at bedside; - On 02/11/25 at 9:28 A.M., the resident lay in the bed with oxygen via NC at 3.5 LPM; - On 02/12/25 at 12:36 P.M., the resident lay in the bed with oxygen via NC at 3.5 LPM. During an interview on 02/10/25 at 12:47 P.M., the resident said he/she always uses oxygen and has for quite some time, wears a BIPAP at bedtime, and the nurses put it on at night. During an interview on 02/13/25 at 10:03 A.M., Licensed Practical Nurse (LPN) D said residents with BIPAPs have an order for the settings and residents that wear oxygen have an order for oxygen. During an interview on 02/13/25 at 10:08 A.M., Registered Nurse (RN) C said residents should have an order for oxygen if they are using it, and he/she would look at the order for BIPAP settings prior to applying the BIPAP to the resident. During an interview on 02/13/25 at 10:25 A.M., the Assistant Director of Nursing (ADON) said they use a company to set up a BIPAP machine when it's ordered. During an interview on 02/13/25 at 2:18 P.M., the Director of Nursing (DON) and the Administrator said they expect residents that wear oxygen to have a physician's order for oxygen and BIPAP orders should include settings for the BIPAP.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 35 opportunities with three errors made, for an error rate of 8.57%, which affected three residents (Residents #32, #102 and #133) out of seven sampled residents. The facility's census was 139. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration; - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. Review of the NovoLog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) instructions, revised February 2015, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing; - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; - Press and hold button and make sure drop of insulin appears; - Select dose; - Give injection. Review of the Insulin Lispro (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) KwikPen (insulin in a pen-type device manufacturer instructions for use, revised July 2023, showed: - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; - Not priming before each injection may result in too much or too little insulin; - Turn the dose knob to select two units; - Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top; - With the needle pointing up, push the dose knob until it stops and zero is seen in the dose window, hold and count to five slowly; - There should be insulin at the tip of the needle, if not, repeat no more than four times. 1. Review of Resident #32's Physician's Order Sheet (POS), dated February 2025, showed an order for Novolog per sliding scale (progressive increase in the pre-meal or nighttime insulin dose based on pre-defined blood glucose ranges) for a blood sugar 200-250, give three units dated 09/15/24. Observation of the resident on 02/12/25 at 11:56 A.M. showed: - Certified Medication Technician (CMT) A administered Novolog three units subcutaneously (an injection just beneath the skin) to the resident per sliding scale for a blood sugar of 204; - CMT A failed to prime the Novolog pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 2. Review of Resident #102's POS, dated February 2025, showed an order for Insulin Lispro, inject per sliding scale, for a blood sugar 221-260, give six units, dated 01/28/25. Observation of the resident on 02/12/25 at 11:51 A.M. showed: - CMT B administered Insulin Lispro six units subcutaneously to the resident per sliding scale for a blood sugar of 236; - CMT B failed to prime the Insulin Lispro pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 3. Review of Resident #133's POS, dated February 2025, showed an order for Insulin Lispro, inject three units subcutaneously with meals, dated 12/19/24. Observation of the resident on 02/12/25 at 12:02 P.M. showed: - CMT A administered Insulin Lispro three units subcutaneously to the resident; - CMT A failed to prime the Insulin Lispro pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. During an interview on 02/12/25 at 12:05 P.M., CMT A said he/she was taught to prime the pen when it was used for the first time. During an interview on 02/12/25 at 12:08 P.M., CMT B said he/she thought the insulin pen should be primed when it was first opened. During an interview on 02/12/25 at 12:15 P.M., the Assistant Director of Nursing (ADON) said she expects staff to follow insulin pen manufacturer's guidelines for insulin administration. During an interview on 02/13/25 at 2:18 P.M., the Director of Nursing (DON) and the Administrator said they expect to have a medication error rate of less than five percent.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care for one resident (Resident #31) out of 28 sampled residents. The facility's census was 139. Review of the facility's Handwashing/Hand Hygiene Policy, dated 2001, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections; - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors; - Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids or contaminated surfaces, after touching a resident or resident's environment, before moving from work on a soiled body site to a clean body site on same resident and immediately after glove removal; - Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; - The use of gloves does not replace hand hygiene/hand washing. Review of the facility's EBP policy, revised August 2022, showed: - Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activity when contact precautions do not otherwise apply; - Gloves and gowns applied prior to performing high contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting to bathroom, during device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care; - EBPs are indicated for residents with wounds and/or indwelling medical devices; - EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 1. Observation of Resident #31's foley catheter care/peri care on 02/13/25 at 9:30 A.M., showed: - Resident's door with EBP signage and supplies accessible and hung on inside of door; - Certified Nursing Aide (CNA) E, entered the resident's room, donned gloves without washing or sanitizing hands, and did not don gown; - CNA E removed blanket from resident and removed gloves; - CNA E obtained wet washcloths, gloved, and provided catheter care, cleaning catheter tubing from peri area and down several inches; - CNA E folded washcloth and cleaned the resident's front peri area down the left side, folded washcloth and cleaned down the right side of the peri area; - CNA E obtained a clean washcloth and wiped under abdominal folds, removed gloves and did not sanitize or wash hands; - CNA E donned clean gloves without washing or sanitizing hands, obtained a clean washcloth and cleaned the catheter tubing again; - CNA E removed gloves, gathered trash, did not wash or sanitize hands and left the room with the bag of trash. During an interview on 02/13/25 at 9:45 A.M., CNA E said he/she had only worked at the facility for three weeks and did not know where the gowns were located. Hands should be washed in between dirty and clean and before leaving the room. He/She would have normally washed hands before leaving the room and sanitized again in the hall. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing said they would expect staff to wear proper PPE for EBP when indicated, and for staff to perform hand hygiene between dirty and clean and prior to leaving resident rooms. 49879

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for eleven residents (Resident #18, #25, #28, #34, #44, #49, #53, #81, #111, #126, and #131) out of 28 sampled residents and one resident (Resident #139) outside the sample. The facility's census was 139. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, revised October 2022, showed: - Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; - Each resident will be permitted to remain in the facility, and not be transferred or discharged unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; - The resident and representative are notified in writing of the following information: the specific reason for the transfer or discharge, including the basis; the effective date of the transfer or discharge; the specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged ; the Notice of Facility Bed-Hold and policies; - A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative; - When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected; - Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility; - Under the following circumstances, the notice is given as soon as it is practicable, but before the transfer or discharge: the health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; the resident's health improves sufficiently to allow a more immediate transfer or discharge; an immediate transfer or discharge is required by the resident's urgent medical needs; or a resident has not resided in the facility for 30 days; - Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). 1. Review of Resident #18's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/21/24; - The resident transferred to the hospital on [DATE] and returned to the facility 07/09/24; - The resident transferred to the hospital on [DATE] and returned to the facility 08/13/24; - The resident transferred to the hospital on [DATE] and returned to the facility 09/24/24; - The resident transferred to the hospital on [DATE] and returned to the facility 10/16/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 2. Review of Resident #25's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfers. 3. Review of Resident #28's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 05/02/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 4. Review of Resident #34's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/23/24; - The resident transferred to the hospital on [DATE] and returned to the facility 06/18/24; - The resident transferred to the hospital on [DATE] and returned to the facility 10/25/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 5. Review of Resident #44's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 6. Review of Resident #49's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 7. Review of Resident #53's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 05/27/24; - The resident transferred to the hospital on [DATE] and returned to the facility 08/05/24; - The resident transferred to the hospital on [DATE] and returned to the facility 12/31/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 8. Review of Resident #81's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 12/07/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 9. Review of Resident #111's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 10. Review of Resident #126's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfers. 11. Review of Resident #131's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 12. Review of Resident #139's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. During an interview on 02/13/25 at 1:42 P.M., the Social Services Designee said the floor nurses send out the transfer forms upon discharge. During an interview on 02/13/25 at 1:50 P.M., Registered Nurse (RN) C said the nurse that sends a resident out is responsible for sending the face sheet, medication list, code status, Durable Power of Attorney (DPOA-legal document that allows someone to make decisions for another person), bed hold policy, and Situation/Background/Assessment/Recommendation (SBAR-a structured way to send information between people). The patient transfer form is copied and one goes to the hospital with the resident, the other goes with the ambulance personnel. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said they would expect residents and/or resident's representatives to be notified of transfers in writing.

