Every finding on record at St Joseph Manor Health & Rehabilitation

Based on interview and record review, the facility failed to follow their policy and ensure an injury of unknown origin for Resident #1 was reported to the state survey agency within two hours. The facility census was 62. Review of the facility provided policy Abuse Investigation and Reporting dated July 2017 showed:-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to the Administrator, local , state and federal agencies, and thoroughly investigated;-All alleged violation of abuse, neglect, exploitation, or mistreatment, (including injuries of unknown source) will be reported immediately but not later than: 2 hours if the alleged violation involves suspicion of a crime, abuse or has resulted in serious bodily injury.Review of Resident #1 admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 07/14/26 showed:-Brief Interview of Mental Status (BIMS) of 6 indicated cognitive deficits;-No impairment of upper extremity and lower extremity movement; -Used wheelchair or walker for mobility; -Needed partial staff assistance with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-No pain;-Diagnoses of: Lewy Body Dementia with behavioral disturbance (a progressive brain disorder characterized by confusion, and trouble with attention, problem solving and planning), Depressive Disorder, Post Traumatic Stress Disorder (PTSD) and adjustment disorder (stronger than normal emotional or behavioral reactions to stressful situations).Review of the resident's Comprehensive Care Plan dated 07/10/26 showed:-He/She had impaired safety awareness; -He/She had a communication problem, and was able to make basic needs known; -He/She had acute pain; Staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Monitor/record/report to Nurse any non verbal signs and symptoms of pain such as grimacing, grunting, moaning, restlessness, irritability, etc.; Notify the physician if interventions are unsuccessful.Review of the resident's Nurse Progress Notes showed:-Between 08/01/26 to 08/15/26 no falls, injuries, behaviors, complaints of pain, or resident leaving the facility was documented; -On 08/16/26 at 10:45 P.M., he/she continued to complain of pain with movement of right lower extremity; -08/17/26 at 10:22 A.M., he/she complained of right knee pain and would not stand and walk; -08/18/26 at 3:28 A.M., he/she complained of pain in right knee and hip; the Physician was notified and orders received to send the resident to the hospital. Review of hospital computed tomography (CT: an imaging test that creates detailed images of bones, organs and soft tissues) of the right knee, dated 08/17/26 at 9:20 P.M. showed: a stable hairline crack running up and down on the outer side of the kneecap, where the bone pieces had not separated or shifted out of place. (Vertical, nonseparated/nondisplaced fracture is demonstrated in the lateral patella). During an interview on 08/31/26 at 10:30 A.M., the Administrator said:-The resident's family reported the resident was hurt or fell while in the facility; -The resident had been out with his/her family and returned to the facility in pain; -The facility did not know what happened to cause the fracture; -She did not complete an investigation or report the injury but should have. Intake 3169283

Based on interview, and record review, the facility failed to ensure a complete and effective pain management program was in place for one resident (Resident #1) when staff failed to provide and document interventions when pain medication was ineffective, and failed to notify the physician of unrelieved pain. The facility census was 62. Review of the facility provided policy Administering Pain Medications and Pain Management dated March 2020 showed:-The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain;-Pain management is defined as the process of alleviating the resident's pain based on his/her condition;-Pain management includes: addressing the underlying cause of pain; Developing and implementing approaches to pain management; Modifying approaches as necessary; -Acute(sudden discomfort that acts as a warning sign of bodily injury or illness) pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained;-Pain management interventions shall address the underlying cause; -Pharmacological interventions may be prescribed to manage pain; -The physician and staff will establish a treatment regimen that may include: administering medications around the clock and not only as needed; combining narcotic and non-narcotic medications;-If pain has not been adequately controlled the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments. 1.Review of Resident #1's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 07/14/26 showed:-Brief Interview of Mental Status (BIMS) of 6 indicated cognitive deficits;-No impairment of upper extremity and lower extremity movement; -Used wheelchair or walker for mobility; -Needed partial staff assistance with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-No pain;-Diagnoses of: Lewy Body Dementia with behavioral disturbance (a progressive brain disorder characterized by confusion, and trouble with attention, problem solving and planning), Depressive Disorder, Post Traumatic Stress Disorder (PTSD) and Adjustment Disorder (stronger than normal emotional or behavioral reactions to stressful situations). During an intake interview on 08/18/26 at 4:29 P.M. the resident's Family member said:-The resident was taken out of the facility on 08/16/26 at 2:30 P.M.; -The resident could not move his/her leg and cried out in pain; -At 6:30 P.M., the resident was returned to the facility and staff were told of his/her complaints of pain and the need to be checked on; -At approximately 8:30 P.M. a facility nurse called the family member and asked what had happened to the resident while he/she was out of the facility; -On 08/17/26 at 9:00 A.M., he/she saw the resident and the resident was still in pain and at 7:00 P.M. an x-ray had not been completed;-The resident was sent to the hospital and found to have a broken knee cap. Review of the resident's Comprehensive Care Plan dated 07/10/26 showed:-He/She had impaired safety awareness; -He/She had a communication problem, and was able to make basic needs known; -He/She had acute pain; Staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Monitor/record/report to Nurse any non verbal signs and symptoms of pain such as grimacing, grunting, moaning, restlessness, irritability, etc.; Notify the physician if interventions are unsuccessful.Review of the resident's Medication Administration Record for August 2026 showed Acetaminophen 650 milligrams (mg) every four hours as needed for pain, start date of 07/08/26 was administered: -08/12/26 at 7:57 P.M. for pain rating of 7 on a scale of 0-10,( 0 being no pain and 10 being the worst pain ever felt) and was effective; -08/16/26 at 3:11 P.M. for pain rating of 10, and effectiveness was unknown; -08/17/26 at 4:31 P.M. for pain scale of 10, and effectiveness was unknown; -08/18/26 at 6:55 A.M. for pain scale of 4, and was effective; -08/19/26 at 9:31 A.M. for pain scale of 10, and was ineffective; -08/19/26 at 1:34 P.M. for pain scale of 10, and was ineffective; -08/20/26 at 12:19 P.M. for pain scale of 10, and was ineffective; -08/21/06 at 7:02 A.M. for pain scale of 10, and was ineffective; -08/21/26 at 4:26 P.M. for pain scale of 10 and effectiveness was unknown. Review of the resident's Nurse Progress Notes showed:-On 08/16/26 at 6:30 A.M. he/she was sitting up, had no complaints of pain or discomfort and was confused as normal; -On 08/16/26 at 10:45 P.M., he/she continued to complain of pain with movement of right lower extremity and chest hurting; Nurse Practitioner (NP) was notified, and orders were received to send to the emergency room for increased pain; -08/17/26 at 10:22 A.M., he/she complained of right knee pain and would not stand and walk; his/her family member requested a x-ray of his/her knee; The NP was notified and orders were received for mobile x-ray;-08/17/26 at 2:08 P.M., he/she slid onto the floor from the wheelchair; he/she complained of pain in his/her back, knee and hip; awaiting x-ray to be completed; -08/18/26 at 3:28 A.M., he/she complained of pain in right knee and hip; Family requested the resident be sent to the hospital as mobile x-ray could not be completed until tomorrow; the Physician was notified and orders received to send the resident to the hospital. Review of hospital computed tomography (CT: an imaging test that creates detailed images of bones, organs and soft tissues) of the right knee, dated 08/17/26 at 9:20 P.M. showed: a stable hairline crack running up and down on the outer side of the kneecap, where the bone pieces had not separated or shifted out of place. (Vertical, nonseparated/nondisplaced fracture is demonstrated in the lateral patella). During an interview on 08/31/26 at 3:40 P.M. Registered Nurse (RN) A said: -Certified Medication Technician's (CMT) can give acetaminophen without notifying the Charge Nurse;-He/She would expect the CMT to notify the Charge Nurse if acetaminophen was not effective for pain; -If acetaminophen or any pain medication was not effective he/she would notify the physician and get other orders. During an interview on 08/31/26 at 3:54 P.M. Certified Nurse Aide (CNA) A said:-The resident complained of pain when he/she returned to work on 08/18/26; -The resident would grimace and groan with any movement of his/her leg. During an interview on 08/31/26 at 3:00 P.M. the Administrator said: -He/She would expect the CMT staff to notify the Charge Nurse if any pain medication was ineffective; -He/She would expect the nurse to notify the physician if the pain medication was ineffective.During an interview on 08/31/26 at 3:25 P.M. the Interim Director of Nursing said:-He/She expected the CMT staff to notify the nurse and the nurse notify the physician if pain medication was ineffective. During an interview on 09/01/26 at 10:38 A.M. CMT A said:-He/She gave the resident pain medication because his/her knee was broken and he/she assumed he had pain; -The resident had facial grimacing and grunting to indicate pain; -He/She did not remember what day or time he/she gave the resident medication; -He/She always notified the nurse when pain medication was given and if it was not effective;-He/She did not remember what nurse he/she notified the pain medication was ineffective. Intake 3169283

Based on record review and interview the facility failed to investigate an injury of unknown source as per their policy Abuse Investigation and Reporting when Resident #1 was found to have a fractured knee cap with no known fall, or injury to the area. The facility census was 62.Review of the facility provided policy Abuse Investigation and Reporting dated July 2017 showed:-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to the Administrator, local , state and federal agencies, and thoroughly investigated;-If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual; -The individual conducting the investigation will, at a minimum: Review completed documentation forms; Review the resident's medical record; Interview the persons reporting the incident; Interview the resident; Interview the attending physician; Interview staff members; Interview other residents; Review all events leading up to the alleged incident;-Witness reports will be obtained in writingReview of Resident #1's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 07/14/26 showed:-Brief Interview of Mental Status (BIMS) of 6 indicated cognitive deficits;-No impairment of upper extremity and lower extremity movement; -Used wheelchair or walker for mobility; -Needed partial staff assistance with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-No pain;-Diagnoses of: Lewy Body Dementia with behavioral disturbance (a progressive brain disorder characterized by confusion, and trouble with attention, problem solving and planning), Depressive Disorder, Post Traumatic Stress Disorder (PTSD) and adjustment disorder (stronger than normal emotional or behavioral reactions to stressful situations).Review of the resident's Comprehensive Care Plan dated 07/10/26 showed:-He/She had impaired safety awareness; -He/She had a communication problem, and was able to make basic needs known; -He/She had acute pain; Staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Monitor/record/report to Nurse any non verbal signs and symptoms of pain such as grimacing, grunting, moaning, restlessness, irritability, etc.; Notify the physician if interventions are unsuccessful.Review of the resident's Nurse Progress Notes showed:-On 08/16/26 at 10:45 P.M. , he/she continued to complain of pain with movement of right lower extremity; -08/17/26 at 10:22 A.M., he/she complained of right knee pain and would not stand and walk; -08/18/26 at 3:28 A.M., he/she complained of pain in right knee and hip; the Physician was notified and orders received to send the resident to the hospital. Review of hospital computed tomography (CT: an imaging test that creates detailed images of bones, organs and soft tissues) of the right knee, dated 08/17/26 at 9:20 P.M. showed: a stable hairline crack running up and down on the outer side of the kneecap, where the bone pieces had not separated or shifted out of place. (Vertical, nonseparated/nondisplaced fracture is demonstrated in the lateral patella). During an interview on 08/31/26 at 3:00 P.M., the Administrator said:-The resident's family reported the resident was hurt or fell while in the facility on 08/16/26; -The resident had been out with his/her family and returned to the facility in pain on 08/16/26; -The facility did not know what happened to cause the fracture; -She did not complete an investigation, but should have. During an interview on 08/31/26 at 3:25 P.M., the Director of Nursing said:-He/She was out of the facility at the time the resident's fracture was found; -He/She was not aware an investigation had not been done; -The Administrator was responsible for the investigation.Intake 3169283

Based on observation, interview and record review the facility failed to protect one resident's (Resident #31) right to be free from physical abuse when Resident #5, approached Resident #31 in the smoke room and threw a wheel chair break extender (an accessory that lengthens wheel chair break levers) at resident #31, breaking a window in the smoke room. This affected one of three sampled residents. The facility census was 66. Based on observation, interview and record review the facility failed to protect one resident's (Resident #31) right to be free from physical abuse when Resident #5, approached Resident #31 in the smoke room and threw a wheelchair break extender (an accessory that lengthens wheelchair break levers) at Resident #31, breaking a window in the smoke room. This affected one of three sampled residents. The facility census was 66. Review of the facility's policy titled Abuse Prevent Program, dated December 2016, showed:-Residents had the right to be free from verbal and physical abuse;-The facility will protect residents from abuse;-The facility will implement policies and procedures to prevent abuse or mistreatment of residents.1. Review of Resident #5's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 05/10/26, showed:-No cognitive impairment;-Impairment on the one side of the body;-Substantial assistance with toileting, showers and dressing;-Diagnoses included: Schizophrenia (a chronic brain disorder that affects a person's ability to think, feel, and behave clearly), stroke (damage to tissues in the brain due to a loss of oxygen to the area) and high blood pressure.Review of the resident's care plan dated 08/01/26 showed:-Assistance of one staff member for Activities of Daily Living (ADL)s'-The resident had behaviors; -The resident was verbally aggressive toward staff and other residents;-The resident threw objects.During an interview on 08/03/2026 at 11:19 A.M., the Resident #5 said: -Resident #31 glared at him/her for no reason in the smoke room the other day;-He/She threw the wheel chair break extenders at Resident #31;-The break extenders missed resident #31 and broke the window in the smoke room;-He/She received two tickets after the police came because he/she broke the window. 2. Review of Resident #31's Quarterly MDS, dated [DATE], showed:-No cognitive impairment;-Independent with ADLs;-Diagnoses included: high blood pressure, kidney failure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of the resident's care plan dated 06/18/26 showed:-Above the knee amputation;-Limited physical mobility;-Continent of bowel and bladder; During an interview on 08/04/2026 at 10:28 A.M., the Resident #31 said: -He/She was in the smoke room with Resident #53;-Resident #5 came in the smoke room and threw part of a wheel chair at him/her;-Resident #5 tried to start trouble with him/her by staring at him/her; -He/She felt intimated by resident #5 and resident #5's presence made him nervous;-He/She hoped the resident moved out soon.3. Review of Resident #53's Quarterly MDS dated , 03/17/26 showed:-No cognitive impairment;-Supervision with ADLs;-Diagnoses included: dementia (a group of thinking and social symptoms that interferes with daily functioning), high blood pressure and depression.Review of the resident's care plan dated 6/2/26 showed:-Limited physical mobility-Incontinent of bowel and bladder.During an interview on 08/05/26 at 09:12 A.M. the Resident #53 said:-He/She and Resident #31 sat in the smoke room;-Resident #5 came into the smoke room and yelled at resident #31;-Resident #5 removed the break sticks off his/her wheelchair and threw them at resident #31;-The break stick missed resident #31 and broke a window;-The police came and talked to resident #5-Resident #53 he/she felt angry his/her smoke time was interrupted. Review of the facility's investigation showed:-On 07/29/26 resident #5 threw the foot pedal from his wheelchair at resident #31;-The object missed resident #31 and broke a window in the smoke room;-No residents were injured;-Resident #5 was placed on 15 minute checks;-Resident #5 told the Administrator he/she threw the wheel chair break at resident #31 because resident #31 rammed his/her wheel chair;-The residents lived on opposite sides of the building.During an interview on 08/05/26 at 1:01 P.M., Certified Nurses Aide (CNA) E said:-He/She worked on the day resident #5 threw the wheelchair break extender at Resident #31;-Resident #5 often yelled at resident #31 and other residents;-On 07/29/26 resident #5 came to the smoke room where Resident #31 was sitting with another resident;-Resident #5 asked resident #31 what he/she was staring at;-Resident #5 took the break handles off of his/her wheel chair and threw them at Resident #31;-Abuse was intentional as Resident #5 intended to throw the break at Resident # 31;-All residents had the right to be free from abuse.During an interview on 08/06/2026 12:09 P.M., the Regional Nurse said: -She felt resident #5 intended to hit resident #31 with wheelchair break;-Abuse was done on purpose and intended; -All residents had the right to feel and be safe. During an interview on 08/06/2026 12:48 P.M., the Administrator said: -Abuse was intentional; -Resident #5 was upset with Resident #31;-CNA F told the administrator resident #5 was upset with resident #31;-Resident #5 intentionally threw the wheel chair break at Resident #31 because he/she was upset with Resident #31;-She did not know why the resident's were upset with each other;-All residents had a right be free from abuse. Intake 3122162

Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when a facility staff member physically forced the resident into his/her room. Upon assessment, the resident was had burst blood vessel on his/her left thumb. The facility census was 65.On 6/25/26, the Administrator was notified of the past noncompliance incident which occurred on 6/18/26. On 6/18/26, facility administration was notified of an allegation of staff to resident abuse, an investigation immediately began and corrective actions were implemented to include: Assessment of the Resident, suspension of the accused staff member, interviews with other residents for indications of abuse, and mandatory in-service training for all staff on abuse, dignity and safe resident handling. The noncompliance was corrected on 6/19/26. Review of facility policy, Abuse Prevention Program, revised December 2016, showed:- Residents have the right to be free from abuse, neglect, and misappropriation of resident property;- The administration will protect residents from abuse by facility staff;- Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior;- The facility will identify and assess all possible incidents of abuse, investigate and report any allegations of abuse, and protect resident during abuse investigations. 1. Review of Resident #1's Face Sheet, dated 6/19/26, showed:-The resident was not their own person and had two Designated Power of Attorneys for his/her healthcare;- Diagnosis: stroke, aphasia (neurological disorder that impairs a person's ability to speak, write, and understand spoken and written language), dysphagia (difficulty in swallowing food or liquids), diabetes, GERD (acid reflux), anxiety disorder, and dementia;Review of the resident's Care Plan, undated, showed:- The resident had potential to be physically aggressive due to anger, pain, and frustration. Staff should provide physical and verbal cues to alleviate anxiety and give positive feedback and guide away from source of distress.- The resident had a communication problem. Staff should allow adequate time to respond and repeat as necessary. Do not rush and request clarification from the resident to ensure understanding. - The resident had potential for impairment to skin integrity. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface.Review of the resident's Progress notes, dated 6/18/26 at 3:30 P.M., showed a Late Entry 6/25/26 at 11:54 A.M. note that said CNA (A) pushed the resident down the hall in a wheelchair while resident was expressing audible anger. The resident tried to prevent entry into their room by placing his/her hand on the door frame to stop the wheelchair. CNA (A) forcibly grabbed the resident's hand and removed it from the door frame. CNA (A) then pushed the resident's wheelchair into the room and began to argue with the resident. LPN (A) entered the room and confronted CNA (A) about the incident, CNA (A) left the room without a response. LPN (A) assessed the resident and noted a nickel size bruise to the left hand with no other injuries. LPN (A) calmed the resident down and reported the incident to Human Resources and the Administrator. Record Review of resident Skin Assessment, dated 6/18/26 at 3:30 P.M., showed bruising on the back of the left hand. Review of Follow-up Investigation Form, dated 6/18/26, showed:- Facility staff witnessed CNA (A) pulling the resident's hand from a door frame and speaking to the resident in an abusive manor. Multiple facility staff gave statements of improper behavior by CNA (A). The resident had an area on his/her left thumb with a burst blood vessel. - Incident was reported to physician's office.- CNA (A) was suspended pending investigation.- CNA (A) admitted to Human Resources (HR) and the Administrator that he/she forcefully made the resident return to his/her room. He/she removed the resident from the dining room because he/she was messing with the cabinets and the sugar stored in them. - The resident BIMS score of zero showing the resident had severe cognitive impairment. Trauma screening showed some symptom indicators and resident had mild depression.- Conclusion of investigation by facility showed CNA (A) was aggressive both physically and verbally with the resident per witness statements. CNA (A) was terminated from his/her position. Record review of interviews and statements collected during the facility investigation showed:- Human Resources Manager (HRM) statement showed she interviewed Resident #1, (all dates/times unknown) who said his/her hand did not hurt but it hurt when CNA (A) grabbed his/her hand. The resident had a small bruise on his/her left thumb from this incident. HRM interviewed Resident #4 who said CNA (A) makes him/her feel uncomfortable. HRM interviewed Resident #5 who said CNA (A) speaks very loudly to all of the residents as if each resident required a hearing aid. HRM interviewed Resident #6 who said CNA (A) doesn't listen to the residents and is very negative. HRM interviewed Resident #7 who said CNA (A) is very aggressive and would not listen to the resident when being changed. The whole process with CNA (A) was rough handling by CNA (A). CNA (A) did apologize to the resident several days later. When the HRM and Administrator interviewed CNA (A) he/she said he/she tried to keep Resident #1 from interfering with an activity that was going on in the dining room. The resident was not happy about going back to his/her room and he/she remembers yanking the resident's hand away from the door frame. - CNA (A) statement showed he/she noticed Resident #1 playing with sugar packets in the dining room and he/she needed to go back to his/her room due to his/her behaviors. The resident was being combative all the way back to his/her room. CNA (A) just left the resident at his/her room since he/she was being so combative. - CNA (C) statement showed an incident while working with CNA (A) on 6/17/26. CNA (A) was in Resident #6's room removing trash. CNA (C) entered the room and requested CNA (A) assist him/her in getting the resident ready for bed. CNA (A) was briefed by CNA (C) on the resident's routine for going to bed. CNA (A) turned to the resident and said, We are going to get this done and we're not going to have problems. CNA (C) considered the interaction with the resident rude and unprofessional. The resident looked at CNA (C) with a confused look on his/her face. CNA (C) checked on the resident later to make sure he/her was okay and he/she had no concerns. - LPN (A) statement showed on 6/19/26 at 3:30 P.M. that he/she sat at the North Hall nurses' station when CNA (A) stood up abruptly and went down the hall towards the dining room. CNA (A) came back towards him/her pushing Resident #1's wheelchair. The resident was yelling and CNA (A) attempted to push the resident into his/her room but the resident grabbed the door frame. CNA (A) forcibly grabbed the resident's had and removed it from the door frame and then pushed the resident's wheelchair into the room. CNA (A) told the resident he/she was going to go to bed and the resident was yelling at CNA (A). LPN (A) entered the room and asked CNA (A) what the issue was with the resident and CNA (A) left the room without providing an answer. LPN (A) calmed the resident down and assessed the resident and noted a small bruise to the left hand between the thumb and index finger. Administrator was immediately notified. Record review of Trauma/Abuse/Neglect screening, dated 6/19/26 at 2:25 P.M., showed no concerns.Review of Corrective Action Form, dated 6/22/26, showed:- CNA (A) was terminated for performance/behavioral conduct;- Reason for Action: Speaking and acting aggressively towards a resident, not adhering to resident rights and admitted to performing the aforementioned actions. Observation of the resident on 6/25/26 at 9:45 A.M. at the Nurses' station showed:- The resident was quiet and calm with no anxiety or distress noted;- The resident was unable to communicate when asked questions due to cognitive ability;- No bruises or marks were observed on the resident's hands. During an interview on 6/25/26 at 9:20 A.M., LPN (A) said:- He/She sat at the nurse's station charting and CNA (A) sat at another computer station nearby. CNA (A) abruptly stood up and quickly went to the dining hall. He/She then saw CNA (A) pushing the resident down the hall in their wheelchair. The resident's ability to communicate was very limited but he/she could tell that the resident was extremely distressed since he/she had been taking care of the resident for the last four years. CNA (A) was verbally aggressive with the resident and his/her actions were not calming the resident down at all.- CNA (A) got the resident to their room but before they could enter, the resident grabbed the door frame to resist entering the room. CNA (A) then forcibly removed the resident's hand from the door frame. LPN (A) then approached CNA (A) and asked what caused him/her to react towards the resident in an aggressive manor. CNA (A) did not have an explanation and exited the room and walked away from LPN (A) instead of answering the question. From what he/she observed CNA (A) was trying to put the resident into bed and the resident didn't want to go to his/her room or bed but was forcibly made to by CNA (A). - LPN (A) calmed the resident down and did a skin assessment. The resident appeared to have a small bruise forming between the thumb and index finger which was the location that CNA (A) had grabbed the resident. - LPN (A) then informed HR and the Administrator of the incident. Since the incident the resident has been at baseline behavior with no indications that the incident had any negative effect on him/her. During an interview on 6/25/26 at 2:45 P.M., the Administrator said:- She would expect an abuse incident with a resident to be documented in the resident's progress notes.- She would expect skin assessments for the resident in a physical abuse incident to be recorded in the resident's medical record. - Based on her investigative findings, the incident between CNA (A) and the resident was physical and mental abuse. Residents have the right to be free from abuse. During an interview on 6/29/26 at 9:10 A.M., CNA (A) said he/she admitted that he/she was just trying to get the resident to calm down and putting the resident to bed was how he/she decided it should be handled. During an interview on 6/29/26 at 1:34 P.M., CNA (A) said:- The resident was in the dining room around lunch time and messing around with the dietary supplies and based on the Business Manager's reaction to the resident playing with the sugar packets he/she needed to remove the resident from the dining room and put him/her into bed.- He/She took the resident by wheelchair to his/her room but the resident was being combative about leaving the dining room. CNA (A) doesn't remember if the resident put his/her hands on the door frame to prevent entrance to the room. If he/she removed the resident's hand from the door frame he/she was certain it was done gently and would not leave any bruising. Bruising would indicate a level of abuse in his/her opinion. He/She was very nice to the resident and spoke to him/her with respect during the altercation. Rather than leaving the resident alone at the front of his/her room he/she forced the resident into his/her room because it would be safer than leaving the resident in the hallway Intake 3048841