Based on observation, interview, and record review, the facility failed to maintain infection control practices during perineal care for one resident (Resident #1) out of one sampled resident. The facility's census was 137. Review of the facility's Perineal Care Policy, dated February 2018, showed: - Purpose of procedure is to provide cleanliness and comfort to the resident, to prevent infections, skin irritation and to observe the skin condition; - Place equipment on bedside stand and arrange to be easily reached; - Wash hands thoroughly, dry and put on gloves; - Wet washcloth and apply skin cleanser; - Wash perineal area from front to back; - Turn resident to side and wash rectal area thoroughly, wiping from the base of labia towards and extending over the buttocks; - Rinse and dry thoroughly; - Discard disposable items, remove gloves and wash hands; - Reposition bed covers and make resident comfortable; - Wash and dry hands thoroughly. Review of the facility's Enhanced Barrier Precaution Policy, dated August 2022, showed: - Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activity when contact precautions do not otherwise apply; - Gloves and gowns applied prior to performing high contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting to bathroom, during device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care; - EBPs are indicated for residents with wounds and/or indwelling medical devices; - EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Review of Resident #1's medical record showed: - On 11/21/24, an order to leave Peripherally Inserted Central Catheter (PICC-a long , thin and flexible tube that is inserted into a vein in the upper arm, threaded into a large vein near the heart and used to deliver fluids, blood and medications intravenously) in place for two weeks; - On 11/21/24, an order to change PICC line dressing every seven days. Observation on 11/26/24 at 6:27 P.M. of perineal (peri) care for Resident #1 showed: - EBP signage on front of door alerted staff to wear appropriate protective gear (gown, gloves, masks, eye goggles); - EBP supplies were hung on inside of door; - Certified Nursing Aide (CNA) A went to the resident's bedside and CNA B gathered supplies and washed hands; - CNA A donned gloves without washing hands; - CNA A and CNA B performed perineal (peri) care for Resident #1, rolled the resident on his/her side and placed a brief under the resident's buttocks without cleaning the area first; - CNA A removed gloves, did not wash hands and pulled sheet up and over the resident; - CNA B removed gloves, took supplies to bathroom and washed hands before leaving the room. During an interview on 11/26/24 at 6:35 P.M., CNA A said EBP is used on residents with ostomies (a surgical opening to create an opening from an are inside the body to the outside) and tracheostomies, (an opening surgically created through the neck, into the windpipe or trachea, to allow air to fill the lungs) but just wear gloves for peri care. Even though Resident #1 had a Peripherally Inserted Central Catheter (PICC-a long , thin and flexible tube that is inserted into a vein in the upper arm, threaded into a large vein near the heart and used to deliver fluids, blood and medications intravenously), it was up high on his/her arm so gloves were fine for peri care. He/She said he/she should have washed hands prior to leaving the room. During an interview on 11/26/24 at 6:36 P.M., CNA B said it had been explained to wear EBP when a resident had a Foley catheter (a tube inserted into the bladder to drain urine from the body) or ostomy, but should have wore it since the resident had a PICC line. During an interview on 11/26/24 at 6:40 P.M., Licensed Practical Nurse (LPN) C said EBP should be worn for residents with a gastrostomy tube (G tube- tube inserted through the skin and directly into the stomach, used to provide nutrition, fluids and medications), Foley catheters, tracheostomy or PICC line. He/She said staff should wear a gown, gloves and mask when performing any care to those residents. During an interview on 11/26/23 at 6:45 P.M., Resident #1 said staff had not been wearing a gown during care. Mask and gloves were worn during PICC line care and gloves for peri care. During an interview on 11/26/24 at 7:28 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) said they would expect peri care to be done according to the policy and EBP to be used when providing care for a resident with a PICC line or any other device. Staff should have washed hands prior to leaving the room and between dirty and clean. MO00245248

Based on observation, interview and record review, the facility failed to thoroughly investigate an incident of resident to resident abuse and failed to implement interventions to prevent further abuse from occurring for one (Resident #1) of three sampled residents when Resident #2 initially struck Resident #1 in the head. The facility also failed to take appropriate action to ensure the safety of the five remaining residents who continued to reside on the secured unit with Resident #2. The facility census was 77. The administrator was notified on [DATE] at 5:01 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed, as confirmed by surveyor onsite verification on [DATE]. Record review of the facility's Abuse and Neglect policy, dated (MONTH) (YEAR), showed: - The policy directed staff to identify, correct, and intervene in situations in which abuse was more likely to occur. - The policy directed staff to investigate resident to resident altercations. - In the event of resident to resident abuse, the policy directed staff to determine if immediate discharge was appropriate and to place the resident on one-on-one monitoring until the completion of the investigation or discharge of the resident. 1. Review of a special care unit criteria review sheet for Resident #1, dated [DATE] and [DATE], showed: - The resident had dementia. - The resident habitually wandered. - The resident had significant behavioral problems that seriously disrupted the rights of other residents which was easily managed through low to moderate medication use. - The resident posed a serious danger to self or others. Review of the behavior monitoring sheet for Resident #1, dated [DATE], showed Certified Nurse Aide (CNA) F documented Resident #1 walked around carrying a wet floor sign and entered another resident's (Resident #2) room. Resident #2 knocked Resident #1 down. Staff took Resident #1 back to his/her room, sat him/her in a chair, and left to get supplies. CNA F heard yelling and saw Resident #1 and other resident in the floor again after Resident #1 re-entered the other resident's room. 2. Review of Resident #2's face sheet showed Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of nurses' notes, dated [DATE], [DATE], and [DATE], showed Resident #2 hit other residents who entered his/her room. Resident #2 also had altercations with residents and staff in other areas on [DATE], [DATE], [DATE], and [DATE]. Review of the care plan, updated [DATE], showed staff identified the resident became angry and exhibited combative behaviors, including pushing and threatening to hit other residents. Review of a behavior monitoring sheet for Resident #2, dated [DATE], showed CNA F documented Resident #2 hit another resident (Resident #1). Resident #2 said the other resident came into his/her room and hit Resident #2 with a wet floor sign. The other resident lay in the floor with Resident #2 standing in the doorway cursing and telling staff to keep the resident out of his/her room. Later, CNA F heard yelling and saw the same resident in the floor. Resident #2 said the resident went into his/her room again and threw a cup of ice water on Resident #2. Both residents were in the floor. Resident #2 cursed the resident and told staff to keep him/her away. Resident #2 said he/she used to be a boxer and knew where to hit and that the other resident was not getting up for a while. Review of nurses' notes showed: - On [DATE] at 10:15 P.M., Licensed Practical Nurse (LPN) B noted Resident #1 had a moderate amount of dried blood in his/her hair and all across the back of the recliner. The resident had a small superficial opening on top of a large hematoma (bruise). - On [DATE] at 12:30 A.M.,the resident had a small amount of swelling and new bruising on the right side/crown of the head, moderate sized dark bruising to the left side of the face and eye, and two small puncture type cuts to the lower left side of the jaw. - On [DATE] at 2:45 A.M., staff noted Resident #1 started vomiting and at 2:00 A.M., the physician was called and the resident was transported to the hospital. - On [DATE] at 5:30 A.M., staff noted the hospital notified them at 5:15 A.M. that Resident #1 experienced a brain bleed and would be transferred to another hospital. Review of the ambulance pick up sheet dated [DATE], showed the resident had traumatic injury. Facility staff reported the resident had been struck in the head by another resident with a plastic wet floor sign. Review of hospital records, dated [DATE], showed the resident was assaulted with a sign and sustained multiple acute subdural hematomas (bleeding on the brain), hemorrhagic contusions in the bilateral temporal and right basiofrontal regions (bleeding on the brain) with [MEDICAL CONDITION] (swelling), and traumatic subarachniod hemorrhage (bleeding on the brain). The resident also had hematomas on the left eye area and scalp. Review of the death certificate showed Resident #1's cause of death as [MEDICAL CONDITION], [MEDICATION NAME] force trauma, struck in the head by another person with a janitorial sign, manner of death homicide on [DATE]. Record review on [DATE] showed the facility had not initiated an abuse investigation. Observation on [DATE] at 9:05 A.M. through 12:00 P.M. showed Resident #2 in his/her room with the door closed. Staff had not placed a stop sign on the door or implemented effective measures to ensure further abuse did not occur. During an interview on [DATE] at 9:45 A.M., CNA D said that Resident #1 always wandered and required frequent one-on-one redirection. Resident #2 did not like others in his/her room and yelled and screamed at anyone who entered. CNA D heard that the resident had hit others previously. Staff applied a stop sign to Resident #2's door prior to moving the resident to the secured unit but had not done so since the move. During an interview on [DATE] at 10:00 A.M., the Administrator, Director of Nursing (DON) and Unit Coordinator said they did not investigate abuse, but initiated an investigation on falls with injury concerning Resident #1. They were unaware that an abuse altercation had occurred. The Administrator, DON, and Unit Coordinator had not reviewed the behavior monitoring book or incident monitoring form. They said the documents should have been reviewed. During an interview on [DATE] at 11:05 A.M., LPN A said: - LPN A sat in the common area with other residents. He/she heard a noise and found Resident #1 lying on the floor outside Resident #2's room. Resident #2 had slight bleeding from an area on the neck that appeared as if skin tags had been pulled off, and had redness to the left eye and cheek. Resident #2 stood in the doorway, cursed, and yelled that Resident #1 was in his/her room. Resident #2 called Resident #1 names but did not make threats at that time. Resident #2 told LPN A that Resident #1 came into his/her room. When asked if he/she hit, pushed, or touched Resident #1, Resident #2 did not answer, but LPN A believed he/she did. - While talking to the Administrator about the first incident, LPN A heard a noise and hung up. LPN A saw Resident #1 lying on the floor and Resident #2 kneeling over him/her outside Resident #2's room. Resident #1 did not appear to have been unconscious but had an abrasion on the back of his/her head. - LPN A told the Administrator he/she suspected resident to resident abuse during a phone call at 8:06 P.M. on [DATE]. The Administrator told LPN A not to document anything that he/she did not witness; even circumstances suspected to have caused an incident or what the resident told him/her. The Administrator told LPN A to document the incident as a fall. - LPN A called the DON concerning the second incident at 8:29 P.M. on [DATE]. During an interview on [DATE] at 11:55 A.M., the DON said: - LPN A notified her about Resident #1 falling in the hall. The DON said she figured it occurred because they (Resident #1 and Resident #2) were arguing as Resident #2 did not like anyone in his/her room. - Resident #1 wandered and went into others rooms. - Staff used to apply a stop sign to Resident #2's door, but stopped when he/she moved to the secured unit about three weeks ago. During an interview on [DATE] at 3:20 P.M., the Administrator said staff told her that Resident #1 had the wet floor sign and a cup of water in Resident #2's room and they both fell . She did not previously know the incident occurred in the hall or that staff suspected abuse. The administrative staff investigated falls but did not review the medical record or notes pertaining to the incident. During an interview on [DATE] at 5:10 P.M., the Administrator and DON said the facility had not provided one-on-one monitoring of Resident #2 following the altercations, but that staff would immediately be assigned. During an interview on [DATE] at 1:42 P.M., the Coroner said Resident #1 died due to head trauma caused when he/she was hit by another resident with a wet floor sign. The death was referred to Law Enforcement and the Prosecuting Attorney as the cause of death was listed as homicide. At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint #MO 3

Based on observation, interview and record review, the facility failed to ensure two (Residents #1 and #2) of three reviewed residents who resided on the secured unit remained free from abuse. Staff identified Resident #1 wandered into other residents' rooms and that Resident #2 became angry and struck out when others came into his/her room. The facility failed to implement interventions to prevent abuse and failed to provide sufficient protection for Resident #1 by not immediately intervening after an altercation. Resident #1 suffered head trauma and subsequently death as a result of an altercation with Resident #2. The facility's census was 77 with six residents residing on the secured unit. The administrator was notified on [DATE] at 5:01 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed, as confirmed by surveyor onsite verification on [DATE]. Record view of the facility's Abuse and Neglect policy, dated (MONTH) (YEAR), showed the policy directed staff to identify, correct, and intervene in situations in which abuse was more likely to occur. The policy also directed staff to investigate resident to resident altercations. Review of the facility's Unmanageable Residents policy, dated (YEAR), showed the purpose of the policy was to provide a safe place for residents. The policy directed staff to notify appropriate parties and intervene if the resident should pose an immediate danger to him/herself or others. 