Based on observation, interview and record review, the facility failed to implement the Resident Smoking Policy when one sampled resident (Resident #3) out of 5 sampled residents was observed smoking cannabis, a federally illegal substance, 10 feet from the building in a non-designated smoking area. The facility census was 65.Record review of the facility's policy, Smoking Policy, dated 10/2/24, showed:- Smoking will only be allowed in designated area(s) at designated times in the facility that are not near flammable substances or where oxygen is in use. - The Smoking Policy outlines the designated areas, notices, education and requirements for smoking on the facility property to ensure precautions are taken for the resident's individual safety as well as the safety of others in the facility. - Individualized approaches and directions for safety and assistance will be documented in the resident plan of care and communicated to direct care staff. Documentation will detail situations when residents are not allowed to smoke.- Education about the Smoking Policy will be provided to the resident/resident representative. - Residents who can sign out per responsible party, may ask for their smoking materials after signing out and must leave the property to smoke at will. - All residents who smoke need to be supervised by a facility staff member or personal family member at the designated locations.- The smoking of other federally illegal substances is never permitted, and violators may be issued a discharge. Record review of the facility's policy, THC Policy & Procedure, undated, showed:- THC (cannabis or marijuana) smoking is not permitted at the facility due to conflict between state and federal laws regarding cannabis.- Directly allowing smoking is problematic due to broader clean-air and healthcare setting regulations, as well as the risks associated with cannabis smoke. - Consuming THC, in any manner or form, in a nursing home environment is not permitted due to current federal regulations and associated risks.- THC remains a Schedule 3 substance under federal law, considered to have no accepted medical use and a high potential for abuse. 1. Review of Resident #3's face sheet, dated 6/25/26, showed:- Resident was a Medicaid/Medicare recipient;- Resident was their own responsible person;- Diagnoses: neuropathy, gastric ulcer, GERD (acid reflux), stage 3 kidney disease, major depressive disorder, and edema;Review of Resident's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 5/24/26, showed:- Resident was cognitively intact;- Resident had no mood or behavioral concerns;Review of Resident's Care Plan, undated, showed:- Resident receives Norco medication daily and the use of this drug with other depressants may result in profound sedation, coma, and death;- Resident was dependent on tobacco and was instructed on the facility smoking policy (locations, times, rules, safe smoking practices);- Resident can smoke unsupervised;- Resident had a behavior problem using cannabis products while on facility grounds;- Intervene as necessary to protect the rights and safety of others. Remove from cannabis smoking situation and take to alternate location as needed;Observation outside the facility at the front lobby door on 6/25/26 at 11:15 A.M., showed:- Resident was smoking a small rolled cigarette 10 feet in front of the side entrance lobby doors to the facility which was not a designated smoking area.- The smell of cannabis was strongly noticeable from 50 feet away from Resident #3.During an interview on 6/25/26 at 11:22 A.M., Resident #3 said:- He/she was smoking marijuana while being observed by the surveyor.- He/she gets the marijuana from an outside source and the staff does not help him/her obtain it or condone him/her smoking it. He/she smokes it to feel relaxed and is not going to stop using it. During an interview on 6/25/26 at 11:55 A.M., CMT (A) said:- The designated smoking areas are located on the patio for independent smokers and they can smoke anytime they want. There is an inside smoke room that is monitored and the dependent smokers have designated times they can go there to smoke. During an interview on 6/25/26 at 12:10 P.M., CNA (B) said: - Residents can smoke in the courtyard or in the smoking room that is set aside for smokers;- Independent smokers are supposed to smoke away from the facility if they go outside but usually they go out in the front of the building which is near the front entrance;- He/she has observed one of the residents, who has since discharged , a few weeks ago to strongly smell of marijuana;- He/she has never seen or heard of staff providing marijuana to residents;During an interview on 6/25/26 at 2:25 P.M., the Administrator said:- She would not expect or condone residents smoking 10 feet from a building entrance and definitely not marijuana;- She has had issues with Resident #3 in the past with regards to smoking illegal substances and has documented it in his/her care plan. She is considering enforcing a no tolerance policy that results in immediate discharge of the resident after the first warning due to the difficulty in enforcing the smoking policy with marijuana at the facility. - Residents who are independent and want to smoke outside the facility must move to at least 100 feet away from the buildings or they are in violation of the Smoking Policy. During an interview on 6/29/26 at 12:53 P.M., the Nurse Practitioner said:- The Resident has not been prescribed, nor would he/she ever be prescribed cannabis while at a skilled nursing facility. The Resident has the potential for an adverse effect by using cannabis when combined with his/her current medication regimen. Narcan (a lifesaving medication designed to rapidly reverse an opioid overdose) should be added to his/her orders based on him/her using cannabis. Intake 3034148

Based on record review and interviews, the facility failed to obtain written authorization from one resident (Resident #2) to deposit pension personal funds into the facility operating account. The facility census was 65.Review of facility policy, Deposit of Residents' Personal Funds, revised March 2021, showed:- Residents are not required to deposit personal funds with the facility;- If a resident chooses for the facility to hold, safeguard, and manage his or her personal funds, the facility will deposit the funds in an interest-bearing account that is separate from facility operating accounts;- A copy of the resident's or representative's authorization designating the facility as the agency to manage the resident's funds I filed in the resident's financial record;1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 3/30/26, showed:- Resident was cognitively intact;- Diagnoses: obstructive uropathy (blockage of the urinary tract), diabetes, dementia, and chronic obstructive pulmonary disease;During an interview on 6/25/26 at 11:15 A.M., the Resident said:- A letter with his/her pension check was not delivered to him/her. Instead it was delivered to the Business Office Manager (BOM). The BOM called the Resident to her office and showed him/her the letter which the BOM had opened. The letter was addressed to the Resident but the BOM said she had opened it by mistake. Since the Resident owed the facility money the BOM deposited it into the facility bank account without getting permission from the resident or a signature on the check. - The Resident was very upset that his/her mail was not delivered and money was taken from him/her without authorization. The Resident knows he/she owed the facility money and would have given them most of the amount from the check but needed some of that money for his/her personal expenses. He/she had not given authorization to the facility to handle his/her pension fund check. Record Review of the facility operating fund, showed:- 5/31/26 a deposit of $283.59 was made into the operating account with a scanned check, #03782267. The scanned check was made out to Resident #2, there was no endorsement signature on the check or receipt on file for the money reflecting a payment from the Resident.Record Review of Resident #2's Resident Trust Fund Authorizations showed no authorizations in place on 5/31/26 for the facility to manage the Resident's pension check. During an interview on 6/25/26 at 1:25 P.M., the BOM said:- On 5/31/26 she was presented by the Resident with a pension check #03782267 and told to deposit the whole check amount, $283.59, into the operating account to counter what he/she owed the facility.- She did not have a signed receipt from the Resident for the funds given to the Business Office and she did not have a signed endorsement on the back of the check since the bank would accept it without a signature. She did not have a signed authorization from the Resident giving the facility permission to manage the Resident's pension check as of 5/31/26. During an interview on 6/25/26 at 2:15 P.M., the Administrator said:- The facility should obtain signed receipts for deposits given to the Business Office and whenever money changes hands between the facility and the residents.- Purchases on behalf of the residents require receipts and residents need to sign when they have received materials purchased for them. - Checks turned over to the Business Office should be endorsed on the back of the check by the person who the check is made out to. - Mail addressed to a resident is never opened by facility staff unless requested by the resident. Intake 3017541

Based on observations, interviews and record review, the facility failed to keep four residents (Residents #1, #2, #3, and #4) free from resident-to-resident physical abuse, resulting in injury when Resident #1 scratched Resident #2 on the neck and Resident #2 hit Resident #1 on the cheek causing redness. On a separate occasion Resident #3 scratched Resident #4's fingers. Facility census was 68.Review of the facility's Abuse Prevention Program policy, dated 2001, showed:-Our residents have the right to be free from abuse;-This includes but is not limited to freedom from verbal, mental, or physical abuse;-As part of the resident abuse preventions, the administration will protect residents from abuse by anyone, including, but not necessarily limited to other residents; -Develop and implement policies and procedures to aid our facility in preventing abuse or mistreatment of the residents. 1. Review of Resident #1's electronic medical records on 05/12/26 showed:-Diagnoses included: Dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), and mood disorder (a mental health condition characterized by persistent and pervasive change in a person's emotional state). Review of the annual Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 03/08/36,showed:-The resident had adequate hearing, clear speech, and was able to make self understood;-He/She scored 12 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating moderately impaired cognitive skills;-He/She displayed no behaviors during the assessment period. Review of the resident's comprehensive care plan, dated 04/20/26, showed interventions related to the resident had potential for aggression toward others related to dementia, impaired cognitive function, and depression and mood disorder. Review of Resident #2's electronic medical record on 05/12/26 showed:-Diagnoses included: Chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, stroke), and major depressive disorder. Review of the admission MDS, dated [DATE], showed:-He/She had adequate hearing, clear speech, made self-understood, and understood others;-He/She scored 15 on the BIMS indicating no cognitive impairment;-He/She displayed no behaviors during the assessment period. Review of the comprehensive care plan, dated 05/06/26, showed interventions related to potential for aggression toward other residents, elopement risk, anxiety/bipolar disorder, depression, mood, and COPD. Review of the facility investigation, dated 05/08/26, showed:-On 05/02/26 at 6:30 P.M., the nurse was alerted by staff in the dining room that Resident #1 and Resident #2 were involved in an altercation;-When the nurse entered the dining room, Resident #1 was sitting at the dining table, and three scratches were visible on the resident's neck;-Resident #1 said that another resident came into the dining room and said he/she hated it at the facility and no one wanted to help him/her;-Resident #1 said he/she told the resident the resident could leave the facility;-The other resident then left the dining room;-Resident #2 then approached Resident #1 and told Resident #1 to quit talking about the other resident;-The two residents then got into a verbal altercation;-Resident #2 then scratched Resident #1 on the neck, and Resident #1 hit Resident #2 in the face; -Resident #2 had redness and swelling to the right cheek; -The staff separated the residents;-The residents were assessed and no other injuries were noted; -When interviewed, both residents said they felt safe at the facility;- No documentation that abuse education was provided to the staff after the resident to resident altercation. During an interview on 05/12/26 at 3:01 P.M., Resident #1 said:-He/She felt safe at the facility;-He/She told the resident who complained about the facility that they didn't have to live there, and Resident #2 didn't like that;-The two residents yelled at each other until Resident #2 reached out and scratched Resident #1, so Resident #1 hit Resident #2;-He/She has been avoiding Resident #2 since the incident and has had no other issues. During an interview on 05/12/26 at 3:10 P.M., Resident #2 said:-He/She felt safe at the facility;-He/She overheard Resident #1 tell the other resident he/she could leave if he/she didn't like the facility;-Resident #2 said Resident #1 didn't have the right to talk to anyone that way and went over and told Resident #1 that; -Resident #1 yelled at Resident #2 and Resident #2 rolled his/her wheelchair closer to Resident #1;-Resident #2 thought Resident #1 was going to hit him/her, so he/she put his/her hand out and scratched Resident #1's neck;-Resident #1 then hit Resident #2 on the right side of the face;-Resident #2's right cheek was red for a bit but he/she had no other injuries. During an interview on 05/12/26 at 2:40 P.M., the Social Services Designee (SSD) said: -He/She was aware of the altercation involving Residents #1 and #2; -The resident who said he/she didn't like living at the facility and Resident #1 told him/her could leave is Resident #2's relative;-Resident #2 had lived at the facility for approximately a month, but his/her relative lived at the facility for much longer;-There have been no issues with Residents #1 and #2 prior to this altercation. 2. Review of Resident #3's electronic medical records on 05/12/26 showed:-Diagnoses included: Cerebral infarction, hemiplegia/hemiparesis following cerebral infarction affecting left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing), history of traumatic brain injury (a disruption in normal brain function caused by an external physical force), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and major depressive disorder. Review of the quarterly MDS, dated [DATE], showed:-He/She had adequate hearing, unclear speech, usually made self-understood and understood others;-He/She scored 15 on the BIMS;-He/She displayed rejection of care and wandering during the assessment period. Review of the comprehensive care plan, dated 05/12/26, showed interventions related to potential for aggression towards others, behaviors related to alcohol and cannabis use in facility, schizoaffective disorder, depression, mood, anxiety, and chronic pain. Review of Resident #4's electronic medical record, dated 05/12/26, showed:-Diagnoses included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), cerebral infarction, cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), restlessness and agitation, and major depressive disorder. Review of the annual MDS, dated [DATE], showed:-He/She had minimal difficulty hearing, clear speech, made self-understood and understood others;-He/She scored 15 on the BIMS;-He/She displayed no behaviors during the assessment period. Review of the comprehensive care plan, dated 05/12/26, showed interventions related to potential to be physically and verbally aggressive toward others, daily complaints about food, restlessness and agitation, attention seeking behaviors, hoarding, depression, Parkinson's disease, and impaired vision and hearing. Review of the facility investigation, dated 05/12/26, showed:-On 05/11/26 during dinner, Licensed Practical Nurse (LPN) A was notified there was an altercation in the small dining room;-Resident #3 entered the small dining room, rolled his/her wheelchair up to Resident #4's table and pushed Resident #4's plate to the floor;-Resident #4 stood up, grabbed Resident #3's reacher and proceeded to hit Resident #3 in the upper thigh six or seven times;-Resident #3 grabbed Resident #4's hand and dug his/her fingernails in the top of Resident #4's hand;-Resident #4 turned and walked away but turned back around and threw his/her drink on Resident #3;-The residents were separated; -The nurse assessed each resident and provided treatment to Resident #4's hand;-Resident #3 had no injuries;-The Administer arrived at the facility at 6:15 P.M. and Resident #3 was sitting out front and was holding a full urinal;-When asked why he/she had the urinal, Resident #3 responded it was to throw on Resident #4;-LPN A took the urinal from Resident #3 and disposed of it;-Both residents were interviewed and educated on appropriate behaviors, being courteous to one another and avoiding each other.-On 05/12/26, the residents were placed on 15-minute checks for safety;-On 05/12/26 Resident #3 was moved to a different hall on the other side of the facility. During an interview on 05/12/26 at 2:40 P.M., the Social Services Designee (SSD) said:-Resident #3 has had problems in the past following rules and being aggressive with other residents and staff;-SSD has met with Resident #4 and discussed this behavior. During an interview on 05/12/26 at 2:50 P.M., LPN A said:-There was an incident on 05/10/26;-Both residents were outside of the facility;-Resident #4 was using the hose to water the flowers and sprayed Resident #3;-Resident #4 said it was an accident, Resident #3 felt it was done on purpose; -LPN A intervened during the altercation in the small dining room on 05/11/26;-Resident #3 told LPN A that he/she was still mad about being sprayed with the hose the day before and went to find Resident #4. During an interview on 05/12/26 at 2:35 P.M., Resident #3 said:-He/She felt safe in the facility;-He/She did not have an altercation with another resident in the dining room;-He/She did not know why staff would say that or why it would be documented in his/her medical record;-He/She had no issues with Resident #4.-If he/she had issues with another resident or did not feel safe, he/she would go to the social worker, nurse or administrator. During an interview on 05/12/26 at 3:07 P.M., Resident #4 said:-He/She felt safe at the facility;-He/She had a fight with Resident #3 in the small dining room on 05/11/26;-He/She thought Resident #3 was still mad that Resident #4 accidently sprayed him/her with the water hose a couple days ago;-Resident #3 came up to Resident #4's table during dinner and pushed Resident #4's plate to the floor;-Resident #4 stood up and Resident #3 tried to hit Resident #4 with a reacher;-Resident #4 tried to grab the reacher from Resident #3 and Resident #3 grabbed Resident #4's hand and dug his/her fingernails in, causing cuts; -Resident #4 got his/her hand away and turned to walk away;-However, he/she felt that Resident #3 was still coming at him/her and Resident #4 threw his/her drink on Resident #3;-The nurse came and got between the residents; -Resident #3 left the dining room and the nurse attended to the cuts on Resident #4's hand; -They eat in different dining rooms;-If Resident #4 sees Resident #3, he/she goes the other way. During an interview on 05/12/26 at 1:30 P.M., the Administrator said:-He/She expected residents to be respectful and polite to each other;-He/She expected staff to be aware of resident's behaviors and needed interventions and care planned interventions used to keep residents safe;-Resident #3 was placed on 15 minutes checks on 05/12/26;-Resident #3 was moved to a different hall on the opposite side of the facility from Resident #4 on 05/12/26;-Staff received education on abuse and neglect, and monitoring all residents involved in the altercations to assist them in avoiding each other on 05/12/26.Intake 3009620Intake 3010826

Based on observation, interview and record review the facility failed to honor the resident's right to self determination for one resident (Resident #1) when the facility did not honor the request for a bedside urinary catheter bag to be placed at night while sleeping, and left the resident in a leg bag causing urinary leakage, a saturated bed, loss of dignity and mental anguish. This affected one resident out of five sampled residents. The facility census was 58.Review of the facility's undated Resident Rights Policy showed every resident has the right to a dignified existence, self-determination, and to right to be a part of their care and treatment plan decision making.1.Review of Resident #1's most recent Minimum Data Set, (MDS) A mandatory facility assessment completed by facility staff on 11/14/2025 showed the resident was alert and oriented, own responsible person and could communicate all needs, and understood others without difficulty. Had a urinary catheter with recent urinary tract infection. Diagnoses included urinary retention, diabetes, hypertension, chronic urinary tract infections, and a left below the knee amputation.Review of the resident's care plan dated 5/20/25 showed the resident was independent for meeting emotional, intellectual, physical and social needs. The staff are to encourage and honor the residents' choices, self-expression, interests, and include the resident in all plans of care choices and activities of daily living. The resident's care plan did not address the resident's new supra pubic catheter (An indwelling urinary tube inserted through the abdomen to collect urine from the bladder.) or how the catheter should be cared for. Did not address the wishes of the resident regarding the care of the catheter, such as the use of leg bag urinary collection bag during the day when up in electric scooter, and a bedside gravity drainage collection bag when lying down.Review of the resident's physician's orders showed the resident's supra pubic catheter was placed on 10/18/2025 with orders to change the catheter every month on the 16th with a new #16 size French urinary catheter and a new drainage collection bag. On 11/23/25 the resident was sent to the hospital for no urine output from supra pubic catheter, a new one was placed and new antibiotic oral medication orders to treat a new urinary tract infection. There were no orders for leg bag collection or bedside collection bag, just a drainage bag order.Review of the resident's treatment record for the month of November showed the supra pubic and the collection bag was not documented that it had been changed on the 16th by the facility nursing staff for the month of November per the physician's order.During an interview and observation on 12/16/25 at 1:05 P.M. showed the resident sat in the living room in a motorized chair visiting with another resident. The resident had a urinary collection leg bag attached to his/her right thigh and the bag was full or dark yellow colored urine. The resident was observed to be angry and frustrated regarding the lack of care and assistance from the facility nursing staff regarding the urinary collection bag assistance that he/she had requested. The resident said I have asked my aides and the nurses to change the catheter bag at night when I lay down from the leg bag to a bedside one, because the leg bag backs up with urine, leaks, and then my bed is wet with urine all night and no one checks on me. I have to wait until the morning to get out of my wet bed. The resident said this is very frustrating and I know I have rights, I have even talked to the local Ombudsman about it, but nothing has been done, can you help me?Observation of the resident's room on 12/16/25 at 2:00 P.M. showed there was no gravity bedside collection bag located in the resident's room or bathroom.During an interview on 12/16/25 at 2:30 P.M. LPN A said all residents who use leg bags for urinary collection, should be changed to a bedside drainage bag when lying down to rest and at night. Not doing this could cause increased risk for urinary tract infections, and catheter leakage.During an interview on 12/16/25 at 2:55 P.M. LPN B said Resident #1 should have his/her leg bag changed to a bedside collection gravity bag when lying down and at night. LPN B additionally said that the resident had requested this weeks ago, and he/she thought that the night shift had done this for the resident already. LPN B went to retrieve a gravity urinary collection bag from supply closet where there were five available gravity bedside collection bags available.During an interview on 12/16/25 at 4:00P.M. the Director of Nursing and Administrator said all residents with a urinary catheter should have physician orders for supplies to be used, care needed, when catheters should be changed, and should have a beside collection bag when lying down and at night. They both said that Resident #1 and all resident's had the right to self-determination as a resident in the facility and that the facility staff should honor the resident by following up on requests, concerns, or needs.Intake 2687665

Based on interviews, record review, and facility policy review, the facility failed to maintain an effective infection prevention and control program (IPCP) as follows: 1. The facility staff failed to clean and disinfect the multi-use glucometer with the correct disinfectant per the manufacturer's instructions when performing fingerstick blood glucose testing between residents (Resident (R) 10 and R19). 2. The facility staff failed to wear the proper personal protective equipment (PPE) when sorting dirty linens and personal clothes in the soiled linen room of the laundry room. 3. The facility staff failed to wear the proper PPE when entering a resident's room that was on airborne precautions due to a COVID positive status (R22). 4. The facility staff failed to wear the proper PPE for enhanced barrier precautions while administering medications through a gastrostomy tube for R54. These failures placed 56 of 56 residents of the facility at risk for the transmission and spread of infections. Review of the facility's Enhanced Barrier Precautions policy dated 04/01/24 revealed the facility implements required guidance on Enhanced Barrier Precautions (EBP) . 1. Educate all staff on the Enhanced Barrier precautions and use during high-contact resident care activities to include . g. Device care or use of but not limited to . feeding tube . 1. During an observation and interview on 03/20/25 at 11:45 AM, Licensed Practical Nurse (LPN) 3 completed a blood sugar check on R19. After she completed the blood sugar check, LPN3 cleaned the glucometer with a Clorox wipe. She then completed a blood sugar check on R10. After she completed the blood sugar check on R10, she again cleaned the glucometer with a Clorox wipe. LPN3 confirmed she used a Clorox wipe to clean the glucometer in between using the glucometer on R19 and then R10. LPN3 confirmed she had Micro Kill wipes on the cart that she used on hard surfaces that clean blood borne pathogens. LPN3 revealed that she was informed by the Regional Nurse Consultant (RNC) and the Infection Preventionist (IP) that the Clorox wipes were appropriate to clean the glucometer between uses. During an interview on 03/20/25 at 12:30 PM, the IP revealed Clorox wipes could be used to clean the glucometer between resident uses if the residents did not have a bloodborne pathogen. However, the IP was unaware if all or any of the residents who required a blood sugar check had recently been tested for any blood borne pathogens. Review of the Assure Platinum Blood Glucose Monitor manufacturer's instructions provided by the facility (undated) revealed . disinfecting the meter can be accomplished with an EPA [Environmental Protection Agency] registered disinfectant detergent or germicide that is approved for a healthcare setting, or a solution of 1:10 concentration of sodium hypochlorite (bleach) . In accordance with CDC [Centers for Disease Control and Prevention] guidelines, we recommend that the meter be cleaned and disinfected after each use for individual resident care. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018 revealed, Policy Statement, Resident-care equipment, including reusable items . will be cleaned and disinfected according to current CDC recommendations for disinfection and the OHSA [Occupational Safety and Health Administration] bloodborne pathogen standard. Policy Interpretation and Implementation . Reusable items are cleaned and disinfected or sterilized between residents. 2. Observation on 03/21/25 at 10:58 AM in the laundry area revealed there were no gowns located in the soiled linen room. Continued observation revealed the Housekeeping Director (HD) removed a cloth gown from a clear plastic container on the bottom shelf in the clean linen room in the laundry area. During an interview on 03/21/25 at 11:00 AM, the HD confirmed she did not wear a gown when sorting dirty linen or personal clothing unless it was in a red biohazard bag, or the clear bag had COVID written on it in the soiled linen room, but she wore gloves when sorting them. During an interview on 03/21/25 at 11:07 AM, Laundry Aide (LA) 1 confirmed he wore gloves when he sorted dirty linens and personal clothes and wore gloves and a gown when he sorted clothes that were in a red biohazard bag or clear plastic bag with COVID written on it. LA1 stated he had worked at the facility for five years and that was the way he had always sorted the clothes. During an interview on 03/21/25 at 11:13 AM, the Infection Preventionist (IP) stated she had not been through the laundry room yet, so she had not identified any infection control issues there. During an interview on 03/21/25 at 11:15 AM, the Administrator stated she expected the laundry staff to wear a gown and gloves when they sorted the dirty linens and personal clothes to prevent the transmission and spread of infections. Review of the facility's policy titled Departmental (Environmental Services) - Laundry and Linen, revised January 2014, revealed, . the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . General Guidelines . Sorting Soiled Linen l. Employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected. 2. Use heavy-duty rubber gloves for sorting laundry. Always wash hands after completing the task and removing gloves . 3. Review of R22's Admission Record, located in the EMR under the Profile tab, revealed R22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included COVID. Review of R22's Progress Note, dated 03/13/25, located in the EMR under the Prog Notes tab, revealed . Patient did test positive for COVID while being evaluated. Patient does continue to have a cough and SOB [shortness of breath] . patient returned to the facility on the same day . Review of R22's comprehensive Care Plan, dated 03/13/25 and located in the EMR under the Care Plan tab, revealed a problem area of Resident tested positive for Covid 19 with interventions for DROPLET ISOLATION: 1. Keep door to room closed 2. Staff and Visitors to wear PPE at all times while in room . Observation on 03/18/25 at 12:39 PM on the 200 Unit revealed a yellow hanger on the outside of R22's room door that contained the following PPE: Gowns, gloves, N95 and face shield. Also, observation of R22's room door revealed an airborne precautions sign posted on it that read, Everyone must: Perform hand hygiene, wear gown and gloves before entering the room and wear N-95 mask and eye protection prior to entering room. Observation on 03/18/25 at 12:42 PM, Certified Nursing Assistant (CNA) 6 wore a surgical mask as she walked down the hallway with a lunch meal tray in her hands and then entered R22's room without donning a gown, gloves, N95 mask and eye protection. Continued observation revealed CNA6 exited the room with the same surgical mask on. During an interview on 03/18/25 at 12:43 PM, CNA6 confirmed she wore the surgical mask and not the PPE posted on the airborne precautions sign outside of R22's room door. CNA6 stated that she did not touch R22, so she did not have to wear the PPE hanging on the outside of his door. CNA6 stated airborne precautions were spread in the air through a cough and she should have put on a gown, gloves, N95 mask, and eye protection before entering his room. During an interview on 03/21/25 at 11:39 AM, the IP verified R22 returned from theER on [DATE] with COVID so she posted the airborne precautions sign and placed a hanger with PPE on the outside of R22's room door. The IP stated she trained the nursing staff in January and February 2025 on airborne, droplet, and enhanced barrier precautions (EBP). The IP indicated she placed a binder with the training in it along with a list of the residents' names and what type of precaution they were on at the nurse's station. The IP indicated the facility staff should don the PPE posted on the airborne precautions sign on the door prior to entering R22's room and doff the PPE prior to exiting his room. During an interview on 03/21/25 at 11:46 AM, the Administrator stated facility staff were expected to follow the airborne precaution sign on the outside of R22's room door to prevent the transmission and spread of COVID. Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, dated October 2018, revealed, Policy Statement Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation . Airborne Precautions l. Airborne precautions are indicated when an individual is infected with a pathogen that is very small (5 microns or smaller in size) and can be transmitted long distances though the air . Any individuals who enter the room of a resident placed on airborne precautions must wear approved respiratory protection. 5. A resident on airborne precautions will wear a mask when leaving the room or coming into contact with others. Depending on the organism, a special filtration mask may be necessary . 4. During an observation and interview on 03/20/25 at 1:35 PM with LPN2 revealed prior to going in R54's room to administer medications via his g-tube, LPN2 put on gloves and a mask. The door to the resident's room had a sign that read, Enhanced Barrier Precautions, employees must put on a gown, gloves, and a mask before providing any direct care. LPN3 confirmed she did not put a gown on before administering R54's medications via his g-tube and should have. She confirmed the sign on the door indicated to wear a gown, gloves, and a mask when providing direct care. She further confirmed there was personal protective equipment (PPE) hanging on the door to include gowns, gloves, and masks. During an interview with the IP on 03/20/25 at 2:00 PM, the IP confirmed LPN2 should have put on a gown in addition to the gloves and mask she was wearing when she administered medications via R54's g-tube. She confirmed the resident was on EBP.