1. Record review of Resident #1's face sheet showed the resident entered the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a special care unit criteria review sheet, dated [DATE] and [DATE], showed: - The resident had dementia. - The resident habitually wandered. - The resident had significant behavioral problems that seriously disrupted the rights of other residents which was easily managed through low to moderate medication use. - The resident posed a serious danger to self or others. Review of nurses' notes showed: - On [DATE], staff heard yelling and found Resident #1 lying in the doorway of another resident's room. Resident #1 sustained a small hematoma (bruise) behind the right ear. The nurse's note contained no further information related to the cause of the injury. - On [DATE], staff found Resident #1 in the door way of another resident's room. The other resident was yelling for Resident #1 to leave. - On [DATE], staff moved Resident #1 to another unit and the resident exhibited verbal and physical aggression. Review of the care plan, updated [DATE], showed: - Staff identified the resident moved to a secured unit with goals of monitoring behavior. Interventions included monitoring and charting how the resident adapted to the change in living arrangements. - Staff identified the resident had dementia, refused care, displayed uncooperative behaviors, and had a history of [REDACTED]. Interventions included assess the cause and address immediately, document all behaviors, and report all behaviors to the physician. - Staff identified the resident as at risk for wandering with a goal of remaining safe. Interventions included removing the resident from other residents' rooms and unsafe conditions but did not address ways to prevent Resident #1 from entering other residents' rooms. Review of a nurse's note, dated [DATE], showed the resident combative with staff during care. Resident #1 hit the nurse and tried to squeeze his/her fingers. Review of a nurse's note, dated [DATE] at 7:40 P.M., showed Licensed Practical Nurse (LPN) A documented he/she heard a noise and found the resident lying on the floor in the hall on his/her left side. He/she had adequate range of motion and neuro checks (an assessment to detect neurological injury) were within normal limits. Staff assisted Resident #1 to his/her room. Review of a tracking record for improving resident safety, dated [DATE], showed LPN A documented the resident experienced an unwitnessed fall in the hall due to a loss of balance while ambulating in the bedroom. LPN A noted the resident hit his/her head, had slight bleeding to the left side of the neck due to a scab off, and had slight redness to the left side of the face. Review of a nurse's note, dated [DATE] at 8:10 P.M., showed LPN A documented he/she heard a noise and found Resident #1 lying flat on his/her back on the floor in the hall with water on the floor. The resident had an abrasion on the back of the head, adequate range of motion, and neuro checks within normal limits. Review of a tracking record for improving resident's safety, dated [DATE], showed LPN A documented the resident had an unwitnessed fall in the hall due to slipping in water while ambulating. The resident had an abrasion with slight bleeding on the back of the head. Review of the behavior monitoring sheet, dated (MONTH) 2019, showed: - On [DATE], Resident #1 exhibited behavioral symptoms not directed at others, hallucinations or delusions, and wandering. - On [DATE], Certified Nurse Aide (CNA) F documented Resident #1 walked around carrying a wet floor sign and entered another resident's (Resident #2) room. The other resident knocked Resident #1 down. Staff took Resident #1 back to his/her room, sat him/her in a chair, and left to get supplies. CNA F heard yelling and saw Resident #1 and other resident in the floor again after Resident #1 re-entered the other resident's room. Review of nurses' notes showed: - On [DATE] at 10:15 P.M., LPN B noted Resident #1 had a moderate amount of dried blood in his/her hair and all across the back of the recliner. The resident had a small superficial opening on top of a large hematoma. - On [DATE] at 12:30 A.M.,the resident had a small amount of swelling and new bruising on the right side/crown of the head, moderate sized dark bruising to the left side of the face and eye, and two small puncture type cuts to the lower left side of the jaw. - On [DATE] at 2:45 A.M., staff noted Resident #1 started vomiting and at 2:00 A.M., the physician was called and the resident was transported to the hospital. - On [DATE] at 5:30 A.M., the hospital notified staff at 5:15 A.M. that Resident #1 experienced a brain bleed and would be transferred to another hospital. Review of a post incident behavior monitoring flow sheet, dated [DATE], showed the resident had an altercation in Resident #2's room. Review of the ambulance pick up sheet dated [DATE], showed the resident had traumatic injury. Facility staff reported the resident had been struck in the head by another resident with a plastic wet floor sign. Review of hospital records, dated [DATE], showed the resident was assaulted with a sign and sustained multiple acute subdural hematomas (bleeding on the brain), hemorrhagic contusions in the bilateral temporal and right basiofrontal regions (bleeding on the brain) with [MEDICAL CONDITION] (swelling), and traumatic subarachniod hemorrhage (bleeding on the brain). The resident also had hematomas on the left eye area and scalp. Review of the death certificate showed Resident #1's cause of death as [MEDICAL CONDITION], [MEDICATION NAME] force trauma, struck in the head by another person with a janitorial sign, manner of death homicide on [DATE]. 2. Record review of Resident #2's face sheet showed the resident entered the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses' notes showed: - On [DATE], Resident #2 hit another resident with his/her cane while in the dining room. - On [DATE], Resident #2 blocked the door to keep others out of his/her room. Resident #2 cursed at staff when they attempted to come into the room. - On [DATE], another resident opened Resident #2's door. Resident #2 yelled and began hitting the resident on the back and shoulders. - On [DATE], Resident #2 shook and hit another resident in the face. - On [DATE], Resident #2 punched another resident on the side of the head. - On [DATE], Resident #2 became verbally aggressive. Law enforcement came to the facility and the resident continued to be verbally abusive and threatened the officer. He/she was transported to the hospital. Review of a Psychiatrist's note, dated [DATE], showed the resident displayed unpredictable behavior and hit another resident for disrupting his/her privacy. Review of a nurse's note, dated [DATE], showed staff found another resident lying on the floor of Resident #2's room. The resident cried and said Resident #2 kicked and stomped all over him/her. Resident #2 yelled, cursed, and threatened staff and the resident. Review of a Psychiatrist's note, dated [DATE], showed the resident displayed behavioral problems due to dementia, was agitated and easily upset. The resident was upset concerning a transfer to the secured dementia unit but calmed after being told he/she would have more privacy and less disturbances. Review of the care plan, updated [DATE], showed: - Staff identified the resident moved to the secured unit on [DATE] with goals of monitoring for adjustment to the new room. Interventions included monitoring and charting how the resident adapted to the change. - Staff identified the resident became angry and agitated with care at times, and displayed verbal and physical behaviors with a goal of no adverse effects from resisting care or assistance. Interventions included the resident yelled and cursed, and the resident often barricaded his/her door. - Staff identified the resident became irritated with certain residents, exhibited combative and verbal behaviors in the past, and had pushed, and threatened to hit other residents. Goals included the resident's behaviors would not cause injury or disturb the quality of life for other residents, and the resident's needs would be met. Interventions included the resident became angry and yelled at other residents, reassure the resident's concerns would be addressed, redirect from the other resident to avoid a physical confrontation, attempt to address what was upsetting resident, psychiatric evaluations as need, documentation of behaviors, and notify the physician of any changes in behaviors. The care plan did not address interventions to keep other residents out of Resident #2's room. Review of a nurse's note, dated [DATE] at 8:10 P.M., showed LPN A noted he/she heard a noise and found Resident #2 sitting on the floor in the hall outside his/her room with water on the floor. The resident did not experience injury. Review of a tracking record for improving patient safety, dated [DATE], showed staff identified the resident experienced an unwitnessed fall in the hallway due to slipping in water. Review of a behavior monitoring sheet, dated (MONTH) 2019, showed: - On [DATE], staff identified the resident exhibited verbal and physical behavioral symptoms directed at others and rejected care. - On [DATE], CNA F documented Resident #2 hit another resident (Resident #1). Resident #2 said the other resident came into his/her room and hit Resident #2 with a wet floor sign. The other resident lay in the floor with Resident #2 standing in the doorway cursing and telling staff to keep the resident out of his/her room. Later, CNA F heard yelling and saw the same resident in the floor. Resident #2 said the resident went into his/her room again and threw a cup of ice water on Resident #2. Both residents were in the floor. Resident #2 cursed the resident and told staff to keep him/her away. Resident #2 said he/she used to be a boxer and knew where to hit and that the other resident was not getting up for a while. Review of a post incident monitoring flow sheet, dated [DATE], showed Resident #2 had an altercation in his/her room. Observation on [DATE] at 9:05 A.M. through 12:00 P.M. showed Resident #2 in his/her room with the door closed. Staff had not placed a stop sign on the door or implemented interventions to discourage the other five residents who continued to reside on the unit from entering Resident #2's room. During an interview on [DATE] at 9:45 A.M., CNA D said that Resident #1 always wandered and required frequent one-on-one redirection. Resident #2 did not like others in his/her room and yelled and screamed at anyone who entered. CNA D heard that the resident had hit others previously. Staff applied a stop sign to Resident #2's door prior to moving the resident to the secured unit but had not done so since the move. During an interview on [DATE] at 9:50 A.M., CNA [NAME] said that Resident #1 had a history of [REDACTED]. Resident #2 got mad and yelled at others if they entered his/her room. CNA [NAME] heard Resident #2 hit other residents prior to being moved to the secured unit. During an interview on [DATE] at 10:00 A.M., the Administrator, Director of Nursing (DON) and Unit Coordinator said they investigated falls with injury concerning Resident #1. They were unaware that an altercation had occurred. The Administrator, DON, and Unit Coordinator had not reviewed the behavior monitoring book or incident monitoring form. They said the documents should have been reviewed. During an interview on [DATE] at 10:30 A.M. CNA F said: - He/she saw Resident #1 walking around with a wet floor sign before going to assist another resident. CNA F saw LPN A with Resident #1 who was lying in the hall. Resident #2 stood by him/her, cursing and yelling for them to keep Resident #1 out of his/her room. CNA F took Resident #1 to his/her room. Resident #1's mouth lightly bled and CNA F got the resident a cup of water. He/she then went to the nurses' station leaving Resident #1 in his/her room. - CNA F heard yelling and saw Resident #1 on the floor outside Resident #2's doorway with water on the floor. CNA F thought Resident #1 was knocked out. He/she was as stiff as a board. Resident #2 knelt on the floor over Resident #1 and yelled for them to keep Resident #1 out of his/her room, and said he/she was a boxer and knew how to keep him/her out. Resident #2 said Resident #1 went into his/her room and threw water on Resident #2 and hit him/her with a wet floor sign. Staff took Resident #1 to the common area and he/she sat in a chair. Resident #1 said he/she had a headache big enough to fit a horse. The Certified Medication Technician (CMT) administered Tylenol. -Resident #1 had a history of [REDACTED]. After the incidents with Resident #2, Resident #1 tried to go into someone else's room but was redirected. When Resident #1 wandered, staff tried to redirect and keep him/her out of other residents' rooms and in the common area. - Resident #2 did not like others in his/her room. CNA F thought that Resident #2 got mad and went for Resident #1 when he/she entered the room. Staff had a stop sign they applied to the resident's door prior to him/her moving to the secured unit but they did not apply one on the unit. - CNA F talked to the nurse about Resident #2 saying to keep Resident #1 out of his/her room and threatening him/her. The nurse told CNA F to document the behaviors but he/she had initially been afraid to do so because the Administrator told staff not to document anything unless they actually saw the incident occur; even if the resident reported the incident. During an interview on [DATE] at 11:05 A.M., LPN A said: - LPN A sat in the common area with other residents. He/she heard a noise and found Resident #1 lying on the floor outside Resident #2's room. Resident #1 had slight bleeding from an area on the neck that appeared as if skin tags had been pulled off, and had redness to the left eye and cheek. Resident #2 stood in the doorway, cursed, and yelled that Resident #1 was in his/her room. Resident #2 called Resident #1 names but did not make threats at that time. Resident #2 told LPN A that Resident #1 came into his/her room. When asked if he/she hit, pushed, or touched Resident #1, Resident #2 did not answer, but LPN A believed he/she did. - While talking to the Administrator about the first incident, LPN A heard a noise and hung up. LPN A saw Resident #1 lying on the floor and Resident #2 kneeling over him/her outside Resident #2's room. Resident #1 did not appear to have been unconscious but had an abrasion on the back of his/her head. - Resident #1 tended to wander. Staff tried to redirect Resident #1 and keep him/her out of other residents' rooms. - Resident #2 became angry and upset if anyone entered his/her room. - LPN A told the Administrator he/she suspected resident to resident abuse. The Administrator told LPN A not to document anything that he/she did not witness; even circumstances suspected to have caused an incident or what the resident told him/her. The Administrator told LPN A to document the incident as a fall. - LPN A called the DON concerning the second incident. During an interview on [DATE] at 11:30 A.M., CNA G said Resident #1 wandered and staff attempted to redirect. Resident #2 became angry when others came into his/her