Based on interviews and facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition service since August 2024. This failure had the potential to affect 55 residents who received food from the kitchen. The facility census was 56. Review of the facility's undated job description titled Dietary Manager, revised 04/16/12, provided by the facility, revealed, . Employment Standards: Education: Must possess, as a minimum, a high school diploma, completion of approved dietary manager's course is preferred. Experience: Must have, as a minimum, two (2) years experience in a supervisory capacity in a hospital, skilled nursing care facility, or other related medical facility. Training in cost control, food management, diet therapy, etc. is preferred. Any combination of experience and training which provides the required skills, knowledge and abilities . During an interview on 03/18/25 at 10:33 AM, the DM confirmed he began working at the facility in October 2024 as a temporary employee and then full-time as the DM in February 2025. The DM stated he did work at another facility for a long time in the kitchen but did not have prior experience working as the DM, was not a Certified Dietary Manager (CDM), and was not currently enrolled in a CDM course. The DM also stated a full-time the RD was not employed at the facility since he started working as the DM. During an interview on 03/19/25 at 5:41 PM, the RD confirmed she was not a full-time employee and worked at the facility as a consultant. The RD stated she visited the facility once a month for eight hours and provided clinical coverage for the resident population. During an interview on 03/20/25 at 5:25 PM, the Administrator confirmed the facility had not had a CDM since August 2024, the DM started in February 2025, and the DM was not a CDM. The Administration stated the RD did not work for the facility on a full-time basis.

Based on interview and record review, the facility failed to ensure that psychotropic medications ordered on an as needed (PRN) basis for three of 16 sampled residents (Resident (R) 19, R35 and R16), included a stop date no later than 14 days after receipt of the order, resulting in the potential for adverse side effects from unnecessary medications. The facility census was 56. Review of the facility policy titled, Antipsychotic Medication revised December 2016 revealed, Policy Statement . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medication will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication . 1.Review of R19's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R19 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbances and cognitive communication deficit. Review of R19's quarterly Minimum Data Set Assessment (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 12/02/24, revealed R19 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated R19 was moderately cognitively impaired. Review of R19's Medication Administration Records (MAR), revealed R19 had an order dated 02/07/25 for .Lorazepam (an anti-anxiety medication) Intensol oral . on a PRN basis. There was no stop date for the prn medication. It was recorded R19 received two doses on 02/19/25 and 02/24/25 and one dose on 03/16/25. During an interview on 03/21/25 at 1:50 PM, the Director of Nursing (DON) stated there should be a 14 day stop date for any PRN medication like Lorazepam. The DON stated she had spoken with Hospice regarding orders for PRN psychotropic medications needing to have a stop date listed. R19's February and March 2025 MARs were reviewed with the DON. The DON confirmed the Lorazepam Intesol (liquid) dose should have had a 14 day stop date, and she stated she was under the impression this medication had been discontinued as R19 had a routine dose of Lorazepam three times a day scheduled. 2. Review of R35's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression and anxiety. Review of R35's quarterly MDS, with an ARD of 02/02/25 and located under the MDS tab of the EMR, revealed a BIMS score of 14 out of 15, indicating the resident had intact cognition. The MDS indicated no behaviors were present and there were no concerns with her mood. Review of R35's Physician Orders, dated 03/14/25 and located in the EMR under the Orders tab of the EMR, revealed an order for Trazodone HCI (an antidepressant) 50 milligrams (mg), give one tablet by mouth every 24 hours as needed (PRN) for agitation and anxiety related to depression. There was no end date for the PRN medication. The order indicated the medication was indefinite. Review of R35's Progress Notes, located in the EMR under the Progress Notes tab, revealed no evidence the resident was experiencing agitation or anxiety prior to the PRN Trazadone being ordered. Review of R35's MAR, located in the EMR under the Orders tab and dated March 2025, revealed the resident had not received the PRN Trazadone since it was ordered on 03/14/25. During an interview on 03/21/25 at 2:00 PM, the DON confirmed R35 was ordered Trazadone on 03/14/25 as a PRN medication without a stop date and confirmed that a stop date should have been indicated on the order. She further confirmed there was no evidence as to why the medication was ordered. 3. Review of R16's admission Record, located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with multiple diagnosis including repeated bipolar disorder, major depressive disorder, and anxiety disorder. Review of R16's quarterly MDS, with an ARD of 12/04/22 and located in the EMR under the MDS tab, revealed a R16 had a BIMS score of one out of 15, indicating R31 was severely cognitively impaired Review of R16's Physician's Orders, located under the Orders tab of the EMR, revealed orders for quetiapine fumarate [an antipsychotic medication] oral tablet 50 milligrams (MG) give one tablet by mouth [PO] every six hours as needed [PRN] for anxiety related to bipolar disorder with a start date of 09/30/24 and no end date, and Seroquel Oral Tablet 50 MG (quetiapine fumarate) give 50 MG PO at bedtime related to major depressive disorder give 50 MG PO every HS AND give 50 MG PO every 12 hours PRN for anxiety give as needed PO BID [twice a day] for anxiety with a start date of 02/26/25 and no end date. Review of R16's MAR, dated March 2025 and located under the Orders tab of the EMR, revealed R16 was administered quetiapine fumarate 50 MG every six hours PRN on 03/02/25, 03/06/25 once, 03/08/25 once, 03/09/25 once, 03/10/25 twice, and on 03/19/25 once. Continued review revealed R16 was administered quetiapine fumarate 50 MG every 12 hours PRN on 03/17/25 once and on 03/19/25 once. During an interview on 03/21/25 at 1:59 PM, the DON stated the nurses entered the medication orders in the EMR, the Administrator checked the orders, and then she rechecked the orders for accuracy. The DON stated that R16's order for quetiapine fumarate 50 MG every six hours PRN was missed because it was included in the order for quetiapine fumarate 50 MG daily. The DON indicated she reviewed all the pharmacy recommendations and did not find one for the PRN order with a start date of 09/30/24, but the pharmacy consultant had not reviewed the order for quetiapine fumarate 50 MG 12 hours PRN yet. During an interview on 03/21/25 at 2:28 PM, the Pharmacy Consultant stated he was not at his computer to determine if he made a pharmacy recommendation for 14-day stop date on the quetiapine fumarate 50 MG every six hours PRN order last year and had not performed a review for the February orders yet.

Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to restraints for seven of 16 sampled residents (Resident (R) 26, R32, R34, R10, R9, R19, and R20), fall assessments for three of 16 residents (R35, R4 and R55) and a urinary tract infection (UTI) for one (R22) of 16 residents. This deficient practice increased the potential for missed opportunities of care or services. The facility census was 56. Review of the facility's policy titled, Proper Use of Side Rails, dated December 2016, revealed, . Definition: Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . (prevent the resident from leaving his/her bed) . 1. Review of R26's Admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated an admitted [DATE] and diagnoses of Alzheimer's, muscle weakness, and difficulty in walking. Review of R26's significant change MDS, with an Assessment Reference Date (ARD) of 12/22/24 and located in the EMR under the MDS tab, revealed that R26 was coded as having restraints. During an observation on 03/18/25 at 11:00 AM, it was noted that R26 used halo side bars, also known as enabler bars, for bed positioning and mobility. The halo bars did not impede R26 from getting in or out of bed. 2. Review of R32's Admission Record, located in the EMR under the Profile tab, indicated an admitted [DATE] and diagnoses of chronic respiratory insufficiency, muscle weakness, and difficulty in walking. Review of R32's admission MDS, with an ARD of 12/14/24 and located in the EMR under the MDS tab, revealed that R32 was coded as having restraints. During an observation and interview on 03/18/25 at 12:30 PM, it was noted that R32 had halo side bars, also known as enabler bars, for bed positioning and mobility. R32's bed was also observed to be full of personal belongings and it did not appear that R32 used the bed to sleep in. When R32 was asked where she slept, R32 stated . I sleep in my recliner always . 3.Review of R34's Admission Record, located in the EMR under the Profile tab, indicated an admitted [DATE] and diagnoses of spina bifida, muscle weakness and diabetes. Review of R34's quarterly MDS, with an ARD of 06/23/24 and located in the EMR under the MDS tab, revealed that R34 was coded as having restraints. During an observation and interview on 03/18/25 at 1:00 PM, it was noted that R34 had halo side bars, also known as enabler bars, for bed positioning and mobility. During the interview with R34, she stated she used the halo bars to reposition herself in bed. 4. Review of R10's Admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R10's Care Plan, initiated on 11/07/22 and located in the EMR under the Care Plan tab, revealed the resident had quarter length bilateral side rails on her bed as an enabler for bed mobility. Review of R10's Informed Consent for the Use of Bed Rails, dated 01/30/24 and located in the EMR under the Documents tab, revealed the consent for Bed Rails was signed by R10's Power of Attorney (POA). The risks and benefits were provided. Review of R10's quarterly Bed Rail Use Assessment Form, dated 01/23/25, revealed the resident was assessed for the use of the bed rails for positioning and mobility. The benefits included the bed rails assisted the resident in turning from side to side, getting out of bed, and assists in standing for balance when attempting to get out of bed. Review of R10's quarterly MDS, with an ARD of 01/26/25 and located under the MDS tab of the EMR, revealed a BIMS score of five out of 15, indicating severe cognitive impairment. The MDS indicated the resident used bedrails daily, and they were coded as a restraint. During an observation on 03/17/25 at 10:30 AM, R10 had bilateral quarter length side rails in the up position attached to her bed. The resident was observed to use the side rails to turn and reposition herself. 5. Review of R9's Admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R9's Care Plan, initiated on 11/01/22 and located in the EMR under the Care Plan tab, revealed the resident had quarter length bilateral side rails on her bed as an enabler for bed mobility. Review of R9's Informed Consent for the Use of Bed Rails, dated 01/30/24 and located in the EMR under the Documents tab, revealed the consent for Bed Rails was signed by R9 and the risks and benefits were provided. Review of R9's quarterly MDS, with an ARD of 01/05/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out 15, which indicated the resident was cognitively intact. The MDS indicated the resident used bed rails daily, and they were coded as a restraint. During an observation and interview on 03/18/25 at 12:19 PM, R9 was in her bed with bilateral side rails in the up position attached to her bed. She revealed she used both side rails to turn herself from side to side and to assist her in getting up. 6. Review of R19's Admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R19's Care Plan, initiated on 04/19/23 and located in the EMR under the Care Plan tab, revealed the resident had quarter length bilateral side rails on her bed as an enabler for bed mobility. Review of R19's quarterly MDS, with an ARD of 12/29/24 and located under the MDS tab of the EMR, revealed a BIMS score of eight out 15, which indicated the resident was moderately cognitively impaired. The MDS indicated the resident used bed rails daily, and they were coded as a restraint. 7. Review of R20's Admission Record, located in the EMR under the Profile tab, revealed he was admitted to the facility on [DATE] with diagnosis that included Parkinson's and Alzheimer's Disease. Review of R20's Physician's Orders, dated 01/30/24, revealed an order for 1/4 upper bilateral side rails for bed mobility and transfer ability. Review of R20's annual MDS, with an ARD of 12/29/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. The MDS revealed bed rail used in bed daily was coded in as a physical restraint. During an interview on 03/19/25 at 2:50 PM, the MDS Coordinator (MDSC) confirmed that the residents used halo bars, or u-shaped bars bilaterally, and they were not a restraint but used for bed mobility/positioning. The MDSC also stated she . errs on the side of caution with the side rail coding . and codes them as a restraint, but they do not impede or stop the resident from getting in or out of bed. The MDSC also stated the facility did not have a specific policy for following the MDS, but the MDS nurses followed the MDS manual for coding. During an interview on 03/19/25 at 4:30 PM, the MDS consultant for facility stated she had not completed any trainings or in-services with the MDSC regarding restraint coding on the MDS and did not complete any random audits or review for accuracy of MDS'. The MDS consultant stated the Resident Assessment Instruction (RAI) manual description for restraints did not meet the definition of a restraint as coded by the MDSC. During an interview on 03/19/25 at 4:31 PM, the MDS Consultant stated that she misunderstood the definition of physical restraints in the RAI Manual and would inform the facility to not code side rails as a physical restraint if it did not meet the definition. 8. Review of R35's Admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R35's Care Plan, initiated on 12/18/24 and located in the EMR under the Care Plan tab, revealed the resident was attempting to self-transfer from her wheelchair to her bed without assistance and fell . There was no major injury. The resident was reminded to use the call light to request assistance with transfers. Review of R35's quarterly MDS, with an ARD of 02/02/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident had intact cognition. The MDS did not indicate the resident had a fall prior to the last assessment. During an interview on 03/19/25 at 3:50 PM, the MDSC confirmed R35 had a fall on 12/17/24 and the quarterly MDS with an ARD of 02/02/25 did not indicate the resident had any falls since the last assessment. She stated it was missed during the completion of the MDS. 9. Review of R4's Admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur and fracture of unspecified carpal bone, left wrist. Review of R4's Nurse's Note, dated 11/11/24 and located in the EMR under the Prog Note tab, revealed, . At approximately 12:45 PM resident was in the shower room with shower aide, resident slipped out of the shower chair while attempting to transfer to wheelchair. Resident landed on his buttocks and hit his left arm on the shower wall resulting in scrapes to lower left arm with redness and swelling. New order to obtain a 2-view left forearm and left wrist x ray, order called into [the x-ray provider] who is here now doing x ray . Review of R4's Nurse's Note, dated 11/12/24 and located in the EMR under the Prog Note tab, revealed, . Res [resident] was taking his neb tx [treatment], then 7:10 PM, res was hollering for help, res found laying on floor, eyes shut perpendicular to his wc [wheelchair] res laying on his back w/ [with] feet facing towards his roommates in front of bathroom, eyes shut, c/o [complained of] breaking his lt [left] leg, res tugging his lt hip. Writer called [the physician] no orders to send to ER [emergency room ], instead do STAT [immediate] XRAY 2 view lt [the xray provider] called, they will come tonight to x-ray lt hip . Review of R4's Progress Note/H and P [history and physical], dated 11/14/24 and located in the EMR under the Prog Note tab, revealed, . Nature of presenting illness: Patient is being seen for an acute visit for x-ray results. Left femur x-ray - nondisplaced fracture at the neck of left femur noted . Review of R4's quarterly MDS, with an ARD of 02/03/25 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. The MDS revealed R4 had not had a fall since admission/entry or reentry or prior assessment and number of falls since admission or prior assessment - major injury was not coded. During an interview on 03/19/25 at 2:52 PM, the MDSC confirmed R4 had a fall with injury on 11/11/24 and on 11/12/24 and she did not code it under falls with major injury on the quarterly MDS with an ARD of 02/03/25. The MDSC stated she reviewed the progress notes and x-ray results but missed coding it. The MDSC stated the facility's MDS consultant company did not review the quarterly MDS. 10. Review of R55's Admission Record, located in the EMR under the Profile tab, revealed R22 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, repeated falls, and unsteadiness on feet. Review of R55's Nurse's Note, dated 12/19/24 and located in the EMR under the Prog Notes tab, revealed, CNA's were in residents bathroom taking care of her husband. [R55] spilled her coffee and slipped on it and hit her head on the right side of her forehead by her eye. Review of R55's quarterly MDS, with an ARD of 02/23/25 and located in the EMR under the MDS tab, indicated she had a BIMS score of nine out of 15, which revealed the resident was cognitively intact. It was recorded that the resident did not have any falls and that the resident did not have a fall with injury. During an interview on 03/21/25 at 1:33 PM, the MDSC verified her coworker completed the MDS and did not code the fall items accurately. The MDSC stated she reviewed the MDS but did not catch that the number of falls with no injury and injury were not coded accurately. 11. Review of R22's Admission Record, located in the EMR under the Profile tab, revealed R22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included urinary tract infection (UTI). Review of R22's Physician's Orders, dated 03/13/25 and located in the EMR under the Orders tab, revealed Cephalexin oral capsule [an antibiotic] 500 milligrams (MG) give one capsule by mouth four times a day related to UTI for seven days. Review of R22's Progress Note, dated 03/13/25 and located in the EMR under the Prog Notes tab, revealed R22 was sent to the emergency room (ER) for significantly elevated white blood cell count and tested positive for UTI. Review of R22's Hospital Discharge Lab Results, dated 03/13/25 and provided by the facility, revealed the urine culture showed 70000 colony forming units per milliliter (cfu/ml) of Escherichia coli. Review of R22's quarterly MDS, with an ARD of 03/15/25 and located in the EMR under the MDS tab, indicated he had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. Review of the MDS revealed it was coded the resident had not had a UTI in the last 30 days. During an interview on 03/21/25 at 1:35 PM, the MDSC stated she did not find lab results for a urine culture in the hospital discharge report, so she did not code the UTI in the last 30 days on the MDS.

Based on interview, record review, document review, and policy review, the facility failed to ensure an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotic was ordered for a urinary tract infection (UTI) in order to reduce the development of antibiotic-resistance organisms for one of three residents (Resident (R) 22) reviewed for UTIs out of a total sample of 16. This failure had the potential to affect all residents' safety related to antibiotic usage and increased the risk of antibiotic-resistance. The facility census was 56. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, revealed, . Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and Implementation 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents . When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. 6. Discharge or transfer medical records must include all of the above drug and dosing elements . Review of the IP's job description titled, Infection Control Specialist/Clinical Educator,, revealed . Major Duties and Critical Tasks . The Infection Preventionist will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidenced-based infection prevention and control practices . Review of R22's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included UTI. Review of R22's Physician's Orders, dated 03/13/25 and, located in the EMR under the Orders tab, revealed Cephalexin [an antibiotic] oral capsule 500 milligrams (MG) give one capsule by mouth four times a day related to UTI for seven days. Review of R22's Progress Note, dated 03/13/25 and located in the EMR under the Prog Notes tab, revealed R22 was sent to the emergency room (ER) for a significantly elevated white blood cell count and tested positive for UTI. Review of R22's Lab Results, dated 03/13/25 and provided by the facility, revealed the urine culture showed 70000 colony forming units per milliliter (cfu/ml) of Escherichia coli. Review of the LTC UTI Infection Worksheet, provided by the facility, revealed the infection screening had not been completed for R22 until 03/20/25. During an interview on 03/21/25 at 11:54 AM, the IP stated she was not informed by the charge nurse that R22 had a UTI when he returned from the ER. The IP confirmed she did not pull R22 orders to see if he had orders for an antibiotic, therefore, she did not complete the UTI infection worksheet to determine if the right antibiotic was prescribed by the physician based on the results of the urine culture. The IP indicated she was responsible for collecting and analyzing infection and antibiotic usage data. During an interview on 03/21/25 at 11:55 AM, the Administrator stated they would start reviewing new orders in the morning clinical meeting so they would not be missed any longer.

Based on record review, interview, review of the Social Services Director (SSD) job description, and facility policy review, the facility failed to ensure one of one (Resident (R) 21) reviewed for a serious mental health illness out of a sample of 16 residents was offered medically related services to include a support plan based on the Preadmission Screening and Resident Review (PASRR) Level II evaluation. This had the potential for the resident to have unmet mental health needs. The facility census was 56. Review of the Position Description, revised 01/11/12 and provided by the facility, revealed, Job Title: Social Services Director, Summary Description: The Social Services Director is responsible . to ensure that the medically-related emotional and social needs of the patient/resident are met/maintained on an individual basis. Essential Functions and Responsibilities . 2. Meets with administration, medical and nursing staff, and other related departments in planning social services. 3. Develops and maintains a good working rapport with intra-department personnel, other departments within the facility, and outside community health, welfare, and social agencies, to ensure that social services programs are properly maintained to meet the needs of the patients/residents. 7. Assists in developing and implementing policies and procedures for identifying the medically-related social and emotional needs of the patient/resident . 29. Works with emotional needs including assisting patient/resident/family with anxiety and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness . 32. Interprets social, psychological and emotional needs of the resident for the medical staff, attending physician and other patient/resident care team members. Review of the facility undated policy titled, Behavioral Health Services revealed, Policy Statement . residents will receive behavioral health services as needed to attain or maintain the highest practicable, physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of the facility policy titled, Trauma Informed Care, revised March 2019, revealed, Purpose: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma . Organizational Strategies: 5. Develop relationships with community support organizations for services, referrals, training, and information . Resident-Care strategies: 1. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. 2. Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma . Review of R21's Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder and Post Traumatic Stress Disorder (PTSD). Review of R21's PASRR Level II Summary of Findings, dated 09/24/23 and provided by the facility, revealed the evaluation indicated the resident's needs could be met in a nursing facility. The evaluation indicated the following supports and services were to be provided by the Nursing Facility: Behavioral Support Plan and a Personal Support Network. The PASRR revealed the resident had a severe mental illness. Under the section titled, Psychiatric Assessment/History diagnoses of major depressive disorder with anxiety, PTSD, and social anxiety disorder were listed. The assessment further revealed the resident reported her mother used to abuse her as well as her husband. She said she was bothered by memories of past abuse. The evaluation revealed the resident had received previous psychiatric services. Review of the Mood and Content of Thought section revealed the resident had trouble falling asleep, felt easily annoyed or irritable, had little interest or pleasure in doing things, felt down, depressed, or hopeless, had a poor appetite, felt bad about herself, felt like she was a failure and had let her family down, felt nervous, anxious, and on edge, felt afraid that something awful might happen, and felt like people were talking about her. The resident reported that she did not want to go to a nursing facility and felt anxious about her upcoming move. Review of the Interpersonal Functioning section revealed the resident had serious difficulty interacting appropriately and communicating effectively with other persons, had a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, and social isolation. Under the section, Adaptation to Change it was recorded the resident had serious difficulty in adapting to typical changes in circumstances. The evaluation revealed that as a result of her major mental disorder, she has had psychiatric services. Under the section titled, Summary it was recorded the resident had trauma history including childhood and marital abuse. The Summary section revealed the resident needed provision of specific services to address her mental health and behavioral needs, and psychiatric follow up to prescribe and manage her medications. Review of R21's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/24 and located under the MDS tab of the EMR, revealed a Brief Mental Status Interview (BIMS) score of eight out of 15, indicating the resident was moderately cognitively impaired. The MDS indicated that the resident felt down, depressed, and hopeless for several days. Review of R21's Care Plan, initiated on 01/09/24 and located in the EMR under the Care Plan tab, revealed the resident had depression related to major depressive disorder and anxiety disorder. Interventions included arranging psychiatric consultation and follow up as indicated. There was no evidence in the EMR that the resident ever received a psychiatric consultation, and there was no evidence the resident had a Care Plan developed related to her PTSD diagnosis. Review of R21's Care Plan, initiated 01/09/24 and located in the EMR under the Care Plan tab, revealed the resident had thrown her lighter at another resident during smoke time. Interventions included removing the resident from the smoke room when she exhibited aggressive behavior. Review of R21's Care Plan, initiated on 08/21/24 and located in the EMR under the Care Plan tab, revealed the resident had behavior problems related to her cussing at residents/visitors/staff, was resistive to cares at times, exhibited physical aggressiveness, exhibited verbal aggressiveness. Interventions included discussing the resident's behavior with the resident and to explain why behavior is inappropriate and/or unacceptable. Review of R21's Progress Note, dated 12/27/23, written by the Nurse Practitioner, and located in the EMR under the Progress Note tab, revealed the resident reported she was scared to be in a new facility. Review of R21's Nurse's Note, dated 01/08/24 and located in the EMR under the Progress Notes tab, revealed a Certified Nursing Assistant (CNA) reported while in the smoking room there was an issue where R21 became agitated and allegedly attempted to light another resident's clothing with her lighter. Then a few moments later R21 yelled at another resident calling her a (expletive) and proceeded to throw her lighter striking the resident in the shoulder. R21 was told she could no longer smoke today and she became angry and went to her room. Review of R21's Nurse's Note, dated 11/04/24 and located in the EMR under the Progress Note tab, revealed R21 was witnessed ramming her walker to the back of a resident in a wheelchair because she was taking too long to move for a smoke break. Review of R21's Trauma Abuse Screenings, dated 03/26/24, 06/24/24, 09/23/24, and 12/23/24, located in the EMR under the Assessment tab, and completed by the Social Services Director (SSD) revealed there were 10 categories, and the resident scored one point for each category where there was a yes response. On all four screenings, the resident scored one point related to the resident's vulnerability, history of being exploited, and likelihood for psychiatric, behavioral, and/or physical symptomology related to trauma. One of the categories was history of abuse or neglect;, including physical, emotional, or domestic violence; and it was marked no. Another category on the screening was for psychiatric history and/or present mental health diagnosis, and it was marked no. The last category on the screening was for a history of mistreating others, verbally or physically, and it was marked no. Review of R21's Progress Notes, dated 03/06/25 and located in the EMR under the Progress Notes tab, revealed a note written by the nurse practitioner recording the resident had diagnoses of Major Depressive Disorder and PTSD and to continue Trintellix (an anti-depressant) 20 milligrams (mg), give one tablet by mouth in the morning for major depressive disorder and to continue mirtazapine (an anti-depressant), 7.5 mg, give one tablet by mouth at bedtime. During an interview on 03/20/24 at 7:46 PM, the SSD confirmed she completed the Trauma Abuse Screenings for R21 on 03/26/24, 06/24/24, 09/23/24, and 12/23/24. She confirmed she scored the resident one point only out of 10 categories listed on each of the screenings. The SSD confirmed the response should have been yes on the categories of history of abuse, history of psychiatric history and/or present mental health diagnosis, and for mistreating others per the Level II PASSR screening and the resident's Progress Notes. The SSD confirmed she did not review the resident's PASSR Level II screening which indicated the resident needed provision of specific services to address her mental health and behavioral needs, and psychiatric follow up to prescribe and manage her medications. She confirmed the resident was not offered any mental health services when she was admitted nor had the resident had a psychiatric consultation. The SSD revealed she was not aware of the next steps to take when a resident scored points on the Trauma Abuse Screenings.