room and staff redirected. During an interview on [DATE] at 11:55 A.M., the DON said: - LPN A notified her about Resident #1 falling in the hall. The DON said she figured it occurred because they (Resident #1 and Resident #2) were arguing as Resident #2 did not like anyone in his/her room. - Resident #1 wandered and went into others rooms. - Staff used to apply a stop sign to Resident #2's door, but stopped when he/she moved to the secured unit about three weeks ago. During an interview on [DATE] at 12:02 P.M., the Administrator and DON said LPN A relayed that Resident #2 yelled at Resident #1, but did not say that Resident #2 was kneeling over Resident #1, or that he/she suspected abuse occurred. During an interview on [DATE] at 2:10 P.M., the Administrator said Resident #2 resided on the secured unit due to behaviors. Resident #2 had a history of [REDACTED]. She denied the resident hit or pushed anyone. The Administrator was unaware of documented incidents in the medical record. The Administrator also said Resident #2 had a stop sign on his/her door prior to being transferred to the secured unit and it should have been carried over after the move. The Administrator did not know why staff did not continue to use the stop sign. During an interview on [DATE] at 2:45 P.M., the Administrator said Resident #1 resided on the secured unit due to wandering. Resident #1 had a history of [REDACTED]. During an interview on [DATE] at 2:50 P.M., the Administrator, DON and Assistant Director of Nursing (ADON) said the Unit Coordinator should have monitored behaviors. They did not know why she did not do so. During an interview on [DATE] at 3:20 P.M., the Administrator and DON said the facility did not have a current policy for behavior monitoring of aggressive residents. The Administrator said staff told her that Resident #1 had the wet floor sign and a cup of water in Resident #2's room and they both fell . She did not previously know the incident occurred in the hall or that staff suspected abuse. The administrative staff investigated falls, but did not review the medical record or notes pertaining to the incident. During an interview on [DATE] at 4:20 P.M., Law Enforcement Officer I said he/she was familiar with Resident #2 and described the resident as not well-behaved. During an interview on [DATE] at 5:10 P.M., the Administrator and DON said the facility had not provided one-on-one monitoring of Resident #2 following the altercations, but that staff would immediately be assigned. During an interview on [DATE] at 1:42 P.M., the Coroner said Resident #1 died due to head trauma caused when he/she was hit by another resident with a wet floor sign. The death was referred to Law Enforcement and the Prosecuting Attorney as the cause of death was listed as homicide. At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint #MO 3

Based on interview and record review the facility failed to recognize, thoroughly and accurately assess and document the condition of Resident #1's cast (soft or hard material fitted snugly to keep fractured bones in line) which resulted in displacement to the resident's original wrist fracture and an open wound exposing the fractured bone. The facility census was 75. 1. Record review of Resident #1's Nurse Notes showed: - On 12/7/17 at 1:30 A.M., Resident #1 sent to the hospital for evaluation of left wrist pain; - On 12/7/17 at 5:20 A.M., the resident returned to facility with a [DIAGNOSES REDACTED]. - On 12/7/17, appointment made for orthopedic follow up on 12/8/17 at 11:30 A.M.; - On 12/7/17, resident non-compliant with sling and keeping wrist immobile; - On 12/8/17 at 1:30 P.M., the resident returned from an orthopedist appointment with left wrist casted and a new order to inspect the resident's cast and verify no skin breakdown; - On 12/13/17 at 7:45 A.M., Resident #1 returned to the facility from an orthopedic surgery appointment with no surgery done because the resident complained of chest pain; - On 12/13/17 at 2:00 P.M., staff received a call from orthopedic doctor's office with instructions to send resident to an appointment at the cardiologist's office that date to get clearance for surgery. The facility nurse explained no transportation would be available for this appointment and it would need to be rescheduled; - No further documentation regarding cardiac assessment until 12/20/17 when staff noted Resident #1's primary care doctor ordered cardiac testing; - No documentation regarding follow up on cardiac testing from 12/22/17 to 1/2/18; - From 12/13/17 to 12/30/17 no documentation regarding the condition of Resident #1's cast; - On 12/31/17, the staff noted dryness to the skin on left hand and the cast wet/damp with dried food; - From 12/13/17 through 1/3/18 the staff did not notify the physician of the condition of the resident's cast. - On 1/2/18 the resident received clearance for surgery from cardiologist; - On 1/4/18, Resident #1 directly admitted to the hospital from the orthopedist's office for surgery (22 days after original surgery date). Record review of Resident #1 Physician order [REDACTED]. - [DIAGNOSES REDACTED]. - An order, dated 12/8/17, received after cast application to inspect cast and verify no skin breakdown; - An order received on 12/13/17, to inspect cast daily and verify no skin breakdown and to follow-up with cardiologist appointment arranged by the orthopedic doctor's office. Record review of Resident #1's Treatment Administration Record (TAR), from 12/8/17 to 1/4/18, showed no orders or instructions to inspect cast daily and check for skin breakdown. Record review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool completed by staff, dated 12/7/17, showed the Brief Interview for Mental Status (used to determine resident's attention, orientation, and ability to understand and recall information) score was four (a score of zero to seven indicates severe mental impairment). Record review of resident's care plan showed staff added an update on 12/7/17, to maintain the resident's level of functioning while healing left arm fracture and improve safety awareness. Review of Resident #1's care plan showed another update on 12/28/17 which identified the resident had been shoving things and food up in cast. Interventions included to provide redirection and attempt to cleanse left hand and fingers where cast is. Staff also noted in the update that it is difficult to assess Resident #1's skin under the cast for damage done from picking at the cast and attempting to place objects in the cast related to dementia, but offered no direction to staff. Record review of Progress Notes, from the Orthopedist, dated 1/4/18, showed: - Resident #1's cast in severely poor condition, almost all of the soft roll and padding had been removed from the proximal end of the cast as well as the distal end. Fiberglass exposed on all margins; - As a result of the lack of soft roll and padding, the resident's arm slid proximally in the cast with her fingers inside the cast itself. A significant issue as the fingers should protrude through the cast by four to five inches; - A severe foul odor was coming from the cast; - Drainage was present on the ulnar aspect (side of cast on wrist below fifth finger) of the fiberglass; - A wound, with large amount foul yellow drainage, was found on the left ulnar when cast removed; - Radiological examination of left wrist showed severely displaced wrist with prominence dorsally and complete radial collapse, unstable fracture with simple traction caused fracture fragments to move across each other; - Wound on the ulnar side indicates an open