Based on interviews and record review, the facility failed to keep one resident (Resident #1) free from verbal and physical abuse. Certified Nurse Aide (CNA) A engaged in a verbal altercation with Resident #1 which escalated to CNA A pushing the resident from his/her wheelchair. The facility census was 67. Review of the facility's policy on Abuse Prevention, dated December 2016, showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. -As part of the resident abuse prevention, the administration will: -Protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. -Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. -Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and and work environment without reprimand or retaliation; b. Instruct staff regarding appropriate ways to address interpersonal conflicts and; c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated resident assessment conducted by staff, dated 2/4/24, showed: -He/She had adequate hearing, clear speech, understands others and makes self understood; -He/She scored 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluated aspects of cognition in elderly persons). This indicated no cognitive impairment. -He/She used a manual wheelchair; -He/She required substantial assistance with all Activities of Daily Living (ADL), including dressing, bathing, personal hygiene and transfers; -He/She had the the following diagnoses: cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), hemeplegia/hemaparesis to left side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), diabetes mellitus type II (a chronic condition that happens when a person has persistently high blood sugar levels), unsteady on feet, muscle weakness, personal history of traumatic brain injury, anxiety, major depressive order, history of alcohol abuse, schizoaffective disorder (mental health condition including schizophrenia and mood disorder symptoms). Review of the resident's Comprehensive Care Plan, dated January 17, 2024, showed: -He/She had an ADL self-care performance deficit related to left hemiparesis and stroke. He/She required assistance with bathing/showering, bed mobility, dressing, using the toilet and transfers. He/She used a manual wheelchair that he/she propels independently; -He/She had a mood problem related to diagnoses of schizoaffective disorder. He/She required medications as ordered. Assist the resident in identifying coping skills. Monitor, record, and report to the physician any changes in episodes of feelings of sadness, loss of interest, increased anxiety or anger; -He/She had chronic pain related to left side hemiplegia related to stroke. The resident's pain was aggravated by standing and movement. He/She needed medications administered as ordered; -The resident had voiced anxiety as evidenced by statement I can't defend myself. Provide reassurance to the resident that he/she is safe and will be protected. Review of the facility's incident investigation documentation, dated 2/14/2024, showed: -At approximately 1:15 A.M., Resident #1 turned on his/her call light to ask for assistance. CNA A answered the call light and made statements like you're wanting too much and It is ridiculous that you want to get up this early when you're just going to want to lay back down. The resident questioned CNA A about CNA A's desire to work in healthcare and encouraged the CNA to work somewhere else. CNA A left the room and the resident self-transferred to the wheelchair. As CNA A was leaving the room, he/she made the comment to the resident Everyone is sick of your shit. -At approximately 1:25 A.M., the resident went down to the nurses' station and asked CNA B Does anyone else have a beef with me because I wanted to get up this early? CNA A then came out of another resident's room and said No, that's not what the fuck happened. I'm just sick of your shit. Resident #1 then said, Man, why don't you go back to school and make something of yourself? CNA A turned back to the resident and said Man, you fucking bitch. The resident then threw a drink at CNA A and said You don't want a beef with me. -CNA A then ran at the resident and shoved him/her out of the wheelchair. The resident rolled over the side of the wheelchair, flipping over and landing on his/her knees. CNA B told CNA A to clock out and leave the facility. CNA B then informed Licensed Practical Nurse (LPN) A, the charge nurse, of the incident. LPN A immediately informed the Director of Nursing (DON). Approximately 5 minutes after the DON was notified, CNA A returned to the hall and was instructed to leave by LPN A and he/she complied. The resident was assessed and was free of injury. He/She was tearful. Law enforcement was notified and arrived at the facility. -While LPN A was assessing the resident, the resident said The only thing that hurts is my pride right now, I can't fight back. During an interview on 2/22/2024 at 3:18 P.M., Resident #1 said: -CNA A became upset with him/her during the night when the resident asked for assistance in getting out of bed. -The resident got into a verbal altercation with CNA A while in the resident's room. CNA A then left the room. The resident transferred him/herself to the wheelchair and wheeled into the hall to speak to other staff. -While in the hall, CNA A heard the resident talking to another CNA and came out into the hall. CNA A continued to yell at the resident. The resident yelled back at CNA A and threw a cup of water at CNA A. CNA A then ran at the resident and shoved him/her. The resident flipped over the arm rest of the wheelchair and landed on his/her knees. -The resident was not physically hurt, but the incident did scare him/her. -The resident felt safe in the facility now that CNA A was no longer in the facility. During an interview on 2/22/24 at 3:45 P.M., the DON said: -It is his/her expectation that staff walk away from a situation if they become overwhelmed or upset with a resident. -It is his/her expectation that the staff notify the charge nurse of an issue with a resident and let the charge nurse know he/she needs a break to calm down. -Staff are to never have verbal or physical altercations with residents. During an interview on 2/22/24 at 3:45 P.M., the Administrator said: -It is his/her expectation that when staff member become frustrated with a resident, they inform the charge nurse of the situation and then go to a neutral area to calm down. -It is her expectation that staff do not engage in verbal or physical altercations with residents. MO231860 MO232102

Based on observation, interview and record review, facility staff failed to follow physician's order for wound treatment for one resident's (Resident #322) Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon and muscle caused by prolonged pressure to a bony area) on the left Ischium (the bottom of the pelvic bone), when facility staff used a bordered gauze dressing to cover Resident 322's wound instead of a Tegaderm dressing, when facility staff packed the resident's wound with gauze instead of Aquacel Ag ribbon, when facility staff failed to reposition the resident every two hours, and when facility staff failed to ensure the resident was not setting in a chair for longer than two hours. The staff failed to follow-up with a scheduled wound clinic appointment per hospital discharge orders, failed to address the resident's complaints of pain in the pressure ulcer area, failed to ensure the resident's low air loss mattress was set to the correct settings according to manufacturer's recommendations, and failed to ensure staff used correct infection control during perineal and wound care when staff did not wash hands and apply clean gloves after gloves were soiled, and when staff wiped feces into an open wound. Additionally, the facility staff failed to apply a pressure relieving device to one resident's (Resident #13) right foot when he/she developed a Stage 3 pressure ulcer to his/her right outer ankle. The facility census was 72. The facility Administrator was notified on 1/26/24, at 4:07 P.M. of an Immediate Jeopardy (IJ) which began on 1/24/24. The IJ was removed on 1/29/24. Review of the facility's Pressure Ulcers/Skin Breakdown Clinical Protocol, revised April 2018, showed: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; -The staff and practitioner will examine the skin of newly admitted resident for evidence of existing pressure ulcers or other skin conditions; -The physician will order pertinent wound treatments; -The physician evaluates and documents the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds; -Current approaches should be reviewed for whether they remain pertinent to the resident's medical condition. Review of the facility's Prevention of Pressure Injuries policy, revised April 2020, showed: -The purpose of this procedure is to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors; -Inspect the resident's skin on a daily basis when performing personal care or Activities of Daily Living (ADLs): -Reposition the resident as indicated on the care plan; -Clean the resident's skin promptly after episodes of incontinence; -Use facility-approved protective dressings for at risk individuals; -Reposition all residents with/or at risk of pressure injuries on an individualized schedule; -Evaluate, report, and document potential changes in the skin; -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's Repositioning policy, revised May 2013, showed: -The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to promote comfort for all bed or chair bound residents and to prevent skin breakdown and provide pressure relief for residents; -Review the resident's care plan to evaluate for any special needs of the resident; -Repositioning is a common, effective intervention for preventing skin breakdown and providing pressure relief; -Repositioning is critical for a resident who is dependent upon staff for repositioning; -Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing; -Evaluate the resident for an existing pressure ulcer; -A positioning program includes continuous consistent program for changing the resident's position; -The position program should be document, monitored, and evaluated; -Residents who are in bed should be on at least every two hour repositioning schedule; -Residents with a stage I pressure ulcer or above pressure ulcer, every two hour repositioning schedule is inadequate; -Residents who are in a chair should be on every one hour schedule; -The position in which the resident was placed should be documented. Review of the facility's Support Surface Guidelines policy, revised September 2013, showed: -Procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown; -Selecting a mattress for the resident based on pressure ulcer risk is clinically appropriate; -Use a pressure ulcer risk scale such as the Braden Scale to help determine need for a pressure relieving device. Review of the facility's Pain policy, revised March 2018, showed: -The staff and physician with identify the characteristic of pain such as location, intensity, frequency, pattern, and severity; -The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning; -The staff will provide the elements of a comforting environment and appropriate physical interventions, such as repositioning; -The staff will reassess the individual's pain at least every shift. Review of the facility's Pain Assessment and Management policy, revised March 2020, showed: -Procedure is used to help the staff identify pain in the resident; -Possible behavioral signs of pain are, verbal expressions such as groaning or crying, facial grimacing, guarding, or favoring a part of the body; -Identifying the causes of pain such as pressure, venous or arterial ulcers; -Review the resident's treatment record to identify any situations where an increase in the resident's pain may be anticipated, for example; treatments such as wound care or dressing changes and repositioning; -Document the resident's reported pain level with adequate detail. Review of the facility's Wound Care policy, revised October 2010, showed: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; -Verify that there is a physician's order for this procedure; -Review the resident's care plan for orders for pain medication as needed to be administered prior to wound care; -Use no-touch technique, use sterile tongue blades and applicators to remove ointments and creams from their containers; -Be certain all items are on a clean field; -Document the type of wound care given; -Document all assessment data. Review of the facility's Dressings, Clean/Dry policy, revised September 2013, showed: -The purpose of this procedure is to provide guidelines for the application of dry, clean dressings; -Explain the procedure to the resident; -Establish a clean field; -Place equipment on the clean field, -Wash and dry hands; -Put on clean gloves; -Remove old dressing; -Pull glove over dressing and discard; -Wash and dry hands; -Open clean dressing by pulling corners of the exterior wrapping outward, touching only the exterior surface; -Label dressing with date, time, and initials and place on clean field; -Using clean technique, open other products; -Wash and dry hands; -Put on clean gloves; -Cleanse the wound with ordered cleanser, use clean gauze for each cleaning stroke, clean from the least contaminated area to the most contaminated area (from the center outward); -Use dry gauze to pat the wound dry; -Apply the ordered dressing and secure; -Discard disposable items; -Remove gloves and wash hands; -Document the date and time the dressing was changed; -Document the wound appearance, including wound bed, edges, and the presence of drainage; -Report any other information in accordance with facility's policy and professional standards of practice. Review of Protekt Aire manufacturer's recommendations, undated, showed the low air loss mattress is to be set according to the resident's weight. 1. Review of Resident #322's hospital referral to the facility, dated 11/28/23, showed the wound clinic physician documented the following: -11/17/23 patient's wound stable; -Peri-wound fragile, pink, red; -Wound bed pink, red, yellow; -Measured 2 centimeters (cm) x 1.5 cm x 1.8 cm; -Tunneling 4.5 cm at 10 o'clock; -Undermining 2.5 cm deepest at 9 o'clock -Wound healing 81%; -Stage 4; -Treatment order- clean with wound cleanser, loosely pack with Aqua Ag ribbon, apply transparent adhesive film, change daily. Review of the hospital infection disease physician's progress note, dated 11/18/23, showed the physician documented left buttock/hip ulceration with osteomyelitis (infection of the bone), ulcer to the level of bone with exposed bone in the base and circumferential undermining (separation of wound edges from the surrounding tissue). Review of the hospital discharge record, dated 11/30/23, showed the following orders: -Acetaminophen 500 milligrams (mg) every four hours if needed (PRN) for mild pain; -Continue current wound care recommendations; -Follow-up with wound care in one to two weeks; -Ambulatory referral to wound clinic, office visit; -Flush the wound with wound cleanser; -Loosely pack the wound with Aqua ribbon and cover with clear dressing or a wound vac drape; -Change daily and as needed for soiling/drainage and disruption; -Needs a low air loss mattress with every two hour turns while awake; -Resident is not to be in a chair for longer than two hours at a time; -Scheduled appointment with Wound Care clinic January 2, 2024, at 10:45 A.M. Review of the resident's admission assessment, dated 11/30/23, showed the following were not checked as completed: -Physician notified; -New orders obtained; -Physician and family notified and new orders received under the skin assessment section. Review of the resident's admission skin assessment, dated 11/30/23, showed: -Pressure injury to left buttock; -Measured 4 cm x 3 cm with a depth of 4 cm, and was unstageable: -No wound to the resident's coccyx was found; -No documentation the physician or the family had been notified. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/23, showed: -Moderate cognitive impairment; -Dependent on staff for ADLs; -Dependent on staff for turning and repositioning; -Pressure reliving devices in chair and bed; -At risk for pressure ulcers; -One unhealed pressure area; Stage 3 -Uses non-verbal, vocal complaints and facial grimacing as indicator of pain; -Pain observed 1 to 2 days out the last 5 days; -Always incontinent of bowel and bladder; -Uses a wheelchair; -Dependent on staff for mobility: -Diagnosis included: osteomyelitis (a serious infection of the bone), end stage kidney disease, non-pressure chronic ulcer of back, Down Syndrome (a genetic chromosomal disorder that can a cause causing lifelong intellectual disability and developmental delays), diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), peripheral vascular disease (progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and atrial fibrillation (a type of abnormal heartbeat). Review of the resident's weekly skin assessments, dated 11/30/23 to 12/31/23, showed staff documented the following: -11/30/23 and 12/8/23: left buttock pressure ulcer, measured 4 cm by 3 cm by 4 cm, unstageable; -12/15/23: left buttock pressure ulcer, measured 4 cm by 3 cm by 4 cm, Stage III (full thickness loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed); -12/22/23 and 12/29/23: left buttock pressure ulcer, measured 3 cm by 3 cm by 6 cm, Stage III, wound is tunneling, treatment done per order. -Review showed staff did not document a description of the resident's wound bed, drainage, location of tunneling, description of the wound edges or if there was an odor. Review of the resident's Braden Scale assessment (predicts pressure ulcer risk), dated 1/5/24, showed a score of 14, indicating a moderate risk for pressure ulcer development. Review of the resident's weekly skin assessments, dated 1/1/24 to 1/19/24, showed staff documented the following: -1/5/23: left buttock pressure ulcer, measured 3 cm by 2 cm by 6 cm, Stage III, wound is tunneling, treatment done per order; 1/12/23: left buttock pressure ulcer, measured 3 cm by 3 cm by 6 cm, Stage III, wound is tunneling, treatment done per order; 1/19/23: left buttock pressure ulcer, measured 3 cm by 1.5 cm by 4 cm, Stage III, wound is tunneling, treatment done per order. -Review showed staff did not document a description of the resident's wound bed, drainage, location of tunneling, description of the wound edges or if there was an odor. Review of the resident's Weights and Vitals Summary, dated 1/10/24, showed staff documented the resident's weight as 128 lbs. Review of the resident's care plan, dated 1/17/24, showed: -Resident has an ADL self-care performance deficit related to impaired balance and limited mobility; -Resident is incontinent of bowel and bladder; --Resident to be checked every 2 hours and as needed for incontinent every shift; --The resident required a skin inspection daily; -The resident has chronic pain related to end stage kidney disease, dialysis, and left buttocks wound; --Administer analgesic as needed for pain, give 1/2 hour before treatment or care; --Anticipate the resident's need for pain relief and respond immediately to any complaints of pain; --Evaluate the effectiveness of pain interventions daily and every shift; --Monitor probable cause of each pain episode; --Monitor and report to the nurse any signs and symptoms of non-verbal pain; -The resident has actual impairment to skin integrity of the left buttock related to wound; --Check the resident's skin daily while providing cares to the resident and notify the nurse of any areas of skin break down; --Monitor and document location, size and treatment of skin injury, report failure to heal or signs and symptoms of infection to the physician; --Resident to be turned or repositioned every 2 hours when in bed and in chair; --Ensure resident is not laying on left buttocks wound, use pillows to shift resident's weight and prevent further skin breakdown; --Resident needs pressure relieving/reducing device while up in chair; --Resident needs pressure relieving/reducing mattress while in bed; --Weekly skin assessments to be done by nurse, observe, measure, document and report any areas of skin break down and current wound status to provider for treatment orders if required. Review of the resident's Physician's Order Sheet (POS) for January 2024 showed: -admitted [DATE]; -Start date: 11/30/23 - no end date, assess pain every shift; -Start date: 11/30/23 - no end date, barrier cream to peri area, buttocks, and sacral coccyx after each incontinent episode; -Start date: 12/1/23 - no end date, flush wound left buttocks with wound cleanser, loosely pack Aqua Ag ribbon into the wound and secure with Tegaderm or wound vac drape. Change daily and as needed for soilage/drainage, one time a day for wound left buttock; -Start date: 11/30/23 - no end date, implement wound care protocol as necessary -Start date: 11/30/23 - no end date, pain management, obtain consult and treatment as needed for patient health and comfort; -Start date: 12/1/23 - no end date, weekly skin assessment every Friday; -Start date: 11/30/23 - no end date, Acetaminophen tablet, 500 mg, give one tablet by mouth every 4 hours as needed for pain; -No order for a loss air mattress; -No order to turn the resident every two hours; -No order to ensure the resident was not in a chair for more than two hours at a time; -No order to see the wound care clinic. Review of the resident's Medication Administration Record (MAR), dated January 2024, showed: -Order start date: 11/30/23 - no end date, Acetaminophen tablet 500 mg, give one tablet by mouth every 4 hours as needed for pain; --The resident received one tablet of Acetaminophen 500 mg on 1/17/24 at 12:30 A.M., with a pain level of 5 on a 0 - 10 pain scale; --The resident received one tablet of Acetaminophen 500 mg, on 1/17/24 at 7:31 P.M., with a pain level of 2; -No other entries the resident received Acetaminophen; -Order start date: 11/30/23 - no end date, assess pain every shift; -1/1/24 through 1/24/24, the resident's pain rating was assessed at 0 (indicating no pain) on the day shift and the night shift. Review of the resident's medical record dated, 11/30/23 - 1/24/24, showed no documentation the resident went to his/her wound clinic appointment on 1/2/24 or that the wound care clinic was contacted or followed the resident as ordered. During an interview on 1/25/24 02:05 P.M., wound clinic staff said: -He/she usually speaks with the transportation supervisor regarding appointments at the facility; -Someone from the nursing home called on 12/13/24 at 2:44 P.M., to cancel the resident's appointment. During an interview on 1/25/24, at 2:45 P.M., the transportation supervisor said: -He/she was not aware of any wound clinic appointment for the resident; -He/she had not taken the resident to any wound clinic appointment. During an interview on 1/25/24 at 3:16 P.M., the wound care physician said: -The facility staff canceled the resident's wound clinic follow up appointment scheduled for 1/2/24; -The facility staff told the wound physician the resident's wound would be taken care of in-house; -Someone from the facility called on 12/13/24 at 2:44 P.M., to cancel the resident's appointment; -The office usually talks to the transportation supervisor when scheduling or canceling appointments. Review of the resident's Treatment Administration Record (TAR) dated, January 2024, showed 1/1/24 through 1/23/24 the resident's wound was treated daily. Observation and interview on 1/23/24 at 7:26 P.M., showed: -The resident's low air loss mattress was set to 300 lbs (pounds); -Certified Nurse Aide (CNA) B and Nurse Aide (NA) A transferred the resident to the bed with the mechanical lift; -CNA B removed the resident's brief and provided perineal care; -CNA B and NA A positioned the resident on his/her left side; -A half dollar size open wound was observed on the resident's left ischium; -There was no dressing covering the wound. The dressing was not in the brief, in the trash, or on the resident's floor; -The wound was draining a penny size amount yellow/green drainage. The wound edges were macerated and undefined. The wound bed was cream colored with a thin black border, and no odor was present; -CNA B washed his/her hands and applied clean gloves. CNA B took a wipe and wiped down the resident's buttocks towards the rectum, wiping feces into the wound and left the wipe soiled with feces laying at the opening of the wound; -CNA B and NA A did not apply barrier cream; -CNA B and NA A said they do not apply barrier cream; -CNA B said the resident had the wound since he/she was admitted ; -NA A said he/she had been working at the facility a few weeks and the resident had the wound since he/she started working; -CNA B said only the nurses do anything with the resident's wounds; -CNA B said he/she was not sure if the wound should be covered or not, but he/she would tell the nurse; -NA A said he/she did not do anything with the low air loss mattress settings; -CNA B said he/she did not know what the settings should be, the nurses set the low air loss mattress settings. Observation and interview on 1/23/24 at 7:45 P.M., showed: -CNA A told Licensed Practical Nurse (LPN) A the resident needed a new dressing applied; -CNA A did not tell the nurse which dressing needed changed; -The LPN A removed the blanket from the resident down to his/her upper abdomen; -The nurse looked at the PICC line dressing on the resident's left chest; -The nurse did not look at the wound on the resident's left ischium; -The nurse said there were no other dressings that needed to be changed today; -The nurse said he/she had been gone and just returned to the facility today and usually does not work this hall; -LPN A said the mattress settings are set at the time the mattress was set up and he/she did not know who set up the mattress or what the settings should be. Continuous observation on 1/24/24 at 7:03 A.M. until 1/24/24 at 4:30 P.M., showed: -7:03 A.M.- 7:45 A.M., the resident sat in his/her wheelchair in the dining room eating and looking out the window. The resident had a cushion in his/her wheelchair; -7:45 A.M., the resident continued to sit in his/her wheelchair in the dining room and propelled himself/herself away from the table and stopped approximately one foot away from the table; -7:45 A.M. - 8:09 A.M., the resident sit in his/her wheelchair in the dining room; -8:09 A.M., the resident continued to sit in his/her wheelchair, he/she waved his/her hands in the air and said he/she was ready to lay down; -8:12 A.M., the resident told NA B please lay me down, I am done; -8:17 A.M. - 8:21 A.M., the resident continued to sit in his/her wheelchair, waving his/her hands in the air and saying he/she was ready to lay down; -8:21 A.M., NA B took the resident back to his/her room in his/her wheelchair; -8:22 A.M., NA B positioned the resident's wheelchair beside the bed with the resident facing the hall and NA B set a bedside table in front of the resident, placed the call light on the table, and turned a movie on. -8:23 A.M., NA B left the resident's room; -8:23 A.M. until 10:01 A.M., the resident continued to sit in his/her wheelchair in his/her room; -10:01 A.M. - 10:05 A.M., the resident continued to sit in his/her wheelchair in his/her room coloring. LPN D stopped at the resident's door and asked if the resident wanted to lay down or stay up and color. The resident told LPN D he/she wanted to stay up and color. LPN D did not offer to reposition the resident in his/her wheelchair, offer incontinent care, or assess the resident for pain. -10:05 A.M. - 10:24 A.M., the resident continued to sit in his/her wheelchair in his/her room coloring; -10: 25 A.M. - 10:44 A.M., the resident continued to sit in his/her wheelchair in his/her room coloring. The resident was leaning to the right, raising his/her bottom up off the seat of the wheelchair; -10:44 A.M. - 10:45 A.M., the resident was leaning to the right with his/her hands on the arms of the wheelchair, raising his/her bottom up off the seat of the wheelchair. Housekeeper A looked in the resident's room while the resident had facial grimacing and was saying ow, ow, that is sore; Housekeeper A did not tell the nursing staff the resident was complaining of pain; -10:46 -10:50 A.M., the resident is continued leaning to the right with his/her hands on the arms of the wheelchair, raising his/her bottom up off the seat; -10:50 A.M. - 11:30 A.M., the resident continued in his/her wheelchair looking around and coloring in his/her room. Staff had not repositioned, offered to change, or assessed him/her for pain; -11:30 A.M., CNA G propelled the resident to the dining room table and handed the resident his/her crayons and coloring pages. The CNA did not offer to toilet or reposition the resident; -From 11:30 A.M.- 11:49 A.M., the resident sat in the dining room in his/her wheelchair coloring. -11:49 A.M. -11:55 A.M., the resident continued to sit in his/her wheelchair coloring. Multiple staff walked around the dining room. Staff did not offer toileting or any positioning assistance to the resident. -11:55 A.M., an unidentified kitchen aide stopped and talked to the resident and walked away. The resident continued to sit in his/her wheelchair. Staff did not reposition the resident, check the resident for incontinence, or assess the resident for pain; -11:56 A.M. - 12:03 P.M., the resident continued to sit in his/her wheelchair at the dining room table looking out the window; -12:04 P.M. - 12:08 P.M., the resident continued to sit at the dining room table in his/her wheelchair with his/her position unchanged. The resident looked around the dining room, he/she used his/her arms to push against the wheelchair arms to lift their left side off of wheelchair. The resident had facial grimacing. -12:09 P.M. -12:20 P.M., the resident continued in the same position without staff assistance and staff walked by passing out lunch trays. The resident had occasional facial grimacing; -12:21 P.M.-12:28 P.M., the resident was in the dining room in his/her wheelchair. CNA F came into the dining room and patted the resident on the back and did not offer to reposition or toilet the resident. The resident continued to have occasional facial grimacing and lifted his/her left buttock off of the wheelchair cushion; -12:28 P.M., the resident received his/her lunch tray, an unidentified dining room assistant sat down next to the resident and moved his/her coloring sheet. Staff did not offer to position or provide toileting assistance to the resident. -12:28 P.M. - 12:53 P.M., the resident ate his/her pureed food and no staff offered to toilet or reposition resident; -12:53 P.M. - 1:00 P.M., the resident continued at the dining room table trying to lift himself/herself up in the chair and said, it hurts. Observation showed staff were in the dining room passing trays. -1:00 P.M. -1:05 P.M., the resident continued in the dining room in his/her wheelchair. CNA F asked the resident if he/she was doing ok and the resident said yes. -1:05 P.M. - 1:19 P.M., the resident continued to eat his/her lunch in dining room. Staff did not reposition or toilet the resident; -1:20 P.M., the resident tried to push his/her plate away from him/her. CNA F stopped and assisted the resident in moving his/her plate and helped the resident get his/her crayons. The CNA did not offer assistance with toileting or positioning. -1:20 P.M., - 1:40 P.M., the resident continued to sit at the dining room table in his/her wheelchair looking around. The resident continued to say he/she needed someone to push him/her, that he/she had pain, and he/she had a sore on his/her buttock. The resident had facial grimacing. CNA G and CNA F passed back and forth through the dining room. -1:40 P.M. - 1:46 P.M., the surveyor reported to CNA G, CNA F, and the Director of Nursing (DON) the resident was asking to be taken back to his/her room. CNA G went to the resident and came back and said the resident wants to stay for bingo; -1:46 P.M., CNA G moved the resident to another table for bingo. CNA G did not provide incontinent care or reposition the resident; -1:46 P.M. - 1:50 P.M., the resident sat in his/her wheelchair in the dining room and waited for bingo to start. -1:50 P.M. - 2:00 P.M., the resident continued in his/her wheelchair trying to push his/herself up off the wheelchair. The resident had facial grimacing and said ow. Multiple staff walked by the resident and did not provide assistance; -2:00 P.M. - 2:25 P.M., the resident continued to sit in his/her wheelchair in the dining room playing bingo and looking around. The resident had facial grimacing and repeatedly said my butt is sore, and ow, ow; -2:25 P.M.-2:28 P.M., CNA G walked over to the resident at the dining room table during bingo asked the resident if he/she needed changed and checked the resident's brief. The CNA told the resident he/she was fine. Staff did not reposition the resident; -2:28 P.M. - 2:40 P.M., the resident continued to sit in his/her wheelchair in the dining room with facial grimacing and saying ouch, using his/her arms to push himself/herself up off of the wheelchair with wheelchair arms. -2:40 P.M., the resident said he/she cannot keep off of his/her buttock, his/her buttock was sore and hurts. The resident continued to have facial grimacing and said ow multiple times; -2:41 P.M. - 3:05 P.M., the resident remained at the dining room table in his/her wheelchair playing bingo. Staff did not offer to reposition or provide toileting assistance; -3:06 P.M. - 3:20 P.M., multiple staff walked by the resident without offering to take the resident to his/her room, reposition, or provide toileting assistance, after bingo. The resident continued to have facial grimacing and said ow multiple times; -3:21 P.M., the resident said, somebody help me. Staff were passing out prizes to residents for bingo. No staff assisted the resident. -3:26 P.M., the activity aide asked the resident what was wrong after the resident said ouch. The resident told the staff that his/her bottom was sore; - 3:27 P.M. - 3:34 P.M., the resident continued to sit in his/her wheelchair and complain of his/her buttocks hurting with facial grimacing; -3:35 P.M., the hospitality aide said he/she told the charge nurse the resident needs situated, and the nurse should be to the dining room soon. The resident remained in the dining room with position unchanged and no staff assistance; -3:42 P.M. -3:44 P.M., the resident used his/her arms to propel himself/herself slowly away from the dining room table; -3:44 P.M. -3:46 P.M., the resident waved down the Social Services Director (SSD) and the SSD propelled the resident around the halls and into his/her room. The SSD left the resident in his/her room and did not tell staff the resident was back in his/her room. -3:46 P.M. - 4:00 P.M., the resident sat in his/her room in his/her wheelchair leaning to the right side, he/she pushed himself/herself off of the wheelchair cushion. The resident had facial grimacing and said, my butt hurts. There was no staff around. -4:00 P.M. - 4:06 P.M., the resident reached for the call light on the bedside table and dropped the call light on the floor. The resident reached for the call light, but could not pick it up; -4:06 P.M., the DON walked to the door of the resident's room and spoke to the resident. The DON did not offer to reposition, toilet, or assess the resident for pain; -4:07 P.M. - 4:19 P.M. the resident continued to sit in his/her wheelchair next to his/her bed and continued to have facial grimacing. -4:20 P.M., the surveyor asked the CNAs to lay the resident down to see the resident's skin. CNA A and NA B transferred the resident to his/her bed with the mechanical lift. The resident's wheelchair had a white foam cushion with a plastic trash bag covering the cushion. CNA A and CNA B removed the resident's mechanical lift pad, pants, and brief. The resident's brief had a strong ammonia odor and adhesive border gauze dressing with a large amount of yellow/green thick drainage in the brief. The wound on the resident's left ischium was red and had yellow/green thick drainage coming from it. CNA A went to get the nurse. -4:30 P.M., LPN D came into the resident's room with gloved hands, holding a bottle of wound cleanser in one hand and an adhesive border gauze dressing and calcium alginate pad (absorbent non-adherent dressing) in the other hand. The LPN set the wound cleanser and dressing on the resident's mattress. The CNAs rolled the resident to his/her left side. No dressing was on the resident's wound and the wound was red and had yellow/green, thick drainage. The LPN sprayed the wound with wound cleanser and wiped the outer edges of the wound with 2x2 gauze. With the same gloves, the LPN used his/her index finger and pushed the calcium alginate into the wound bed and covered the wound with adhesive border gauze and initialed the dressing. The resident said, that hurts and showed facial grimacing. The resident's low air