fracture with tissue necrosis (dead tissue) along the ulnar margin; - Resident very confused and unable to participate in sensory examination; - We received no contact from the facility regarding the resident having complications with the cast, putting foreign objects in the cast, or any sort of drainage noted from the fractured wrist; - We made multiple contacts with the facility from the office to push them to get medical clearance for surgery. At no time did the facility express concerns about Resident #1's cast; - The Resident to have surgery, wrist needs to be stabilized, anticipate external fixation of wrist., wound vac to the wound after an incision and drainage (clean out the infection) of the wound and anticipate potential long term intravenous antibiotics because of the wound. During an interview on 1/5/18 at 2:20 P.M., Licensed Practical Nurse (LPN) A said: - On 12/7/17 Resident #1 had a fractured left wrist and started with a soft cast (a splint with padding wrapped with ace bandage to immobilize a fracture until surgery or hard cast is applied) but took it apart; - On 12/8/17, resident had a hard cast (stocking is applied to hand and arm and then wrapped with cast padding, to prevent pressure areas and sores, and then wrapped in fiberglass cast material snugly to keep bones in line) applied at the doctor's office; - Resident #1 constantly picked at the cast padding and pulled it out; - Resident #1 had food in the cast at times; - LPN A tried to keep Resident #1's cast cleaned out by using a cotton tip applicator to swipe inside cast; - LPN A did notice some odor coming from the cast, but thought it was from the food; - Resident #1's cast should have been assessed each shift and documented in the nurses notes; - LPN A said he/she did assess Resident #1's cast and thought he/she documented in the notes about the cast. - LPN A did not contact the resident's physician or orthopedist regarding the condition of the cast. During an interview on 1/5/18 at 2:30 P.M., LPN B said: - There was a cardiologist appointment on 12/13/17 when surgery was canceled due to resident's complaint of chest pain. There was a scheduling issue and the resident could not go then; - When an appointment is made by nurse form is filled out and given to front desk to arrange transportation. During an interview on 1/5/18 at 3:00 P.M., LPN D said: - Resident #1 constantly pulled and picked at the cast; - LPN D saw that the cast padding had been pulled out, but did not remember a date; - LPN D said he/she checked the cast for foreign matter, pain and swelling but did not document in chart; - LPN D said a cast should be assessed one time per shift and documented in nurse notes or on Medicare A sheet; - LPN D did not contact the resident's physician or orthopedist regarding the condition of the cast. During an interview on 1/5/18 at 2:55 P.M., the ADON said: - On the day of surgery the resident complained of chest pain after arriving at surgery center; - The resident just had an EKG the day before; - The ADON received call on 12/13/17 from orthopedist office to send resident to cardiologist for surgical clearance, but transportation was unavailable at that time; - The ADON said he/she did not send the resident to the emergency room because the resident was not in distress; - The resident was rescheduled at a later date to have echocardiogram and EKG; - The ADON did not know why it took from 12/13/17 to 1/2/18 to obtain cardiac clearance for surgery. During an interview on 1/5/18 at 3:15 P.M., the Director of Nurses (DON) said: - Staff should have been inspecting Resident #1's cast and wrist every day and documenting as per the physician's orders [REDACTED].>- The order to inspect the cast daily should have been written on the TAR and carried out as per the physician's orders [REDACTED].>- Staff should have notified the doctor of the condition of the cast. During an interview on 1/5/18 at 3:15 P.M., the administrator said: - She would expect physicians orders, assessments and documentation done; - The facility did not have a policy for cast care. During an interview on 1/11/18, the orthopedic nurse practitioner said: - Resident #1 only initially needed one surgery, but has now had two surgeries and three more are expected; - The wound and bone of left wrist are infected and resident is receiving intravenous antibiotics; - She had expected cardiac clearance to be obtained right away; - She expected facility staff to notify the physician of any deterioration of the cast including foreign objects and food. Refer to Complaint MO 374

Based on observation, interview and record review, the facility failed to identify a significant weight loss of 30% in three months for one resident (Resident #10) of 16 sampled residents. The facility census was 80. 1. Record review of Resident #10's admission Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility) dated 5/28/13, showed: - Cognitive status intact; - Clear speech; - Able to make self understood; - Understands others; - No depression; - Supervision and set-up only for eating; - Weight (wt.)146 pounds (lbs.); - No significant weight loss; - No loosely fitting dentures. Record review of the Registered Dietitian's (RD) initial Nutrition Risk assessment dated [DATE] showed: - Weight 145.6 lbs.; - Height 67 inches; - Regular diet with no known food allergies [REDACTED]. - Supplements/snacks: as per care plan; - Weight status - Weight going up; - Oral/Nutrition intake (food) - Intake meets 76-100% of estimated needs -Snacks in room; - Oral/Nutrition intake (fluids) - Consumes 1,500 - 2,000 cubic centimeters (cc)/day; - Skin Conditions - skin intact; - Overall Risk - Moderate to High. Record review of the RD's Dietary Progress Notes showed: - On 6/25/13, Resident #10's weight documented at 149.8 lbs., a slight trend up, and to start Vitamin C and [MEDICATION NAME] to promote wound healing; - On 7/15/13, the resident's weight documented at 147.1 lbs., and to continue current nutritional management; - On 7/29/13 (last progress note entered), the resident's weight documented at 149.9 lbs., weekly weights reflect significant changes likely due to human error; - Resident #10 told RD usual weight 160 lbs. and he/she is trying to gain weight; - He/she is a high nutritional risk; - The resident's intake is 0-50%; - He/she refuses any commercial supplements, but is agreeable to super cereal (extra butter and sugar), power potatoes (extra butter); - RD suggest one fortified food per meal, monitor weight and follow up Review of the facility's Weight Sheet and Weekly Weight Meeting notes dated 5/15/13 through 7/31/13 showed: - May 2013 Weights: 5/15 - 145.6 lbs.; 5/20 - 146.1 lbs.; - June 2013 Weights: 6/07 - 147.2 lbs.; 6/18 - 148.3 lbs.; 6/21 - 149.8 lbs. 6/26 - 150 lbs. - Resident discontinued from weekly weights; - July 2013 Weights: 7/03 - 120.4 lbs. - Reweigh of 130.0 lbs., nursing restarted weekly weights and recalibrated scale; 7/10 - 147.1 lbs. - No reweigh; 7/17 - 107.0 lbs - Reweigh 105.2 lbs.; - A 44.8 lb. (30%) weight loss in three weeks; - Nursing added super cereal with extra butter and sugar and cheesy eggs for breakfast and power potatoes with extra butter at lunch and supper and full panel blood lab work to be drawn on 7/18/13; 7/24 - No weight obtained by facility; 7/31 - 104.2 lbs. with no new interventions initiated. During an interview on 8/6/13 at 4:45 P.M., the ADON said nursing staff weighed Resident #10 and he/she weighed 101.0 lbs. Resident #10 lost 49.0 lbs. (33%) in six weeks. Record review of Resident #10's nursing notes showed: - From 5/15/13 through 7/12/13, the resident's