Based on observation, interview, and record review, the facility failed to address pain for one resident (Resident #322) who had a pressure ulcer to the left buttocks, impaired mobility, and was dependent on staff for all activities of daily living. The facility staff failed to assess the resident's pain and document the resident's pain when the resident voiced pain, and failed to administer pain medication to the resident. The resident repeatedly stated, my butt sore and ow, with facial grimacing. The facility census was 72. Review of the facility's Pain Assessment and Management policy, revised March 2020, showed: -Procedure is used to help the staff identify pain in the resident; -Possible behavioral signs of pain are, verbal expressions such as groaning or crying, facial grimacing, guarding, or favoring a part of the body; -Identifying the causes of pain such as pressure, venous, or arterial ulcers; -Review the resident's treatment record to identify any situations where an increase in the resident's pain may be anticipated, for example; treatments such as wound care or dressing changes and repositioning; -Document the resident's reported pain level with adequate detail. Review of the facility's Wound Care policy, revised, October 2010, showed: -Review the resident's care plan for orders for pain medication as needed to be administered prior to wound care. Review of the facility's Repositioning policy, revised May 2013, showed: -The purpose of this policy is to provide guidelines for the evaluation of resident repositioning needs, to promote comfort for all bed or chair bound residents and to prevent skin breakdown and provide pressure relief for residents; -Review the resident's care plan to evaluate for any special needs of the resident; -Repositioning is a common, effective intervention for preventing skin breakdown and providing pressure relief; -Repositioning is critical for a resident who is dependent upon staff for repositioning; -Residents with a stage I pressure ulcer or above pressure ulcer, every two hour repositioning schedule is inadequate; -Residents who are in a chair should be on every one hour schedule; -The position in which the resident was placed should be documented. Review of Resident #322's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/23, showed: -Moderate cognitive impairment; -Dependent on staff for Activities of Daily Living (ADLs); -Dependent on staff for turning and repositioning; -Pressure reliving devices in chair and bed; -At risk for pressure ulcers; -One unhealed pressure area; Stage 3; -Uses non-verbal, vocal complaints and facial grimacing as indicator of pain; -Pain observed 1 to 2 days out the last 5 days; -Incontinent of bowel and bladder; -Used a wheelchair; -Dependent on staff for mobility: -Diagnosis included: osteomyelitis (a serious infection of the bone), end stage kidney disease, non-pressure chronic ulcer of back, Down Syndrome (a genetic chromosomal disorder that can a cause causing lifelong intellectual disability and developmental delays), diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), and peripheral vascular disease (progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel). Review of the resident's care plan, dated 1/17/24, showed: -Resident has an ADL self-care performance deficit related to impaired balance and limited mobility; -Resident is incontinent of bowel and bladder and dependent on staff to clean and reposition. -The resident has pressure sores and high risk for skin breakdown and pain is to be monitored. -The resident has chronic pain related to end stage kidney disease, dialysis, and left buttocks wound; -Administer analgesic as needed for pain, give 1/2 hour before treatment or care; -Anticipate the resident's need for pain relief and respond immediately to any complaints of pain; -Evaluate the effectiveness of pain interventions daily and every shift; -Monitor probable cause of each pain episode; -Monitor and report to the nurse any signs and symptoms of non-verbal pain -Resident to be turned or repositioned every 2 hours when in bed and in chair; -Staff to ensure resident was not laying on left buttocks wound, use pillows to shift resident's weight and prevent further skin breakdown. Review of the resident's Physician's Order Sheet (POS) for January 2024 showed: -admitted [DATE]; -Start date: 11/30/23 - no end date, assess pain every shift; -Start date: 11/30/23 - no end date, pain management, obtain consult and treatment as needed for patient health and comfort; -Start date: 11/30/23 - no end date, Acetaminophen tablet, 500 milligrams (mg), give one tablet by mouth every 4 hours as needed for pain. Review of the resident's Medication Administration Record (MAR) dated January 2024, showed: -Order start date: 11/30/23 - no end date, Acetaminophen tablet 500 mg, give one tablet by mouth every 4 hours as needed for pain; --The resident received one tablet of Acetaminophen 500 mg on 1/17/24 at 12:30 A.M., with a pain level of 5 on a 0 - 10 pain scale; --The resident received one tablet of Acetaminophen 500 mg, on 1/17/24 at 7:31 P.M., with a pain level of 2; --No other entries that the resident received Acetaminophen were found; -Order start date: 11/30/23 - no end date, assess pain every shift; --1/1/24 through 1/24/24 the resident's pain rating was assessed at 0 (indicating no pain) on the day shift and the night shift. Review of the resident's progress notes dated 1/1/24 through 1/24/24 showed no documentation the resident was in pain. Continuous observation on 1/24/24 at 7:03 A.M. until 1/24/24 at 4:20 P.M., showed: -7:03 A.M.- 8:21 A.M., the resident sat in his/her wheelchair in the dining room eating and looking out the window. The resident had a cushion in his/her wheelchair. At 8:12 A.M. the resident told Nurse Aide (NA) B, please lay me down, I am done. The resident continued to sit in his/her wheelchair in the dining room saying he/she was ready to lay down; -8:22 A.M., NA B positioned the resident's wheelchair beside the bed in the resident's room with the resident facing the hall and set a bedside table in front of the resident, placed the call light on the table, and turned a movie on. -8:23 A.M., NA B left the resident's room; -8:23 A.M.- 10:01 A.M., the resident continued to sit in his/her wheelchair in his/her room and color. -10:01 A.M. - 10:05 A.M., the resident continued to sit in his/her wheelchair in his/her room coloring. Licensed Practical Nurse (LPN) D stopped at the resident's door and asked if the resident wanted to lay down or stay up and color. The resident told LPN D he/she wanted to stay up and color. LPN D did not offer to reposition the resident in his/her wheelchair, offer incontinent care, or assess the resident for pain. -10:05 A.M. - 10:24 A.M., the resident continued to sit in his/her wheelchair in his/her room coloring; -10:25 A.M. - 10:44 A.M., the resident continued to sit in his/her wheelchair in his/her room coloring. The resident was leaning to the right, raising his/her bottom up off the seat of the wheelchair; -10:44 A.M. - 10:45 A.M., the resident was leaning to the right with his/her hands on the arms of the wheelchair, raising his/her bottom up off the seat of the wheelchair. Housekeeper A looked in the resident's room while the resident had facial grimacing and was saying ow, ow, that is sore; Housekeeper A did not tell the nursing staff the resident was complaining of pain; -10:46 -10:55 A.M., the resident continued to lean to the right with his/her hands on the arms of the wheelchair, raising his/her bottom up off the seat of the wheelchair; -10:55 A.M. - 11:00 A.M., the resident continued in his/her wheelchair, in his/her room looking around the room., no staff repositioned him/her or assessed him/her for pain; -11:00 A.M. - 11:30 A.M., the resident continued to sit in his/her wheelchair in his/her room and was leaning to the right, raising his/her bottom up off the seat of the wheelchair while the resident had facial grimacing and said ow, ow, my butt is sore. No staff repositioned or assessed the resident for pain; -11:30 A.M., Certified Nurse Aide (CNA) G propelled the resident to the dining room table and handed the resident his/her crayons and coloring pages. The CNA did not offer to toilet or reposition the resident; -From 11:30 A.M. - 11:49 A.M., the resident sat in the dining room in his/her wheelchair and colored; -11:50 A.M. - 11:55 A.M., the resident continued to sit in his/her wheelchair and color. Multiple staff walked around the dining room. Staff did not offer toileting or any positioning assistance to the resident. -11:55 A.M., an unidentified kitchen aide stopped and talked to the resident and walked away. The resident continued to sit in his/her wheelchair. Staff did not reposition the resident or assess the resident for pain; -11:56 A.M. - 12:03 P.M., the resident continued to sit in his/her wheelchair at the dining room table looking out the window; -12:04 P.M. - 12:08 P.M., the resident continued to sit at the dining room table in his/her wheelchair with his/her position unchanged. The resident looked around the dining room, he/she used his/her arms to push against the wheelchair arms to lift his/her left side off the wheelchair. The resident had facial grimacing; -12:09 P.M. - 12:20 P.M., the resident continued in the same position without staff assistance. Staff walked by passing out lunch trays. The resident had occasional facial grimacing; -12:21 P.M.- 12:28 P.M., the resident remained in the dining room in his/her wheelchair. CNA F came into the dining room and patted the resident on the back and did not offer to reposition the resident. The resident continued to have occasional facial grimacing and lifted his/her left buttock off the wheelchair cushion; -12:28 P.M., the resident received his/her lunch tray, an unidentified dining room assistant sat down next to the resident and moved his/her coloring sheet back. Staff did not offer to reposition the resident; -12:29 P.M. - 12:53 P.M., the resident ate his/her food and no staff offered to reposition resident; -12:53 P.M. - 1:00 P.M., the resident continued at the dining room table trying to lift himself/herself up in the chair and said it hurts. Staff were in the dining room passing trays. -1:00 P.M. - 1:05 P.M., the resident continued in the dining room in his/her wheelchair. CNA F asked the resident if he/she was doing ok and the resident said yes. Staff did not reposition the resident; -1:05 P.M. - 1:19 P.M., the resident continued to eat his/her lunch in dining room. Staff did not reposition the resident; -1:20 P.M., the resident tried to push his/her plate away from him/her. CNA F stopped and assisted the resident in moving his/her plate and helped the resident get his/her crayons. CNA F did not offer assistance with repositioning; -1:20 P.M. - 1:40 P.M., the resident continued to sit at the dining room table in his/her wheelchair looking around. The resident continued to say he/she needed someone to push him/her, that he/she had pain, and he/she had a sore on his/her buttock. The resident had facial grimacing. CNA G and CNA F passed back and forth through the dining room; -1:40 P.M. - 1:46 P.M., the surveyor reported to CNA G, CNA F, and the Director of Nursing (DON) the resident was asking to be taken back to his/her room. CNA G went to the resident and came back and said the resident wants to stay for bingo; -1:46 P.M., CNA G moved the resident to another table for bingo. CNA G did reposition the resident; -1:46 P.M. - 1:50 P.M., the resident sat in his/her wheelchair in the dining room and waited for bingo to start. -1:50 P.M. - 2:00 P.M., the resident continued in his/her wheelchair trying to push himself/herself up off the wheelchair. The resident had facial grimacing and said ow. Multiple staff walked by the resident and did not provide assistance to the resident; -2:00 P.M. - 2:25 P.M., the resident continued to sit in his/her wheelchair in the dining room playing bingo. The resident had facial grimacing and repeatedly said, my butt is sore, and ow, ow; -2:25 P.M.- 2:28 P.M., CNA G walked over to the resident at the dining room table during bingo asked the resident if he/she needed changed and checked the resident's brief. CNA G told the resident he/she was fine. Staff did not reposition the resident; -2:28 P.M. - 2:40 P.M., the resident continued to sit in his/her wheelchair in the dining room with facial grimacing and saying ouch, using his/her arms to push himself/herself up off of the wheelchair using the wheelchair arms; -2:40 P.M., the resident said he/she cannot keep off of his/her buttock, his/her buttock was sore and hurts. The resident continued to have facial grimacing and said ow multiple times; -2:41 P.M. - 3:05 P.M., the resident remained at the dining room table in his/her wheelchair playing bingo. Staff did not offer to reposition; -3:06 P.M. - 3:20 P.M., multiple staff walked by the resident without offering to take the resident to his/her room or reposition, after bingo was over. The resident continued to have facial grimacing and said ow multiple times; -3:21 P.M., the resident said, Somebody help me. Staff were passing out prizes to residents for bingo. No staff assisted the resident. -3:26 P.M., the Activity Aide asked the resident what was wrong after the resident said ouch. The resident told the staff that his/her bottom was sore; - 3:27 P.M. - 3:34 P.M., the resident continued to sit in his/her wheelchair and complain of his/her buttocks hurting with facial grimacing; -3:35 P.M., the hospitality aide said he/she told the charge nurse the resident needs situated and the nurse should be to the dining room soon. The resident remained in the dining room with position unchanged and no staff assistance; -3:42 P.M. - 3:44 P.M., the resident used his/her arms to propel himself/herself slowly away from the dining room table; -3:44 P.M. - 3:46 P.M., the resident waved down the Social Services Director (SSD) and the SSD propelled the resident around the halls and to his/her room. The SSD left the resident in his/her room and did not tell staff the resident was back in his/her room. -3:46 P.M. - 4:00 P.M., the resident sat in his/her room in his/her wheelchair leaning to the right side. He/she pushed himself/herself off the wheelchair cushion. The resident had facial grimacing and said, my butt hurts. -4:00 P.M. - 4:06 P.M., the resident reached for the call light on the bedside table and dropped the call light on the floor. The resident reached for the call light, but could not pick it up; -4:06 P.M., the DON walked to the door of the resident's room and spoke to the resident. The DON did not pick up the call light off the floor, offer to reposition the resident, or assess the resident for pain; -4:07 P.M.- 4:19 P.M., the resident continued to sit in his/her wheelchair next to his/her bed. The resident continued to have facial grimacing; -4:20 P.M., the surveyor asked the CNAs to lay the resident down to see the resident's skin. CNA A and NA B transferred the resident to his/her bed with the mechanical lift. The resident's wheelchair had a white foam cushion with a plastic trash bad covering the cushion. CNA A and CNA B removed the resident's mechanical lift pad, pants, and brief. The resident's brief had a strong ammonia odor and adhesive border gauze dressing with a large amount of yellow/green thick drainage. CNA A went to get the nurse. The resident had facial grimacing and said ow. -4:30 P.M., showed LPN D came into the resident's room with gloved hands. The CNA's rolled the resident to his/her left side. The LPN provided the resident's wound treatment. The resident said, that hurts and showed facial grimacing. The LPN said the resident has had this wound for years and is deeply tunneled. The dressings are completed daily, and the wound is unstageable. The resident was admitted with the wound. Review of the resident MAR, dated January 2024, showed no pain medications were given on 1/24/24. During an interview on 1/24/24 at 4:45 P.M., CNA A and NA B said they provide repositioning and toileting assistance to the resident when they get time. They normally start doing rounds at the beginning of their shift and the standard is every two hours. During an interview on 1/24/24 at 5:10 P.M., LPN D said: -None of the staff told him/her the resident was in pain; -He/she did not assess the resident for pain today; -He/she did not give the resident any medication for pain today; -The resident should be repositioned every two hours, because of his/her wound and pain; -If the resident says that he/she hurts, wants to lay down, or shows facial grimacing the nurse should be notified. During an interview on 1/24/24 at 5:41 P.M., NA B said: -The resident had a sore on his/her bottom; -He/she complained that his/her bottom hurts. That was why he/she sets on a cushion; -It was normal for the resident to say ow and my butt hurts, that is what he/she does; -The resident likes to stay up in his/her chair and watch movies; -If the resident says his/her bottom hurts, he/she gets the nurse and the nurse will give the resident something for pain; -The resident should be checked and repositioned every two hours; -The resident will usually tell them if he/she wants to lay down. During an interview on 1/24/24 at 5:45 P.M., CNA G said: -The resident had a sore on his/her bottom; -When he/she complains that his/her bottom hurts, he/she gets the nurse and the staff lay him/her down; -The resident wanted to stay up and play bingo today that was why he/she was not laid down; -If the resident says his/her bottom hurts, he/she gets the nurse and the nurse will give him/her something for pain; -He/she said if the resident says ouch or something hurts, he/she would tell the nurse should address the pain; -It was normal for the resident to say ow and my butt hurts, that is what he/she does. During an interview on 1/25/24 at 5:31 A.M., LPN A said: -He/she did not give the resident any pain medication last night (1/24/24) prior to wound care as directed by the care plan. During an interview on 1/24/24 at 5:51 P.M., CNA F said: -The resident should be repositioned at least every two hours; -If the resident says he/she hurts, the staff tell the nurse. During an interview on 1/24/24 at 6:07 P.M., the SSD said: -If the resident says he/she is in pain or wants to lay down, he/she gets the nursing staff to lay him/her down; -If the resident shows facial grimacing or moaning, staff should tell the nurse; -The resident should be repositioned at least every two hours; -If the resident says he/she hurts, he/she would tell the nurse. During an interview on 1/25/24 at 6:07 A.M., Housekeeper A said: -If the resident said ouch or showed facial expressions of pain that means the resident is in pain and he/she should tell the nurse; -He/she did not see the resident in pain on 1/24/24. During an interview on 1/25/24 at 6:24 A.M., Certified Medication Technician (CMT) A said: -The resident did not receive scheduled pain medication; -The resident had an order for Tylenol for as needed pain; -The resident did not ask for pain medication; -He/she would look for facial expressions and verbal expression for pain and he/she should tell the nurse; -He/she did not remember the resident being in pain at any time he/she has worked. During an interview on 1/25/24 at 3:16 P.M., the wound care physician said: -He/she expected the resident's pain to be controlled even if it is giving the resident just a Tylenol 30 minutes before wound care and any time he/she is having pain. During an interview on 1/25/24 at 4:18 P.M., Family Member A said: -The resident has more pain when he/she does not change positions or if he/she is up too long; -He/she would not expect the resident to be up in his/her wheelchair all day long. During an interview on 1/26/24 at 8:16 A.M., Physician A said: - If a resident is in pain it should be assessed by a nurse and the appropriate action taken whether it is medication or non-pharmlogical interventions; -If staff notice a resident is in pain they should tell the nurse and if they are a nurse they should administer prescribed pain mediation; -The pain should be addressed as soon as possible. During interviews on 1/26/24 at 9:16 A.M. and 1/27/24 at 12:45 P.M., the DON said: -He/she would expect staff to report to the nurse if the resident said his/her butt hurts; -The staff should not let the resident continue to voice complaints of pain, without interventions for an extended period of time; -It is not acceptable for the CNAs to respond to the resident's facial grimacing and reports of pain by not reporting this to the nurse. -He/she expected CNAs to report pain to the charge nurse; -Staff should document the resident's pain on the MAR. During interviews on 1/26/24 at 9:20 A.M. and 1/27/24 at 12:50 P.M., the Administrator said: -He/she would expect staff to report to the nurse if the resident said his/her butt hurts; -He/she expected CNAs to report pain to the charge nurse. -The staff should not let the resident continue to voice complaints of pain, without interventions for an extended period of time; -It is not acceptable for the CNAs to respond to the resident's facial grimacing and reports of pain by not reporting this to the nurse.

Based on record review and interview, the facility failed to designate a physician to serve as the medical director. The facility census was 72. Review of the facility's policy for medical director, revised July 2016, showed: - Physician services shall be under the supervision of the medical director; - The medical director is a licensed physician in this state and is responsible for: ensuring adequate and appropriate physician services; reviewed practitioner credentials and overseeing physicians and those who perform physician-delegated tasks; reviewing physician performance and providing feedback to try to improve performance; overseeing and helping develop and implement care-related policies and practices; participating in efforts to improve quality of care and services; serving as a liaison with the community; and serving as a source of education, training, and information; - Medical director functions also include, but are not limited to : acting as a liaison between administration and attending physicians; acting as a consultant to the director of nursing services in matters relating to resident care services; helping assure that the resident care plan accurately reflects the medical regimen; participating in staff meetings concerning infection prevention and control, quality assurance and performance improvement, antibiotic stewardship, pharmaceutical services, resident care policies, etc.; assisting with employee health issues and concerns; and assuring that physician services comply with current rules, regulations, and guidelines concerning long-term care. Review of the facility's Quality Assurance and Performance Improvement (QAPI) notes, dated 1/27/24 at 10:15 A.M., showed: - The documentation did not show the medical director was in attendance for any of the meetings. During an interview on 1/27/24 at 10:18 A.M., the Administrator said: - Physician A had not signed the contract to be the Medical Director; - The facility had not terminated their agreement with Physician B, but they had not offered him/her a new contract when the new management had taken over.

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance (QAA) committee that contains the minimum required members. The facility census was 72. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy, dated 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 residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; - The QAPI program will reinforce and build upon effective systems and processes related to the delivery of quality care and services; - The QAPI program will 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 administrator is responsible for assuring this facility's QAPI program complies with federal, state, and local regulatory agency requirements. The facility did not provide a policy regarding their QAA committee. Review of an undated document provided by the facility labeled Monthly Meetings QAPI Members showed: - The following unnamed members Administrator, Director of Nursing, MDS Coordinator, Maintenance, Housekeeping/Laundry, Marketing, Business Office, Therapy, and Medical Director/or Physician. Review of minutes from the monthly QAPI meetings from January of 2023 to January of 2024 showed: - Meeting conducted in the months of January 2023, February 2023, April 2023, May 2023, June 2023, July 2023, October 2023, November 2023, December 2023, and January 2024 without a medical director present. During an interview on 1/27/24 at 10:18 A.M., the Administrator said: - Physician B is the facility's medical director; - Physician B has not attended any meetings; - Physician A is invited to come to QAPI meetings, because he/she practices for most residents in the facility; - Physician A was sent an email for the October 2023 meeting, however no documentation exists to show he/she reviewed the meeting; - The facility's medical director should attend QAPI/QAA meetings.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one resident (Resident #1) when the facility failed to follow up on an urgent x-ray order when the resident had bruising and swelling to left elbow. The facility census was 60. The facility did not provide a policy on following urgent physician orders. 1. Review of Resident #1's Significant Change Minimum Data Set (a federally mandated assessment completed by staff), dated 7/30/23, showed -He/she has the diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), lack of coordination, chronic pain, dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), unsteady on feet, weakness, reduced mobility, dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized idiopathic epilepsy (a subtype of generalized epilepsy and consists of childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, and generalized tonic-clonic seizures alone), history of falls, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and heart failure. -He/She was receiving hospice care (a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness and their caregivers). -He/She had moderate difficulty hearing, usually understands others. He/She scored zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates severely impaired cognitive abilities. -He/She required extensive to total assistance with all activities of daily living, including bathing, dressing, transferring, mobility and personal hygiene. Review of the resident's care plan, dated 8/7/2023 showed: -The resident required assistance with all Activities of Daily Living. -He/She required assistance in positioning in bed and wheelchair. -He/She used a wheelchair for mobility and was unable to propel the wheelchair. -The resident was incontinent of bowel and bladder. -The resident required assistance of two staff and mechanical lift for transfers. Review of the resident's progress notes showed: -9/16/2023 12:00 A.M. (Late Entry): Registered Nurse (RN) A wrote: Certified Nurses Assistant (CNA) showed this writer the resident's left arm. Has bluish bruising to left outer elbow. No swelling observed, continue to observe site. Writer thought resident may have had labs drawn this week and bruising may be from lab. -9/17/2023 02:20 A.M. RN A wrote: CNA called writer to resident's room. Left arm has purple bruising to left outer elbow, left elbow asymmetrical, pain to touch and swelling to left elbow. Writer called hospice nurse. Hospice nurse gave order for STAT (right away) 2 view X-ray to the left elbow to rule out fracture or dislocation. Resident had contractures to both upper extremities. -9/17/2023 7:33 A.M. RN A wrote: Writer called the resident's sister, notified of resident's bruising and swelling to left elbow. Plans for STAT 2 view X-ray to left elbow. -9/17/2023 4:43 PM LPN A wrote: Resident's sister here, worried why X-ray is taking so long. Hospice at bedside. -9/17/2023 5:20 P.M. LPN A wrote: Resident is being sent to emergency room at Mosaic Life Care. Emergency Medical Services (EMS) en route. Hospice, administrator, physician notified. -9/17/2023 9:15 P.M. RN A wrote: Resident returned to facility at 9:15 P.M. Complete oblique fracture through distal (to the elbow) humerus (bone of upper arm) extending to the medial humerus and lateral humerus region. Medial displacement to distal segment at left humerus bone. Has diffused osteopenia ( loss of bone mineral density) and likely hemarthrosis (a condition of articular bleeding, that is into the joint cavity) and surrounding soft tissue swelling. Has soft cast with immobilizer and sling on left arm. During an interview on 9/19/2023 at 10:18 A.M. CNA A said: -He/She worked on the resident's hall on 9/16/2023 from 6:00 A.M. to 2:00 P.M. -He/She reported bruising to LPN A during his/her shift, around lunch time, and LPN A assessed the resident. -There was swelling and bruising to the resident's left elbow and upper arm. -He/She did not work with the resident on 9/17/2023. -The resident's room is small and can be difficult to maneuver the mechanical lift and wheelchair. During an interview on 9/19/2023 at 10:44 A.M., Hospitality Aide (HA) A said: -He/She has worked at the facility almost a year. -He/She makes beds, assist residents in eating, help CNA's in transferring and cleaning residents. -When transferring a resident with a mechanical lift, there should be two staff people. -He/She worked with the resident on 9/16/2023 and 9/17/2023. -On 9/16/2023, the resident's left arm was swollen and bruised. -HA A and CNA A told LPN A about the resident's left arm around lunch time. -LPN A instructed HA A and CNA A to lay down the resident and put a pillow under his/her left arm. -The resident does not move his/her arms on his/her own. During an interview on 9/19/2023 at 12:02 P.M., LPN A said: -He/She worked 9/16/2023, 6:00 A.M. to 6:00 P.M. and 9/17/2023, 6:00 A.M. to 6:00 P.M. -On Saturday, 9/16/2023, at shift change, RN A reported to LPN A that a CNA reported bruising to the resident's left arm, possibly from lab draw. -When LPN A started the shift on 9/17/2023, the resident was already up in his/her chair, wearing a long-sleeved sweater. -He/She assessed the resident after dinner, between 5:00 P.M. and 5:30 P.M. There was bruising to left outer elbow. -Gave report to RN A, the oncoming night nurse, at shift change, reporting the bruising to the elbow. -He/She read in the progress notes that the STAT order for an X-ray to the left elbow was written at 4:00 A.M. on 9/17/2023. -Instructed the staff to leave the resident in bed on 9/17/2023 and assist him/her to eat in his/her room. -The resident receives scheduled pain medication and did not display signs of pain. -He/She did not follow up with the mobile X-ray company or physician in the delay for X-rays being done. -Hospice and the resident's sister arrived at the facility during the afternoon of 9/17/2023 and the decision was made to send the resident to the emergency room . During an interview on 9/19/2023 at 1:25 P.M., the hospice nurse said: -He/She was the on call nurse for hospice on 9/16/2023 and 9/17/2023. -He/She was notified by the night nurse, RN A, on 9/17/2023 at 2:00 A.M. about the bruising and swelling to the resident's left elbow/upper arm. -He/She provided an order for a STAT 2 view x-ray of the left elbow to rule out fracture or dislocation. -He/She received no updates from the facility during the day on 9/17/2023. He/she tried multiple times to call the facility for an update, but no one answered the phone. He/She was out visiting other patients, and stopped at the facility after visiting his/her last patient for the day. He/She arrived at the facility approximately 3:00 P.M. and met the resident's sister while entering the facility. -He/She assessed the resident's left arm. The resident appeared to be in pain and grimaced during the assessment. There was bruising from above the left elbow into the forearm. He/She could see the displacement in the arm. -He/She asked the charge nurse about the status of the X-ray. He/She was informed by LPN A that the X-ray had not been done yet and would be done by 4:00 P.M. -He/She discussed the situation and options with the resident's sister and the decision was made to send the resident to the emergency room for an X-ray and evaluation. -EMS was called, and the resident was transferred to the emergency room . During an interview on 9/19/2023 at 3:15 P.M., the Administrator said: -The mobile X-ray company went to the wrong facility on 9/17/2023. -It is his/her expectation the staff would follow up with the mobile X-ray company and physician regarding the delay in obtaining an X-ray. During an interview on 9/20/2023 at 11:23 A.M., RN A said: -He/She worked the night shift 9/15/2023 into 9/16/2023, 6:00 P.M. to 6:00 A.M., and on 9/16/2023 into 9/17/2023,6:00 P.M. to 6:00 A.M. -A CNA informed him/her of the bruising to the resident's left elbow during the early morning hours of 9/16/2023. -He/She looked at the resident's arm and thought the bruising may have been from a lab draw. -He/She reviewed the lab sheets and the resident had not had any labs drawn recently. -He/She informed LPN A at shift change the morning of 9/16/2023 of the bruising. -During the night shift 9/16/2023 into 9/17/2023, the resident was experiencing tenderness to the elbow. He/She administered pain medication to the resident. -He/She notified hospice of the bruising and received an order for a STAT two view X-ray of the left elbow to rule out fracture or dislocation. -He/She notified LPN A the morning of 9/17/2023 at shift change of the assessment of the resident's elbow and the order for the X-ray. During an interview on 9/25/2023 at 4:30 P.M., the physician said: -He/She is aware of the situation with the resident's fractured elbow. -He/She was notified when the resident was sent to the emergency room . -He/She expected staff to follow up with the mobile X-ray company and the physician if the STAT X-ray had not been obtained within 1-2 hours.

Based on observation, interviews, and record reviews, the facility failed to identify and assess one resident (Resident #1), who was identified as high risk for pressure ulcer (PU) who developed a PU to the sacral area which required multiple surgical debridements (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) in the hospital and an unstageable PU (area of localized tissue necrosis, tissue death, that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time) to the heel. The resident developed moisture associated skin damage (MASD) (prolonged exposure to moisture, including urine or stool, perspiration, or wound drainage; MASD is an inflammation of the skin, occurring with or without erosion or secondary skin infection), to the sacral area which was identified in the emergency room as a Stage 3 PU (a full thickness of the skin and may extend into the subcutaneous tissue layer; at this stage, there may be undermining that makes the wound much larger than it appears). The facility staff failed to identify, monitor and assess the area. The facility failed to develop and implement interventions to prevent the MASD and failed to develop and implement interventions for the development of PU. The facility census was 61. Review of the undated facility policy for Skin Ulcer-Wound showed: -All caregivers are responsible for preventing, caring for, and providing treatment for [REDACTED].>-Purpose: to identity at risk residents for potential breakdown or ulcerations; to prevent breakdown of tissue or ulcerations; to provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -A skin ulcer (wound) is defined as any open area of the skin regardless of the origin. It may also include an area of discoloration that is not open if the nurse identifies an area of concern that may potentially ulcerate and then confirms suspicion with a provider (physician/nurse practitioner/physician assistant) for diagnosis; -Risk factors can increase a resident's susceptibility to develop or to not heal skin issues: impaired/decrease mobility and decreased ability, co-morbid conditions, drugs such as steroids that may affect wound healing, impaired diffuse or localized blood flow, resident refusal or some aspects of care and treatment, cognitive impairment, exposure of skin to urinary and fecal incontinence, under nutrition, malnutrition, hydration deficits; -Licensed staff will, upon admission, perform a head to toe body audit within two hours of admission; -Measurement must be completed weekly; -At the time a skin issue is discovered it must be measured. Wounds are three dimensional; therefore length, width, and depth must be documented if using a measuring instrument; -If a reddened area is identified, the nurse should assess if the area is blanching (occurs when the skin becomes white or pale in appearance). It if is not blanching, the nurse should leave for approximately 30 minutes, then return to assess if the area is blanchable. If it is blanchable, it is not a skin concern. If if is not blanching, then it should be captured on a licensed body audit report; -A wound assessment should be documented in the nurses' notes (or other documentation location) with each dressing change; -It is recommenced to chart on the treatment administration record (TAR) or other location that the dressing is intact every shift, that a dressing change is not performed. Review of the facility policy for Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 3/14 showed: -The nursing staff and attending physician will assess and document an individual's significant risk factors for developing PU; for example, immobility, recent weight loss, and a history of pressure ulcer(s); -The nurse shall describe and document/report the following: full assessments of PU including, location, stage, length, width and depth, presence of exudate (drainage) or necrotic (dead) tissue; pain assessment; the resident's mobility status; current treatments, including support surfaces and all active diagnoses; -The staff will examine the skin of a new admission for ulcerations or alterations in the skin; -The physician will assist the staff to determine the etiology (cause) and characteristics of the skin alteration; -The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for type of skin alteration; -The physician will help identify medical interventions related to wound management: for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing co-morbid medical conditions, managing pain related to the wound or wound treatment; -The physician will help staff characterize the likelihood of wound healing. Review of the facility policy for care planning dated 9/13 showed: -The facility's care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident; -A comprehensive care plan for each resident is developed within seven days of the completion of the resident assessment (MDS-Minimum Data Set); -The care plan is based on the resident's comprehensive assessment and is developed by the care planning/interdisciplinary team which includes, but is no limited to: the attending physician, the registered nurse who is responsible for the resident, the dietary manager/dietitian, the social services worker, activity director, therapist, consultants, the Director of Nursing (DON), the charge nurse responsible for resident care, the nursing assistants responsible for the residents care; -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Review of the facility policy for care plans, comprehensive person-centered dated 12/16 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 comprehensive, person-centered care plan will include: measurable objectives and timeframe's; describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being; include the resident's stated goals upon admission and desired outcomes; include the resident's stated preference and potential for future discharge; incorporate identified problem areas; incorporate risk factors associated with identified problems; build on the resident's strengths; reflect the resident's expressed wishes regarding care and treatment goals; identify the professional services that are responsible for each element of care; aid in preventing or reducing decline in the resident's functional status and/or functional levels; enhance the optimal functioning of the resident by focusing on the rehabilitative programs and reflect currently recognized standards of practice for problem areas and conditions; -Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan; -Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary progress; -Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; -When possible, interventions address the underlying source(s) of the problem areas(s) not just addressing only the symptoms or triggers; -Care planning individual symptoms in isolation may have little, if any, benefit for the resident; -The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessments; -Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change; -The Interdisciplinary Team must review and update 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 assessments 1. Review of Resident #1's admission orders [REDACTED] -[DIAGNOSES REDACTED]. -Orders to cleanse surgical wounds on sternal area (breastbone) and legs with soap and water and keep open to air. Review of the physician orders (POS) for (MONTH) 2019 showed: -House moisturizer as needed (PRN) to skin; -House moisture barrier PRN for incontinence; -Cleanse incision to sternum and left inner leg with soap and water daily, keep open to air. Review of the skilled admission nurses' notes dated 5/14/19 showed: -Moderate pain in the chest area; -Extensive assistance with Activities of Daily Living (ADL's); -Occasionally incontinent of urine, continent of bowels. Review of the admission skin assessment dated [DATE] showed: -Surgical incision to the right upper chest, left and right lower chest and left lower leg; -Bruise to the right hip area and left upper leg; -Pressure ulcer to the coccyx; -Treatment orders to cleanse incisions to the sternum and left inner leg with soap and water daily and keep open to air; -No treatment orders or description for the PU to the coccyx. Review of the Braden Score (an assessment to determine the risk for skin breakdown) dated 5/24/19 showed the resident was at moderate risk for skin breakdown. Review of the Baseline Care plan dated 5/24/19 showed: -Goal: Maintain/regain highest practical level of independence during the stay with interventions of: limited assistance with bathing and dressing, occasionally incontinent of urine, provide assistance with bathing, follow facility protocol for skin impairment, independent with transfers and toileting and discharge plan to return to home. Review of the nurses' notes dated 5/24/19 showed: -Skin assessment was completed, incision sites to the sternum and left lower leg related to CABG, bruising to the left lower leg and abdomen and buttocks reddened. Review of the social services note dated 5/24/19 showed: -The resident plans to return home with home health. Review of the occupational therapy progress report dated 5/25/19 showed: -Requires moderate assistance of one staff for perineal care; -Resident will put on light for nursing staff to apply medication to open coccyx wound Review of the Nurse Practitioner (NP) notes dated 5/27/19 signed by NP A showed: -Resident has diabetes, recent CABG surgery; -Resident is to be discharged to home after therapy; -No documentation of any PU to buttocks or coccyx. Review of the physical therapy treatment notes dated 5/27/19 showed: -The resident ambulated 60 feet two times with contact guard assistance; -Resident spoke with social services about going home this week with home health; -Cushion added to the resident's chair in the resident's room for increased height allowing the resident increased independence with sitting in the chair and standing. Review of the NP progress note signed by NP A dated 5/27/19 showed: -The resident had a CABG and is in the facility for physical and occupational therapy; -[MEDICAL CONDITION] in the lower extremities; -Skin warm and dry. Review of the physician's progress note dated 5/29/19 signed by Physician A showed: -Currently in nursing facility for volume overload and [MEDICAL CONDITION]; -Goal is to return home. Review of the physical therapy progress report dated 5/29/19 showed: -The resident is making consistent progress towards short and long term goals. The resident is compliant with physical therapy; -The resident stated I want to get home. I want to be able to take care of myself; -Patient goals: return to own home as soon as possible; -Potential to achieving goals: the resident demonstrates good rehab potential as evidenced by good cognition, motivated to participate, active participation with physical therapy and motivation to return to prior level of functioning. Review of the Medication Administration Record [REDACTED]. Review of the comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 5/31/19 showed: -Alert and oriented and able to answer questions; -Limited assistance of one staff member for Activities of Daily Living (ADL's); -Continent of bowel and bladder; -No PU; -Moisture associated skin damage (MASD) (caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous, skin, infection). -Not at risk for PU; -Plans to be discharged to the community. Review of the Braden tool dated 6/1/19 showed: -PU to the buttocks/coccyx area; -Minimal risk for PU; -No description of the PU on the buttocks/coccyx area with no interventions to prevent further breakdown or treatment of [REDACTED].>Review of the physical therapy progress notes dated 6/4/19 showed: -Increased difficulty today due to bottom/rectal wound and severe pain with movement. Review of the occupational therapy notes dated 6/4/19 showed: -The resident had pain in the buttocks with tears due to discomfort. The nurse informed and the NP consulted due to the pain hindering the resident's functional mobility. The NP reported that the resident had shearing and moisture in the buttock area and orders were written for nursing to address. Review of the NP progress note dated 6/4/19 signed by NP A showed: -Cleanse peri area and buttocks with soap and water or peri cleanser of facility choice, apply [MEDICATION NAME] cream (a medication used to treat fungal infections) and place calcium alginate (a dressing used in the debridement (removal) of dead or damaged skin, promoting a healthy wound environment that aids in wound healing) between buttocks to absorb moisture two times a day (BID) and as necessary (PRN) after soiling. Review of the NP progress notes dated 6/5/19 signed by NP A showed: -The resident complained of increased swelling in his/her bilateral legs. He/she does complain of pain in his/her buttocks; -Buttocks has gaulding; -Non-pressure chronic ulcer of buttocks limited to breakdown of the skin. The resident had gaulding to bilateral buttocks consistent with MASD, [MEDICATION NAME] bream BID and place calcium alginate between buttocks to help absorb moisture. Review of the occupational therapy notes dated 6/5/19 showed: -The nurse informed of the resident's coccyx wound with increased pain. The resident reported an 8 or 9 out of 10 pain (0 being no pain and 10 being excruciating pain). The nurse administered pain medication and applied a dressing to the coccyx wound. The [MEDICAL CONDITION] in the left extremity with redness to the heel addressed by the nurse. Review of the physical therapy progress noted dated 6/5/19 showed: -Communicated to charge nurse, the residents left lower extremity (LE) warm and red and swollen. Charge nurse aware and will monitor. The resident also has a wound on the coccyx. The resident complained of pain in the coccyx. Review of the physical therapy progress notes dated 6/6/19 showed: -Weekly progress note written and no significant progress made due to severe coccyx wound pain; -The resident complained of severe pain due to coccyx wound. Review of the Braden tool dated 6/7/19 showed: -Pressure ulcer to the coccyx with no measurements, no description of the wound or treatment plan for the wound; -At moderate risk for skin breakdown. Review of the comprehensive MDS dated [DATE] showed: -Alert and oriented and able to answer questions; -Extensive assistance of two people for ADL's; -No PU; -MASD; -Use of pressure reducing devices in chair and bed, on turning and positioning program and receives nutritional interventions for wound healing; -Plans to be discharged to the community. Review of the medical record showed no care plan for the PU on the buttocks or coccyx. No interventions for the nursing staff to utilize. No documentation of any skin issues, appearance of the coccyx/buttocks or complaints of pain to the coccyx/buttocks. Review of the nurses' notes dated 6/8/19 at 12:55 A.M. showed: -The resident was sitting on the side of the bed with two staff members present. The resident stated I'm falling and then pushed him/herself off the bed and slid onto the floor. Assessed the resident and no injuries were noted. Assisted back to bed. The resident denied any chest pain. The resident complained of pain in the coccyx. Review of the physical therapy progress notes dated 6/10/19 showed: -Physical therapy assistant (PTA) spoke with Occupational therapy assistant (COTA) regarding the resident's recent decline. The resident had been able to perform both lower extremity (BLE) exercises when sitting with weights, ambulating outside on uneven surfaces with PTA planning on the resident being discharged to home. The resident had two falls over the weekend and is now a mechanical lift. The resident has call light on frequently requiring assistance with bed positioning, complaints of BLE as well as chest pain. The PTA has notified the resident's nurse as well as the Assistant Director of Nursing (ADON) and social services of concerns regarding the resident's decline. Review of the physical therapy progress notes dated 6/11/19 showed: -Encouraged the resident to get out of bed and come to the therapy department. The resident agreeable despite being in pain. The resident is max assist for bed mobility rolling side to side. The resident transferred into the wheelchair using a mechanical lift and the resident yelled out in pain. The resident stated: I just feel like my whole body is bruised. My butt hurts where my sore is, my legs hurt and my hands feel numb. The resident sat in a wheelchair for one and half hours and then requested to lay down. PTA consulted with the NP regarding the resident's decline. The NP stated that blood had been drawn with no significant changes and that the physician wrote an order for [REDACTED]. Review of the occupational therapy notes dated 6/11/19 showed: -The resident did not want to attempt to stand. The therapist educated the resident on the importance of attempting to stand in order to continue to improve. Attempted to stand with the resident, the resident screamed out in pain when the therapist got to the count of three and stated my legs are completely dead and its too painful in my chest. -Informed the Registered Nurse (RN) of the resident's overall decline. Ten days ago the resident was able to complete all sit to stand with stand by assistance to contact guard assistance and stand for two to 30 minutes. The resident is now dependent upon staff for transfers with a mechanical lift and will scream out in pain with most touch and movement. The resident stated that his/her entire body hurts like one big bruise and that his/her arms and legs continue to feel dead and tingly since recent falls. Review of the NP progress note dated 6/11/19 signed by NP A showed: -Coccyx measures 5.0 cm (centimeters) by 4.0 cm by 0.1 cm. 100% eschar (black, dead skin) with mild odor. Peri-wound (skin surrounding the wound) gaulded. The resident stated that he/she noticed the soreness when he/she was in the hospital and the hospital was putting cream on it. Cleanse wound with normal saline and apply Hydrogel (a water based dressing that keeps the wound moist and aides in protecting the body from wound infection and promotes efficient healing), [MEDICATION NAME] cream to the peri-wound and then place calcium alginate between buttocks every shift. Review of the wound notes dated 6/11/19 showed: -PU to buttocks/coccyx area; -No description of the wound, no interventions for the preventions or the aid in healing the wound. Review of the physical therapy notes dated 6/12/19 showed: -The resident noted with recent decline. The resident noted late last week with increased complaints of soreness in coccyx due to wound as well as BLE weakness. The resident is now a mechanical lift. PTA and social services spoke with the resident regarding decline and lack of progress. The resident was groggy during the conversation. Review of the occupational therapy progress notes dated 6/12/19 showed: -The resident has shown a decline this week with right side weakness, used a wheelchair and unable to complete ADL tasks. Review of the nurses' notes dated 6/7/19 through 6/13/19 showed no documentation of any skin breakdown, any pressure ulcers, interventions for the prevention of further PU. Review of the care plan showed no documentation of the MASD or PU to the coccyx/buttocks, no interventions for the prevention of further PU or treatments for the MASD or PU. Review of the nurses' notes dated 6/13/19 at 3:52 A.M. showed: -On initial assessment, the resident was in the room with family visiting. The family had concerns regarding his/her decrease in level of consciousness. The resident had low blood pressure of 83/49 and oxygen saturation of 86 (normal 95-100). Oxygen at 2 L (Liters) per minute applied. Orders received from physician to sent to the hospital for decline in condition. Review of the emergency room report from a local hospital dated 6/12/19 showed: -The resident in the emergency department (ED) via ambulance with altered mental status and [MEDICAL CONDITION]. The resident has a history of hypertension and a CABG a couple of weeks ago. -Physical examination: The resident had a large sacral wound with foul-smelling purulent material around the wound edges. Darkened tissue noted on examination; -The residents symptoms have been present for more than 24 hours. The residents examination is consistent with generalized weakness and [MEDICAL CONDITION] (a brain disease, damage or malfunction) likely from infectious cause. CT (computed tomography, a specialized x-ray that shows anatomic details of internal organs) of the abdomen and pelvis showed a large area of subcutaneous (under the skin) gas (indicative of infection). Antibiotics started for possible [DIAGNOSES REDACTED] (a serious bacterial infection that destroys tissue under the skin); -Impressions: sacral wound with surrounding [MEDICAL CONDITIONS] present on admission and acute [MEDICAL CONDITION]. Review of the consultation report from a local hospital dated 6/14/19 showed: -On 6/12/19 the resident was admitted to the hospital. There was a large sacral decubitus with malodor. There was extensive soft tissue gas in the gluteal regions and ischiorectal fat. The findings were consistent with extensive soft tissue infections. The resident was taken to surgery for [REDACTED]. The infection extended down to the coccyx. A portion of the coccyx bone was excised (removed). On 6/14/19, the resident was taken back into surgery for [REDACTED]. There is a 5 cm by 4 cm area of ecchymosis (darkening of the skin) on the left heel, consistent with tissue injury; -Impressions: [MEDICAL CONDITION]; sacral pressure ulcer with deep space extension to bone and presumed osteo[DIAGNOSES REDACTED] (infection of the bone). Review of the consultation report from a local hospital dated 6/14/19 showed: -The resident is intubated and sedated and on a mechanical ventilation with a [MEDICATION NAME] feeding tube. (A tube placed in the stomach for nutrition). During an interview on 6/17/19 at 2:30 P.M. Charge Nurse (CN) C said: -When the resident was admitted he/she was one staff member assistance with ADL's, the resident progressively got worse and required more help; -He/she did not work for a week, but when he/she came back to work the resident was a different person, needed more help and had a lot of pain; -The resident developed a small open area on the coccyx, it looked like shearing (friction of the skin on a surface); -The nurses used several different treatments; -The coccyx was difficult to see, the resident buttocks were firm and he/she would sit up in the chair or the recliner; -The resident complained of a lot of pain in the coccyx. During an interview on 6/27/19 at 3:30 P.M. Certified Nurse Aide (CNA) A said: -He/she took care of the resident; -The resident would lay in the bed and roll side to side for the staff to give care; -He/she did not see any red or open areas on the coccyx/buttocks or any red or discolored areas to the heels. During an interview on 6/27/19 at 4:20 P.M. PTA A said: -He/she worked with the resident for the first week the resident was in the facility. The resident had made great progress and discharge plans had been discussed; -He/she was off for a week and when he/she came back, the resident was a changed person. He/she needed more help with ADL's and was no longer walking and had to be lifted using a mechanical lift; -The resident complained of pain in the coccyx/buttock area; -He/she reported the pain to the nurses; -The resident had a small area at the coccyx area that appeared to be a split in the skin; -This was reported to the nurses; -The resident was educated on pressure relief and he/she would roll side to side and lay on his/her side; -There was no special mattress or cushion in the residents bed or chair. During an interview on 6/28/19 at 11:05 A.M. CN [NAME] said: -When the resident was first admitted to the facility, the resident was able to walk and do most ADL's for him/herself. He/she was off work for a few days, and when he/she came back to work the resident was a mechanical lift, incontinent of bowel and bladder and required extensive assistance with ADL's; -The resident had a dark area on the coccyx that was being treated. There was no odor and the area did not appear to be open; -He/she could not assess the area due to the resident had large buttocks that were firm; -The resident did not like to lay down, the treatments were done while the resident was standing at the bedside; -He/she did not assess the resident's buttocks/coccyx while the resident was in the bed; -He/she did not assess the resident's heels. During an interview on 6/28/19 at 11:20 A.M. NP A said: -He/she assessed the resident's skin upon admission and ordered a treatment for [REDACTED].>-The buttocks/coccyx area had a yeasty smell with moisture; -He/she assessed the area while the resident stood up; -The resident would sit in the chair and was non-compliant with laying in the bed; -On 6/11/19, he/she assessed the area while the resident stood up. The area was not open with 100% eschar and no drainage. The area was moist with a slight odor. He/she wrote a new treatment order; -He/she was not informed of any skin issues on the heels. During an interview on 6/28/19 at 12:15 P.M. Physician A said: -He had seen the resident for complaints of pain in the neck, he was not aware of any complaints of pain the buttocks/coccyx area; -He was aware of the MASD in the buttocks/coccyx area that gradually got worse, NP A had written orders for a treatment; -The resident did not have any signs or symptoms of any infections; -He never suspected the resident had an infection. During an interview on 6/28/19 at 3:20 P.M. the MDS coordinator said: -He/she completes the initial base line care plan upon admission; -The nurses should update the care plan as the resident's condition changes; -He/she was aware of the resident's change of condition; -He/she did not assess the residents buttocks/coccyx area, he/she was unaware of the area getting worse; -The nurses should have updated the resident's care plan for interventions to aide in wound healing and in prevention. During an interview on 6/28/19 at 5:00 P.M. the DON said: -She did not assess the resident's buttocks/coccyx area; -NP A is the wound nurse and assesses all wounds and writes treatment orders; -She would expect the nurses to assess the wounds on the buttocks/coccyx area while the resident was lying down; -She would expect the nurses to document in the progress notes the appearance of the wound and notify the physician if the wound got worse or had an odor; -She would expect the nurses to update the care plan for current interventions and treatments. MO 4 and MO 3