appetite good to fair; - From 7/13/13 through 8/6/13, the resident's appetite poor. Record review of the Assistant Director of Nursing (ADON) documentation in the resident's nursing notes dated 7/18/13 showed: - Weight had fluctuated for three weeks; - Restorative Therapy Aides (RTA) personnel (they are in charge of weighing the residents) inconsistent for three weeks; - Resident #10's physical appearance shows drastic change with a decline noted; - Appetite very poor. Record review of Resident #10's admitting Physician order [REDACTED]. - [DIAGNOSES REDACTED]. - Regular diet; - Dietary supplements/interventions per care plan. Record review of Resident #10's POS's dated 7/1/31 through 7/31/13 and 8/1/13 through 8/31/13 showed: - Regular diet; - [DIAGNOSES REDACTED]. - Dietary supplements/interventions per care plan. Record review on 8/6/13 of Resident #10's care plan dated 5/28/13, showed: - No nutritional care plan; - No dietary supplements or interventions in place. During an interview on 8/6/13 at 8:23 A.M., the Director of Nursing (DON) said Resident #10's original care plan dated 5/28/13 did not address the resident's nutritional needs and had not been updated to reflect the change in his/her condition. During an interview on 8/14/13 at 2:19 P.M., the DON said Resident #10's [DIAGNOSES REDACTED]. Record review on 8/6/13 of Resident #10's breakfast dietary card showed: - Regular diet; - Cheesy eggs; - Super Cereal with extra butter and sugar. Observation on 8/6/13 at 8:45 A.M., during Resident #10's breakfast meal showed: - Regular scrambled eggs served without cheese and ate 0%; - One 240 cubic centimeters (cc) bowl Super Cereal served and ate 0%; - One sausage patty served and ate 25%; - One pancake served and ate 0%; - One 180 cc glass of juice served and drank 100%; - One 240 cc glass of milk served and drank 100%; - One 240 cc cup of hot chocolate served and drank 100%; - One 180 cc glass of [MEDICATION NAME] (supplemental drink to help wound healing) served and drank 100%. Observation on 8/6/13 at 9:43 A.M., of Resident #10 showed: - Very thin, bony, and very pale in color; - Skin loose and hung from bones and little muscle tone noted; - Skin fragile with skin tear to left fore arm, several bruises on arms in various stages of healing; - The resident's ribs, backbone, tailbone/coccyx bones, left hip bone, femur (long leg bone from knee to hip) were very prominent and showed through the resident's thin skin; - He/she had developed pressure ulcers on his/her left hip, coccyx and right heel; - The Assistant Director of Nursing (ADON) asked the resident questions, but the resident's top dentures were loose and moved up and down and caused him/her to mumble making him/her not understandable; - The ADON asked the resident to repeat what he/she said, and still could not understand what the resident said. During an interview on 8/6/13 at 10:15 A.M., the ADON said, in the past two weeks, Resident #10 more difficult to understand due to mumbling. The resident at times refused to get up for meals because he/she was too tired, weak and not feeling well. Record review on 8/6/13 of Resident #10's lunch dietary card showed: - Regular diet with no additional fortified foods. Observation on 8/6/13 at 1:15 P.M., during Resident #10's lunch meal showed: - Served one 240 cc bowl of mashed potatoes with extra butter and ate one bite; - One 120 cc bowl of rice pudding served and ate 0%; - One 240 cc bowl of beans and ham served and ate 0%; - One 180 cc chocolate milkshake served and drank 100%; - One 240 cc chocolate milkshake served and drank 100%; - One 120 cc [MEDICATION NAME] served and drank 75%. Observation on 8/6/13 at 1:17 P.M., showed Licensed Practical Nurse (LPN) Manger C encouraged Resident #10 to eat one bite of fortified mashed potatoes and he/she ate one bite and refused to eat more. LPN C offered the resident another chocolate milkshake and he/she agreed and drank 100%. Observation on 8/6/13 at 1:21 P.M., showed the DON tried to get the resident to eat more of his/her fortified potatoes and he/she refused. The DON offered to get the resident something else to eat and he/she refused. The DON said to the resident "you're quite the drinker". During an interview on 8/6/13 at 1:27 P.M., LPN C said Resident #10 refused the turkey dinner that had been served, but agreed to eat ham and beans. LPN C said he/she brought the resident a bowl of ham and beans and he/she drank all the juice in the bowl, but refused to eat the ham and beans. During an interview on 8/6/13 at 2:18 P.M. with resident #10, he/she could not speak clearly due to his/her upper dentures being too large for his/her mouth. The dentures fit loosely and moved up and down when he/she tried to speak. He/she mumbled answers that were not understandable. During an interview on 8/14/13 at 2:19 P.M., the DON said: - Obvious to look at Resident #10, he/she could see the resident had lost a significant amount of weight; - No problem with the scale; - Lack of continuity with the RTA's who weighed the resident; - Licensed nursing staff nor the RD did not weigh the resident; - After 44.8 lb. weight loss the week of 7/17/13, he/she did not know why the next week the resident was not weighed, but should have been weighed; - ADON notified the physician on 7/18/13 of the resident's weight loss and the new interventions; - Physician in agreement with interventions and to continue to monitor resident; - He/she felt the facility had a bad three weeks and obtained bad weights; - He/she did not know what happened; - The resident's dentures were too loose, and they spoke with the family, but they plan to take the resident home 8/15/13 and place him/her on Hospice services; - Feels the facility staff tried everything possible to get the resident to eat, but could have done a better job of documenting what they did. On 8/15/13 at 2:45 P.M. message left with Resident #10's physician to please return call and gave a brief description of needed information. The physician did not return the call. On 8/16/13 at 8:16 A.M. left with Resident #10's physician's nurse to please have the physician return the call and gave him/her a brief description of needed information. Physician did not return the call. Record review of the facility's undated policy, "Health Care Management Resident Weight Policy and Procedure", showed: - Restorative Aide (RA) will be responsible for obtaining resident's weight each month by the 7th; - Weights will be turned in to the Care Plan Coordinator (CPC) and the DON/Designee; - CPC will enter the weights into the NH Care System by the tenth of each month; - CPC will generate a weight status report and a copy given to the Administrator, DON, Dietary Manager (DM), and the consultant dietician; - Weight Committee will meet weekly (Administrator, ADON, DON, CPC, DM, and a representative of the therapy department; - Weight Committee will discuss residents with a significant weight loss (5% or more in 30 days, 7.5% or more in 90 Days, or 10% or more in 180 days); - Weigh Committee will also discuss any resident with a slow progressive unplanned weight loss that may not meet the criteria for a significant loss, but requires interventions to stop weight loss; - Interventions initiated by the Committee will be documented to illustrate ongoing interventions and progress made; - Dietary Cards will be updated by the DM during the meeting to ensure interventions are communicated to and followed through by the dietary department; - CPC will update individual resident care plans during the meeting to reflect progress and any new interventions implemented.