Based on interviews and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one resident (Resident #1). Staff failed to develop a care plan to educate staff and direct them to monitor the resident for the risk of a change in mental status, failed to educate staff on the use of a medication, failed to assure staff administered [MEDICATION NAME] (a laxative used to reduce the amount of ammonia in patients with liver disease) as ordered, and failed to notify Family Member (FM) A of the acute change in the resident's mental status. Staff sent the resident to the emergency room (ER) with a high ammonia level of 163 micromoles per liter (umol/L, normal range of 0-35 umol/L), [MEDICAL CONDITION](rapid heart rate exceeding 100 beats per minute) and the physician admitted him/her to the hospital's intensive care unit. The facility census was 83. 1. Review of Resident #1's hospital discharge summary, dated 5/17/14, the director of nursing (DON) provided, showed: - Admission [DIAGNOSES REDACTED]. - Patient presented to the emergency room (ER) with dizziness, confusion, and a fall. He/she had an ammonia level as high as 128 umol/L. With just [MEDICATION NAME] treatment, we were able to get the ammonia level down to 34 umol/L and mentation (mental activity, state of mind) has cleared. - Patient does have generalized weakness and deconditioning; however, unable to afford skilled nursing facility placement and elected to return home. - Discharge [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. - Admit to intermediate care facility under care of Physician A. - Physical therapy and occupational therapy to evaluate and treat for restorative care. - [MEDICATION NAME] 10 grams (gms)/15 milliliters (ml) give 20 gms by mouth three times a day (TID); - [MEDICATION NAME] 10 milligrams (mg) by mouth twice a day (BID); - Finger sticks (FS, a test to measure the amount of sugar in the blood) before meals and at bedtime; - The POS did not show any [DIAGNOSES REDACTED]. During an interview on 6/4/14, at 11:00 A.M., Licensed Practical Nurse (LPN) A said: - On 5/23/14, he/she worked as the charge nurse from 7:00 P.M. to 7:00 A.M. - Prior to admission to the facility, the resident had two or three falls, at home, and went to the ER. - LPN C, day shift charge nurse, took report from the hospital and ordered the resident's medications. - About 8:00 P.M. on 5/23/14, the resident arrived with Family Member (FM) A for admission. - He/she called Physician B, the on-call physician, who said to continue the medications. - He/she admitted the resident and wrote out the POS and the medication administration record (MAR). - Staff should write an indication for each medication on the MAR, but did not always have the time. The facility had a policy for a second nurse to check the POS and MAR to assure staff wrote the orders correctly. Both nurses signed the POS on the reviewed by line. He/she was very busy that night between the admission, another resident's fall, passing medications, doing treatments, charting, taking vital signs, and FS. The North hall nurse did not have time to check the POS and MAR because he/she had to send a resident to the hospital that night. - He/she wondered why the resident was on two laxatives. - He/she did not know physician's orders [REDACTED]. - Staff scheduled the first dose of [MEDICATION NAME], with early morning medications, so he/she had to wake the resident at 6:30 A.M. The resident sat up, visited, talked clearly, and took the medications without any problems. -The resident never refused the [MEDICATION NAME] or any medication for him/her. Review of LPN C's nurses' note, dated 5/23/14, showed: - Approximately 7:00 P.M., ER staff called with report on the resident. - The resident lived at home with FM A, lost his/her balance, fell , and tests showed no acute injury. - Alert and oriented (A&O); - Generalized weakness, weak legs with swelling; - [DIAGNOSES REDACTED]. Review of nurses' notes showed: - 5/24/14- Resident was A&O; - 5/25/14 at 3:00 A.M. - The resident was pleasant and cooperative, voiced no complaints, up to bathroom with assist of two. - 5/25/14- Resident pleasant and cooperative, visiting with FM A. - 5/25/14 for 7:00 P.M. to 7:00 A.M. - Resident was A&O, visited with FM A, mood pleasant and cooperative. - 5/26/14 for 7:00 A.M. to 7:00 P.M. - Resident was pleasant and cooperative and had no complaints at this time. - 5/27/14- The resident went out on pass with FM A. - 5/28/14- The resident went out with FM A for awhile. - No staff documented they contacted the physician to clarify the two laxative orders. Review of the telephone orders, dated 5/23/14 through 5/28/14, showed no staff documented they contacted the physician to clarify the two laxative orders. During an interview on 6/2/14, at 2:55 P.M., FM A said: - On 5/27/14 and 5/28/14, he/she took the resident out to do some shopping for a couple of hours. Review of the 24-hour reports, dated 5/23/14 through 6/1/14, the DON provided, showed: - No staff documented they contacted the physician to clarify the two laxative orders. - No 24-hour report for 5/31/14. Review of the undated, current, care plan showed: - Staff did not address the resident's risk of increased ammonia levels due to liver failure. - Staff did not identify signs and symptoms staff should monitor for with increased ammonia levels. During an observation and interview on 6/2/14, at 4:25 P.M. and 6:20 P.M., Certified Medication Technician (CMT) A did and said the following: - He/she gave the resident medications on the evening shift. - Removed the resident's bottle of [MEDICATION NAME] from the medication cart and said the pharmacy label read to give 30 ml of [MEDICATION NAME] TID. - He/she pointed to the MAR and said it showed to give 20 ml of [MEDICATION NAME] TID. - He/she pointed to the 20 ml mark on the medication cup and said that was the amount of [MEDICATION NAME] he/she gave the resident. - Pointed at the MAR and said he/she was not sure if CMT B or he/she circled the 5/27/14 mid-day dose initials. CMT A circled his/her initials for the evening doses of [MEDICATION NAME] on 5/27/14 and 5/28/14, because the resident refused those doses. CMT A said the resident told him/her that he/she already had three bowel movements. CMT A knew [MEDICATION NAME] was a laxative and ordered for constipation. He/she did not think anything about the resident not taking those doses of [MEDICATION NAME] because he/she already had three bowel movements. - He/she did not know the physician ordered [MEDICATION NAME] to remove ammonia from the blood. During an observation and interview on 6/3/14, at 12:20 P.M., CMT B did and said: - He/she passed the resident's medications on day shift. - The resident never refused the [MEDICATION NAME]. - He/she pointed to the 20 ml line on a medication cup and said he/she gave the resident 20 ml of [MEDICATION NAME]. - He/she looked at the MAR and said he/she did not know it was 20 gms. He /she thought it was 20 ml because they gave ml. - He/she knew [MEDICATION NAME] was a laxative, but did not know physicians also used it to remove ammonia from the blood. Review of the MAR, dated May, 2014, showed: - [MEDICATION NAME] 100 mg by mouth BID (morning and at bedtime). Staff initialed to signify they gave the [MEDICATION NAME] BID from 5/24/14 through 5/31/14. - [MEDICATION NAME] 10 gm/15 ml oral syrup, give 20 gms TID in early morning, midday, and evening. Staff initialed to show they gave the three doses on 5/24/14, 5/25/14 and 5/26/14. On 5/27/14, staff initialed to show they gave the early morning dose and circled their initials for the midday and evening doses. On 5/28/14, staff initialed to show they gave the early morning and midday doses and circled their initials for the evening dose. On 5/29/14, 5/30/14 and 5/31/14, staff initialed to show they gave the three doses. During an interview on 6/4/14, at 6:29 A.M., Certified Nurse Aide (CNA) A said: - On 5/31/14, he/she work the nightshift with CNA B. - The evening shift CNAs gave a resident report to the night shift CNAs and said the resident was fine. - CNA A and B did rounds together and when they entered the resident's room for the midnight or 2:00 A.M. rounds they found the resident half off the bed. CNA A said it looked like the resident tried to get out of bed, put his/her feet on the floor, and then fell sideways onto the mattress. - CNA A said that was unusual because the resident always turned on the call light for assist to get out of bed. - CNA A and B tried to reposition the resident in bed. The resident talked out of his/her head, did not know where he/she was, or why the CNAs were bothering him/her. CNA A said the resident had never refused to allow staff to assist him/her before that night. The resident continued to argue with them and not allow them to reposition him/her. CNA A said it was not like the resident to disagree and talk mean to staff. After CNA A and B finally got the resident in bed, CNA A immediately described everything to Licensed Practical Nurse (LPN) B. He/she told LPN B something was not right, the resident was half off the bed, incoherent, argued with them, and not behave like himself/herself. - LPN B went to check the resident and the CNAs continued with rounds on other residents. - LPN B told CNA A the resident was okay. - The resident usually turned on the call light when he/she needed to use the bathroom, but did not turn on the light that night. - CNA A and B looked in on the resident the rest of the night, but the resident just slept. During an interview on 6/6/14, at 5:45 A.M., CNA B said: - He/she worked the 10:00 P.M. to 6:00 A.M. shift on 5/31/14, with CNA A. - The evening shift CNAs reported any resident changes to the night shift. - The CNAs did not say anything was wrong with the resident. - On the midnight or 2:00 A.M. rounds, CNA A and B found the resident half out of bed, with his/her feet on the floor and lying to the side on the mattress. When they tried to reposition the resident, he/she became mean, hateful, confused, talked out of his/her head, did not make any sense, and was not at all like himself/herself. - CNA B told CNA A they needed to tell LPN B because everything seemed wrong. - CNA A told LPN B and he/she went to check the resident while CNA A and B continued rounds. - The resident usually turned on the call light to use the bathroom but did not turn it on that night. - Usually when CNA B toileted the resident's roommate at 4:00 A.M., he/she asked the resident if he/she needed to toilet. The resident usually answered CNA B but that night the resident did not respond and really slept soundly. During an interview on 6/4/14, at 6:05 A.M., LPN B said: - Saturday night (5/31/14), he/she worked with CNA A and B. - About 5:00 A.M., on 6/1/14, CNA A said the resident was not acting like herself/himself and thought his/her blood sugar might be low. - He/she did a finger stick and thought the FS was 140 milligrams/deciliter (mg/dl). The resident was grumpy, alert, and had warm and dry skin. He/she thought the resident was fine. - He/she did not record the FS because he/she did not have a physician's orders [REDACTED]. - He/she mentioned it to LPN D, day charge nurse, but did not write a nurses' note because the resident was fine. - Family member (FM) A saw the resident, did not seem alarmed, asked about the FS, and said the resident was his/her grumpy self. During an interview on 6/2/14, at 12:20 P.M., CMT B said: - He/she worked the day shift, but did not usually pass the early morning medications on the resident's hall. - He/she did not know what the resident was like first thing in the morning. - The morning of 6/1/14, was the first time he/she gave the resident early morning medications. He/she could only barely wake the resident enough to take the couple of medications. - When he/she usually saw the resident he/she was up, alert, and with FM A. During an interview on 6/6/14, at 11:38 A.M., LPN D said: - He/she arrived at 6:30 A.M., on 6/1/14. - In report, LPN B said the resident was combative and more fatigued than usual but did not give any details. LPN B said he/she took the resident's vital signs and FS; everything was okay. - After report, he/she went to the resident's room to do the morning FS. The resident was very groggy and his/her hands shook in a jerking movement. LPN D asked CMT B if he/she gave the resident's medication that morning and CMT B said he/she gave the medications. - LPN D saw the resident for the first time that day (6/1/14). - LPN D did sternal rubs (a painful stimuli used to assess the consciousness level of a non-responsive person) and called the resident's name to wake him/her, but he/she was very groggy. - LPN D attempted to take the resident's vital signs and the resident kept pushing him/her away. LPN D asked CNA C if the resident usually acted that way. CNA C said the resident was usually A&O and it was not like him/her to act that way: groggy, mumbling, and pushing at staff. - LPN D thought the resident's blood sugar was low and he/she left to get the FS supplies. When LPN D returned, the resident's hands, shoulders, and legs jerked uncontrollably. The resident did not respond, was lethargic, sweating, pushed him/her away, and mumbled "leave me alone." - FM A was in the room. - LPN D sent the resident to the ER by ambulance. Review of LPN D's nurses' note, dated 6/1/14, at 7:10 A.M., showed: - Resident in room with noted sweating, uncontrolled jerking movements, lethargic, and responded to questions with mumbled speech. - During assessment, resident pulled away or pushed equipment off. - Temperature 98.6 degrees, respirations 22, heart rate 92, blood pressure 142/64, oxygen saturation 96% on room air, an FS 242. - CMT said at 6:15 A.M. the resident was able to respond readily and took pills whole without any difficulty. - Due to status change over the last hour, called ER staff with report, ambulance staff arrived around 7:40 A.M., given paperwork for transfer, and notified Physician C, on-call physician, of transfer. - FM A present at time of transfer and aware of status. During a group interview on 6/2/14, at 2:55 P.M., the resident, FM A, FM B and FM C said: - The resident said he/she took [MEDICATION NAME] to decrease his/her ammonia level. He /she did not remember refusing to take the [MEDICATION NAME] at the facility. - FM A said he/she was at the facility daily from 7:00 A.M. to 7:00 or 8:00 P.M. and never saw the resident refuse the [MEDICATION NAME]. He/she said the resident faithfully took the [MEDICATION NAME] at home and took a larger dose than the facility staff gave him/her. Staff gave him/her one tablespoon of [MEDICATION NAME], which was one-half of a medication cup, and sometimes staff gave him/her a little more. FM A said at home the resident took two tablespoon which was a whole medication cup. - He/she went to the facility every morning to get the resident dressed and up and stayed until the evening. - FM A said on Saturday (5/31/14), he/she left the facility about 8:00 P.M. and the resident was fine. He/she returned on Sunday (6/1/14) at 7:00 A.M., and found the resident curled up in bed with left arm tremors. He/she tried to wake him/her, the resident only grunted, but did not talk. FM A, went to the nursing station, and asked if the resident had a rough night. The female nurse said the CNA went in at 4:00 A.M., and the resident would not respond so he/she did a FS and thought the resident was fine. FM A asked why they did not call him/her and the nurse said they did not have his/her number. FM A said he/she did not understand why staff did not have his/her number. - FM B said he/she went to the facility yesterday (6/1/14), talked to LPN D and the face sheet did not show FM A's name and number. - FM C said the resident was not ready to die and knows that he/she would die if he/she did not take the [MEDICATION NAME]. FM C said the resident told him/her that. Review of the face sheet, staff sent to the hospital, showed: - Did not list FM A name or number. Review of LPN D's nursing home to hospital transfer form, dated 6/1/14, showed: - Usual mental status: A&O and follows instructions; - Code status: full code (all possible measures are taken to revive a person and sustain life); - Reason for transfer: unresponsive and combative. During an observation and interview on 6/2/14, at 5:00 P.M., the administrator and DON, did and said: - The 32-ounce bottle (an ounce equaled 30 ml) of [MEDICATION NAME] 10 gm/15 ml, labeled with the resident's name and directions to give 30 ml three times a day. - The administrator measured the bottle contents and said the bottle contained 21 ounces (11 doses used). - The MAR showed staff signed out 21 doses given and 3 doses refused. - The administrator and DON said staff should give 30 ml / one ounce for each dose. - Both said staff did not give the resident the ordered [MEDICATION NAME]. - They expected the nurses to transcribe an order onto the MAR as written. - Writing a medication in grams on the MAR and expecting the CMT to convert it to ml was above the clinical skills of a CMT. - Staff should write the indication for a medication on the MAR. - They did not know why the resident had scheduled orders for the [MEDICATION NAME] and the [MEDICATION NAME] as that seemed like a lot of laxatives. - They expected staff to ask if they did not understand the dose MAR. - The DON said she observed staff pass medications but never watched staff measure and administer liquid medications. Review of the emergency medical service report (EMS), dated 6/1/14, at 7:45 A.M., showed: - Altered level of consciousness; - Nursing staff said the resident had an altered mental status, involuntary muscle movements, and was unresponsive for several seconds. The resident was incontinent which was abnormal for him/her. The resident became responsive, but had inappropriate responses and became slightly combative. Review of the ER report, dated 6/1/14, showed: - History source: family, EMS, facility records; - Reason for visit: Patient to ER after found unresponsive, combative, and hard to wake up. - Onset: 4:00 A.M. - Presents with "heart racing," with onset of four and one-half hours ago. Degree of onset was severe and degree at present was severe; - Associated symptoms: altered mental status; - Staff found resident with decreased responsiveness at 4:00 A.M. (four hours and 40 minutes ago). When patient was aroused, he/she became combative, diaphoretic, and nauseated at that time. The patient was [MEDICAL CONDITION] (rapid heart rate exceeding 100 beats per minute) when EMS arrived. History of liver disease and recently admitted to the hospital with [REDACTED]. - Pulse 213 (normal heart rate 60 -100 beats per minute); - Alert, no acute distress, combative, smells of ammonia; - Ammonia level 163 umol/L; - Impression - Wide-complex [MEDICAL CONDITION](rapid heart rate that starts in the lower heart chambers), liver failure, diabetes, and altered level of consciousness; - Plan - Admit to the intensive care unit (ICU). During an interview on 6/10/14, at 11:00 A.M., Physician A said: - The resident had numerous hospitalization s and changed [MEDICATION NAME] orders due to diarrhea and dehydration. - The resident and FM A both know the [MEDICATION NAME] decreased the ammonia level. - He/she never knew of the resident refusing the [MEDICATION NAME]. - If the resident had an order for [REDACTED]. - Staff can not interpret, on their own, the intended use of a medication. - Staff should always ask if they do not know why a physician ordered a medication. - If staff did not give the [MEDICATION NAME] as ordered then they must monitor ammonia levels. MO

Based on observation, interview, and record review, the facility failed to assure staff used proper techniques to reduce the possibility of accidents and injuries during a mechanical lift transfer and repositioning of one of 13 sampled residents (Resident #1) and during a gait belt transfer of one additional resident (Resident #19). As a result of an improper transfer and repositioning, Resident #1 rolled out of bed and landed face first on the floor, requiring emergency services. The facility census was 60. 1. Review of the facility's Lift Policy, revised on 11/11, showed: - The purpose of the policy was to ensure a safe work environment for employees and residents by providing and requiring the use of safe materials, equipment and training for the prevention of injury. - Nursing staff are responsible for using all reasonable care to achieve the following goal: the care plan is accurate and based on the resident's ability to assist in transfers. - The director of nursing (DON) will designate the Lift Coordinator, who will be responsible for the implementation of the Resident Lift program under the direction of the DON. - The Lift Coordinator will be responsible to make sure staff is trained on the use of the lifts, residents' transfer status has been appropriately determined and documented in the care plan, and any use of a lift which results in harm to a resident is thoroughly investigated to determine if protocol was not followed. - The lift coordinator will periodically monitor (observe) staff to evaluate if they are utilizing proper body mechanics, following the transfer status documented on the resident's care plan, and performing transfers as trained. Competency checklists should be completed annually and placed in employee files. - Unless otherwise documented, the use of a mechanical lift for transfers will be conducted with the assistance of two staff to prevent resident and/or staff injury. The facility is responsible for having the required number of staff to perform transfers. Employees are responsible for following the lift and transfer procedures. - In rare circumstances, a location may designate a lift transfer be performed with one person. This should be with the approval of the administrator and the Regional Director of Health Services. 2. Review of Resident #1's Care Plan, developed 1/18/11 and revised on 8/18/11, showed: - Impaired physical function relevant to limited mobility, dependent on staff for most cares. Staff directed to transfer resident per facility policy. - Potential for alteration in ADL ability relevant to total assistance with most ADLs. Directed staff to have assistance of one staff member with dressing, grooming, toilet use, and bed mobility. - No indication found to show staff updated the care plan during the annual assessment process. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, 11/1/11, showed: - Usually understands, misses some/part of message but comprehends most of the conversation; - Brief Interview of Mental Status (BIMS) conducted with a score of eight, which indicated moderately cognitively impaired; - No behaviors; not resistive to cares; - Total dependence on two or more staff persons for bed mobility and transfers; total dependence on staff for personal hygiene and toilet use; - Impaired range of motion of both upper and lower extremities; - Always incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. - No recent falls. - Weight of 243 pounds Review of the Care Area Assessment (CAA, indentifies areas of concern that may warrant interventions) Summary Report, dated 11/3/11, showed: - Resident dependent on staff for all activities of daily living (ADLs), used a mechanical lift for transfers into wheelchair and staff propel. Held drink cups and sometimes attempted to feed self. Staff must anticipate resident's needs. - At risk for pressure areas due to immobility and incontinence, needed total assistance with incontinence care and with turning and repositioning. Review of the nurses' notes, dated 12/30/11, showed Licensed Practical Nurse (LPN) G documented the following: - 7:30 P.M. Resident fell out of bed face down on the floor with bed high. Aide at side. Nurse with resident, some bleeding on floor. Emergency Medical Services (EMS) contacted and on their way. - 7:57 P.M. EMS here to transfer resident to hospital. Also resident bleeding from forehead. Vital signs: temperature 94 degrees Fahrenheit, pulse 103 BPM (beats per minute), respirations 28, blood pressure 120/89. - 11:10 P.M. Hospital called and stated they may keep resident for 24 hour evaluation. During an interview on 1/11/12 at 6:45 P.M., LPN G said: - He/she worked on the south hall, where the resident resided, on 12/30/11. - At around 7:15 P.M., he/she stood with a medication cart in the center of the south front hall preparing medications for other residents. - Certified Nurse Aide (CNA) I went into the resident's room alone. - A little while later, around 7:30 P.M., CNA I ran past him/her to find another CNA, and did not stop to tell him/her what was going on with the resident. - CNA I and CNA M ran past him/her down the hall so he/she went to see what happened. - When he/she entered the room, the CNAs were attempting to roll the resident over to put him/her back to bed. He/she instructed them to not move the resident. The resident lay on the floor face down and wore a night gown. - CNA I reported at the time he/she attempted to turn the resident. - Informed CNA I to always have two staff to provide any cares with the resident because he/she was too little to turn the resident alone. - Also informed CNA I he/she should not have left the resident alone in the room, face down, to get another CNA. CNA I should have stopped to get either LPN G or LPN H, who sat at the nurses' station. During an interview on 1/11/12 at 7:00 P.M., CNA M said: - He/she worked on 12/30/11. Originally was assigned to the north hall, but moved to the south hall when someone called in. - He/she floated on both the front and back halls and went around to each resident's room to put gowns on them before they were put to bed. Already put a gown on the resident and moved on down the hall. - Went into a resident room just up the hall to assist another resident when CNA I came to find him/her. - He/she did not know why CNA I came to get him/her first. - He/she did not assist CNA I transfer the resident back to bed after he/she put the resident's gown on. - When he/she arrived in the room to find the resident face down on the floor, he/she instructed CNA I to get the nurse. He/she then removed the mechanical lift and the resident's roommate from the room. - The facility policy indicated staff could never transfer a resident with a mechanical lift alone, always needed to have at least two staff members. - No one really monitored staff to make certain they transferred residents appropriately and repositioned residents appropriately. During an interview on 1/10/12 at 5:20 P.M., CNA H said: - He/she worked on the south back hall on 12/30/11. - CNA I worked on the south front hall and while he/she assisted another resident, CNA I rolled Resident #1 out of bed. - Don't know for sure what happened, but did know administration planned to retrain staff on the proper use of mechanical lifts, a sit-to-stand lift and gait belt transfers. - Facility policy instructed staff to always use two people for mechanical lifts. - He/she would not attempt to reposition or transfer Resident #1 alone due to his/her size. During a telephone interview on 1/12/12 at 2:15 P.M., CNA I said: - He/she received training on the mechanical lift during orientation to the facility in 5/11. Hold on to the sling, always use two staff to transfer. - There were times, during the course of an evening, when two staff were not available. - He/she transferred another resident (who weighed more than 300 pounds) using a mechanical lift alone without any difficulties when he/she removed the lift sling. - He/she worked on 12/30/11 on the south front hall. Administration pulled CNA M to work on the south hall when another staff member called in. CNA M was mad because he/she had been pulled to another hall. - He/she ran behind getting residents ready for bed because of low staffing and a large amount of hall trays. - Resident #1 wanted to go to bed, and he/she could not find another staff member to assist. Later he/she learned both staff had been assisting a resident who only required one staff for assistance on the south back hall. - LPN G worked that night and he/she did not like to assist CNAs when they provided care to the resident so he/she did not ask him/her to assist. - He/she used the mechanical lift to transfer the resident alone without any problem, rolled the resident toward the wall and pushed the lift sling under the resident. - He/she then rolled the resident towards him/her, reached across him/her to pull the sling from under the resident and the resident moved his/her left arm out. The resident's arm hit CNA I, knocked him/her off balance and caused him/her to take a step backwards. At that point, the resident rolled off the edge of the bed and hit his/her face on the floor. Review of CNA I's undated written statement showed: - On 12/30/11, in the resident room and the other CNAs made him/her change the resident by him/herself; - Went to turn resident towards the wall, tucked the sling under, rolled resident back "my way" to pull sling out; - Had resident turned, getting sling out when resident moved left arm and knocked him/her and the resident off balance; resident went onto the floor; - Rushed into the hall and grabbed the first person he/she saw, CNA M, then saw LPN G; called the ambulance. During an interview on 1/12/12 at 9:20 A.M., the assistant Director of Nursing (ADON) said: - She arrived at the facility not long after the incident happened on 12/30/11. - CNA I told her the resident fell when he/she rolled the resident to remove the sling. - Not sure why CNA I was in the room alone with the resident. He/she was too small to provide care to this resident alone. Review of the emergency room report, dated 12/31/11, showed: - admitted resident 12/30/11 at 8:26 P.M. - Resident being transferred and left face down for 15 minutes then began having breathing issues. - EMS placed resident on a BiPAP (a portable ventilator). - Laceration 1 cm (centimeter) in length to left forehead; - Impression and Plan: closed head injury, hypertensive (high blood pressure) urgency. Review of the History and Physical, dated 12/31/11, showed: - Patient usually bed-bound, trying to get off the bed when he/she fell face down; - Breathing issues, EMS placed on BiPAP; - Blood pressure in emergency room noted to be elevated at 202/116, decreased to 187/72, then back up to 210/68. admitted for further evaluation. Review of the Incident Report Form, completed on 12/30/11 by LPN G, and reviewed by DON on 1/3/12, showed: - Resident fell out of high bed with aide at side, landed on floor face down. - Scope/Severity Level (assigned by the DON) = Level 3: Occurrence type which is considered to be "at risk" in nature; with or without injury. - Final Outcome/Disposition: CNA final warning, in-service all nursing staff on transfers and lifts. Review of the Investigation Follow-up form, dated 1/3/12 and completed by the DON, showed: - Description of situation: CNA changing resident in bed, resident rolled off edge of bed and landed face down; - Summary of investigation: CNA I stated the resident moved his/her left arm while lying on left side. CNA I lost his/her balance and stepped back. The resident rolled off the bed. - Recommendations/new interventions: CNA I received a written warning. Review of the Disciplinary Action Record, dated 1/3/12, showed: - CNA I received a final written warning as a result of the incident. - DON noted CNA I violated Rule Number 27. Review of the facility's employee handbook showed: - Category II Work Rules: violations of work rules found in this category are of serious nature; - Rule #27: employees may not engage in negligent or careless behavior resulting in danger, damage, or loss of property related to residents, visitors, fell ow employees, or the location. Review of a memo from the DON to CNA I, dated 1/3/12, showed: - On 12/30/11 at approximately 7:30 P.M., while changing the resident's brief, he/she rolled off the bed onto the floor, landed face down and received a laceration; - During the investigation, you indicated you transferred the resident using a mechanical lift alone; - Facility policy for using mechanical lifts is for two people to perform this type of transfer. - The facility realized CNA I did not have any intention of hurting the resident; - However, due to CNA I's small size and the resident's larger size not having assistance with the brief changing could be construed as careless or negligent behavior (Category II work rules #27); - Not having two people during a total mechanical lift could also be construed as careless or negligent behavior (Category II Work Rules #27). Review of a written summary of the facility's investigation, sent to the Regional Office by the administrator on 1/4/12, showed: - Resident a total care incontinent resident, transferred with a mechanical lift. Dementia and unable to direct any of his/her care; - CNA I in room, changing resident's brief, rolled the resident toward edge of the bed. - Resident's left arm lay up against CNA I when the resident moved the arm and knocked CNA I back a step from the bed. This caused the resident to roll off the bed and land on the floor face down. - CNA I immediately notified the nurse of the fall. - CNA I retrained on lift/transfer procedures on 1/3/12. All nursing staff will be retrained on the new Resident Lift program and policies 1/15/12. During and interview during the initial tour of the facility on 1/9/12 at 8:30 A.M., LPN D said: - The resident was incontinent of bowel and bladder, totally dependent on one to two staff for all ADLs, transferred with a mechanical lift. - Two staff should assist the resident due to his/her size during peri-care and repositioning. - Recently the resident fell out of bed. Observation on 1/10/12, at 7:00 A.M., showed: - CNA D and CNA E entered resident's room. - Resident said he/she hurt all over and had lay in bed too long. - CNA D replaced the resident's gown. - Resident with purple and yellow bruising over right hand, left forearm and several small bruises on his/her outer legs. - CNA D said the resident fell a while back and was bruised at that time. - Staff turned the resident to the right and resident said "You're hurting my bones." Resident moaned or cried out with minimal movement. - Staff transferred the resident to his/her wheelchair. Resident complained of hip pain during transfer. - Resident did not make any independent movements during the time staff changed the resident's clothing and brief, with repositioning, or during the transfer. During an interview on 1/11/12 at 6:45 P.M., LPN G said: - Resident should always have two staff when cares are provided unless it would be washing the resident's face or brushing his/her teeth, due to the resident's size and the involuntary movements caused by his/her Parkinson's diagnosis. - Nurses do not have a lot of time to monitor CNAs in resident rooms unless they are actually assisting with the cares. - No one interviewed him/her about what happened with the resident. During an interview on 1/11/12 at 7:00 P.M., CNA M said: - No one monitored CNAs perform transfers of residents unless they were helping with cares. - Should always be two staff members at least involved with a mechanical lift transfer. - No one interviewed him/her about what happened with the resident. - Administration brought up this incident at a meeting the previous week and told staff they would receive more in-services on transfers. During an interview on 1/12/11 at 2:30 P.M., the DON said: - She received a phone call from staff to inform her that the resident fell out of bed. - LPN G said the resident fell out of bed while the CNA was in the room, the resident's left arm against CNA I, resident moved the arm which caused CNA I to step back. - CNA I is a "little waif of a thing" and it would not take much to knock him/her off balance. - ADON interviewed CNA I who said he/she transferred the resident alone. - Thought CNA I had been performing peri-care when the incident happened and that was why the administrator did not report the correct information the Regional Office. - Knew now CNA I had been removing the sling from under the resident when he/she rolled out of bed. - We do monitor CNAs, but do not document who monitors, how often, or if problems are seen. - Evening shift only randomly monitors due to not having as many staff on duty to assist the residents. - She did not interview the other staff who worked that evening, not necessarily a facility policy to obtain statements for others who were working. - Do think the ADON talked with the other staff. - Don't think CNA I meant to put the resident in harm's way, only wanted to accommodate the resident. - CNA I did not say he/she could not find anyone to assist him/her and did not tell that the other staff were assisting a resident who only required one staff person to assist. - Facility policy required two staff members to operate the mechanical lift used to transfer the resident. - Due to the resident's [DIAGNOSES REDACTED]. 3. Review of the Nurse Assistant in Long Term Care Student Reference Manual dated 2001, showed: - Safety measures with resident transfers: Never transfer a resident by lifting him/her under the arms. This could cause nerve damage, fractures, and shoulder dislocation. - Gait belt: A special belt that is placed around the resident's waist and provides the nurse assistant with a "handle" to hold onto for those who required assistance during transfers, ambulation, or repositioning in the chair. - Purpose of gait belt: To ensure optimum safety and comfort of the resident. To minimize risk of injury to the resident and staff. To facilitate proper body mechanics of the nurse assistant. Allows for better control of the resident when transferring. - Placement: The belt is to be applied snuggly around the resident's waist over clothing and below the ribs so that the nurse assistant's fingers may grasp the belt securely. The belt must be applied securely to prevent the belt from sliding above the resident's waist. To avoid injury to the resident, check the care plan for contraindications that may cause injury to the resident if he/she has a colostomy (an opening on the abdominal wall to allow bowel contents to flow into a bag attached to the skin), an acute rib or vertebrae (spinal) fracture, an abdominal aneurysm (a weakened area and ballooning of the large/main artery in the abdomen, that if the weakened, may ruptures, the resident could die from severe blood loss), a feeding tube inserted into the stomach via the abdomen, or any abdominal surgery. 4. Review of Resident #19's admission information sheet dated 1/9/12, showed: - Staff admitted the resident on 1/9/12. - Staff had not yet completed the admission MDS at the time of the survey. Review of the POS dated 1/1/12, through 1/31/12, showed: - [DIAGNOSES REDACTED]. Review of the certified nurses' aide (CNA) care plan (used to direct staff in resident cares) dated 1/9/12, showed: - Assist of one staff for transfers and toileting. - The care plan did not address the use of a gait belt for transfers. Review of the care plan dated 1/10/12, showed: - Problem: Impaired physical function related to a fractured pelvis and the need for staff assistance and supportive devices. - Goals: Improvement of the resident's current ability to ambulate. - Approaches: Assist of one staff with transfers. Self propels a wheelchair. - Problem: Potential alteration in the ability to perform activities of daily living (ADLs) related to a fractured pelvis. - Goals: The resident would participate in ADLs as able. - Approaches: Assist of one staff for bed mobility and toilet use. - The care plan did not address the use of a gait belt for transfers. Observation on 1/10/12 at 7:40 A.M., showed the following: - CNA J and CNA K entered the resident's room to assist him/her out of bed and into a wheelchair. - CNA K placed the gait belt around the resident's waist. - CNA J told CNA K to place the gait belt above the resident's breast to prevent the resident from having pain in his/her pelvic area because he/she had a fractured pelvis. - CMA J removed the gait belt from the waist and placed the belt above the breasts of the resident and secured the belt to fit snuggly. - CNA J and CNA K placed one hand on each side of the gait belt and one hand on the back of the belt and assisted the resident to stand. - Upon standing, the resident stood taller than both CNAs and holding to the gait belt was awkward and difficult. - The gait belt pulled up and rested under the arms of the resident. - Both CNAs arms rested under the arms of the resident. - During the transfer, the gait belt slipped up and rested in the arm pits of the resident and the CNA's arms rested under the arms of the resident. - With difficulty, the resident turned at the waist, grabbed the arms of the wheelchair, turned his/her feet, and sat down in the seat of the wheelchair. During an interview on 1/10/12, at 9:45 A.M., CNA J said: - Today was the first day he/she worked with the resident. - Staff did not tell him/her where to place the gait belt on this resident who had a fractured pelvis. - He/She knew to place a gait belt around the waist of a resident but he/she told CNA K to place the gait belt above the resident's breasts. - He/She thought if placed around the waist, the belt would cause pain in the resident's pelvic area. - CNAs sometimes made decisions on where to place gait belts on residents. - He/She did not remember an in-service on gait belt placement. During an interview on 1/10/12 at 9:50 A.M., CNA K said: - CNA J told him/her to place the gait belt above the breasts to prevent pain in the pelvic area. - He/She knew staff could place the belt above the breasts because they did that with another resident who had a broken back. Physical therapy told staff they could do this. - He/She did not remember an in-service on gait belt placement. 5. During an interview and observation on 1/10/12, at 10:50 A.M. and 12:00 P.M., Registered Physical Therapist (RPT) A said and did the following: - At 10:50 A.M., she said she evaluated residents for use of gait belts or lifts for transfers. She did not make an evaluation or recommendation for the resident yet, but it would be done today. If a resident had a pelvic fracture, the gait belt should be placed around the waist, not above the breasts. There was no problem placing the belt around the waist unless there was a tube, recent surgery, or spinal issues. The CNAs should not have placed the belt about the resident's breasts, this could cause injury to the arms or the breasts. She would evaluate the resident today and make sure facility staff knew to place the belt around the waist. - At 12:00 P.M.: She instructed staff to place the gait belt around the waist of Resident #19. Do not place above the breasts. There was no reason to place the belt above the breasts. Staff must place the belt around the waist for safety reasons. 6. During an interview on 1/11/12, at 11:15 A.M., the director of nursing (DON) said: - Gait belt use should be used as instructed per each resident. - The CNAs actually were not wrong in placement of the belt above the resident's breasts. - The belt may be placed above the breasts if needed, but staff should not cause problems for the resident if used in this manner. - The resident's height could be an issue with the use of the gait belt on this particular resident. - She did not know of an in-service on gait belt placement and use since she came to work in April, 2011. - The facility did not have a policy related to gait belts.

Based on observation, interview and record review, the facility failed to follow facility policy and standards of practice and respond in a timely manner when one resident (Resident #4) out of 13 sampled residents presented with an acute change in condition. The facility staff assessed the resident on 2/20/11 at 4:15 A.M., with an acute onset of inability to verbalize and an elevation in blood pressure. Staff initially paged the physician at 4:46 and 6:18 A.M., but did not make contact with the physician until 8:30 A.M. The staff transported the resident to the hospital via ambulance at 9:15 A.M. and was assessed with [REDACTED]. 1. Review of the facility policy entitled "Resident Condition Changes that Require Physician Notification", dated 10/1/01, under the subtitle of Categories of Condition Change Notifications revealed: - A situation/condition that would warrant immediate physician notification and intervention (if the physician response is not immediate, determine if resident should be sent to the emergency room ). Such conditions include, but not limited to the following: Significant changes of a chronic condition. - Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. The nurse shall complete an assessment of the condition, including level of urgency. The nurse shall implement appropriate interventions and have accurate information available when contacting the physician. - Documentation of the resident condition change and proper notification shall be the responsibility of the nurse who observes and assesses the change. - Changes in resident condition must be documented in the following locations: resident chart, 24-hour report, and incident/accident report if applicable. - The licensed nurse shall also notify the unit/nurse manager or nursing supervisor and the resident and/or family. - The unit/nurse manager or nursing supervisor is responsible for: Assessing any resident with a condition change, verify proper notification and documentation of the condition change, ensure proper implementation/follow-up of interventions ordered, and provide appropriate follow-up with staff who do not comply with facility guidelines. Review of Federal Resident Rights provided by the regional nurse consultant and interview on 3/10/11 at 1:45 P.M., related to notification of a change in a resident's condition revealed: - The facility followed the regulations. - A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is, (B) A significant change in the resident's physical, mental, or psychosocial status, deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. Review of the undated facility guidelines located in the schedule book at each nurses's station instructed staff to call the DON for a significant change of condition. Review of the facility's job description for the DON or assigned nursing supervisor, dated 9/1/04, and attached to an inservice on 12/29/10, provided by the regional nurse consultant revealed: - Essential Functions and Responsibilities: Selects and institutes appropriate nursing intervention that might be required to stabilize a resident's condition and/or prevents complications. Reports change in resident condition. 2. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. every morning prior to administration of high blood pressure (B/P) medication showed: - 2/12/11, B/P- 118/48. - 2/13/11, B/P- not recorded. - 2/14/11, B/P- 120/72. - 2/15/11, B/P- 122/76. - 2/16/11, B/P- 103/55. - 2/17/11, B/P- 122/74. - 2/18/11, B/P- 148/74. - 2/19/11, B/P- 89/47. - 2/20/11, B/P- 177/94. (the B/P taken at 4:00 A.M.) Review of Resident #4' quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/11, showed: - Speech clear with distinct intelligible words. - Minimal hearing difficulty (difficulty in some environments). - Makes self understood and usually understands others (misses some part/intent of message but comprehends most of conservation). - Cognitive score of eight (moderately impaired). - Requires one person limited assist with activities of daily living. - Active [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 11/23/10, showed: - Staff identified the resident's use of [MEDICATION NAME] (a medication used to prevent blood clots in residents with a history of stroke). - Staff instructed to update the physician with any abnormal findings promptly. - The resident required supervision only to eat. Review of the resident's nurses notes, dated 2/19/11, (incorrect date documented, should be 2/20/11 per interview with day shift supervisor and Licensed Practical Nurse (LPN) E) and timed at 4:15 A.M., showed the night charge nurse Licensed Practical Nurse (LPN) E documented the following: - The resident called for assistance and would not speak. - He/she tried to find out what was going on. - The resident just groaned and pointed. - Vital signs revealed a blood pressure of 179/94, pulse 88, respirations 24, and blood oxygen saturation 92 percent, and both upper extremity grips equal. - He/she reported changes to the physician. - LPN E called the evening shift supervisor and was instructed to call the family to see what they wanted to do. - Family contacted at 6:15 A.M. and informed to do "whatever we think." - The physician re-paged with no answer. - Report given to day shift nurse. - No documentation of any additional assessments or vital signs. Review of the twenty-four hour report sheet (Nursing staff document on the twenty-four hour form to report information related to a resident), dated 2/19/11 (through 2/20/11) for the 11:00 P.M. to 7:00 A.M. shift, and initialed by LPN E showed: - 4:15 A.M.- The resident called and assisted with the urinal. The resident would not or unable to talk. He/she unable to get anything about what was wrong. LPN E reported to the physician. Review of the resident's nurses notes, dated 2/20/11, showed LPN A, the day charge nurse, documented the following: - 7:00 A.M.- Received report of the resident's change in condition. He/she assessed the resident and found resident not speaking, just grunting and groaning, appeared anxious and worried. Resident able to move arms and grips equal, not able to move legs and weak. Vital signs were blood pressure 170/89, respirations 24, pulse 88, blood oxygen saturation 94 percent, and temperature 98.6 degrees. LPN E reported the physician paged between 6:15 A.M. and 6:30 A.M. and waiting for the physician to reply back. He/she will continue to monitor. - 8:30 A.M.- Re-assessed the resident and found the resident not eating, not talking, and still moaning and grunting. LPN A paged the physician and once contact made the physician informed of the change in condition as compared to yesterday during his/her shift. The physician ordered the resident transferred to the emergency room . - 9:00 A.M.- He/she contacted the resident's family and informed of the transfer and the resident's condition. - 9:15 A.M.- Ambulance arrived to transport the resident to the hospital emergency room . Review of the ambulance report, dated 2/20/11, showed: - Call received at 9:10 A.M. - On the scene at 9:14 A.M. - Left the scene at 9:33 A.M. - Assessment revealed the resident had [MEDICAL CONDITION] with left sided weakness. Resident last seen normal at 7:00 P.M. on 2/19/11, and resident normally able to speak. - At 9:23 A.M., blood pressure 172/91, pulse 82, blood oxygen saturation 94 percent. Review of the resident's History and Physical from the hospital emergency room dated 2/20/11 showed: - Change in sensorium, resident fine at 7:00 P.M. on 2/19/11, and this morning not his/her normal self. - On 2/20/11, resident not able to speak anything, able to comprehend but unable to speak anything. This was a new development for the resident. - Resident had left-sided [MEDICAL CONDITION] from his/her previous stroke in 10/2010, and at this time apparently had a right frontoparietal infarct (stroke). - Resident's swallowing is severely impaired at this time. - Assessment: Acute ischemic infarct (stroke) in the left frontal lobe, resulting in dysphagia (inability to speak). - The resident started on the stroke pathway (clot-busting medications administered for stroke to help reduce disability). - Resident requires intermittent suction and decision pending regarding a feeding tube Review of hospital discharge assessment showed the resident returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Review of Registered Nurse (RN) A's, the day shift supervisor's personal documentation and investigation of the sequence of events related to the resident earlier on the morning of 2/20/11, during his/her shift showed: - He/she spoke with LPN E, LPN A, Certified Nurse Aide (CNA) I, and the Director of Nursing (DON). - LPN E paged physician at 4:15 A.M. with no response. - LPN E called the evening shift supervisor and told to call the family. - The family did not want to make decision to send the resident and asked the nurse to call the physician. - Evening shift supervisor called a second time. - Physician paged at 6:15 A.M. with no response. - LPN A paged the physician and spoke with the physician at 8:30 A.M. - Ambulance at facility at 9:15 A.M. - He/she talked to LPN A and LPN E about the proper way to move up the chain of command. To call the supervisor on-call and if you still feel the resident needs to be seen for any changes, you call the DON and then the administrator if it does not get resolved. - He/she spoke with the DON and informed her of the situation. During an observation on 3/7/11 at 2:00 P.M., the resident sat in his/her wheelchair in room. Surveyor made introduction with the resident and the resident responded to questions by nod of head. During an observation on 3/7/11 at 4:35 P.M., LPN D administered medications to the resident and provided oral care. The resident responded to LPN D's questions by nod of head, grunts, or hand gestures. During an observation of the resident on 3/8/11 at 9:20 A.M., staff provided incontinent care, catheter care, and physical therapy assisted the resident into the wheelchair. The resident responded to staff questions by nod of head, gestures, and yes/no verbal responses. During an interview on 3/9/11 at 9:05 A.M., RN A the day shift supervisor on 2/20/11 said: - Arrived on duty at 9:15 A.M., and informed the resident had a change overnight, EMS enroute to transport to hospital. - He/she investigated the incident to find out why the time delay. - He/she informed the DON of the investigation. - Did not document his/her investigation. - Would expect a nurse to call a supervisor if unable to reach a physician and have the supervisor call the physician. - When asked how the facility instructed staff to respond if unable to contact a resident's physician in an acute change in condition, RN A said the facility had not provided instruction but he/she would call the DON and send the resident to the hospital. During an interview on 3/9/10 at 9:30 A.M., the regional nurse consultant and the DON agreed: - Staff were expected to call either the DON , 9-1-1, or the medical director if unable to contact the resident's physician to report a significant change in a resident's condition. - The facility provided the nursing staff the notification guidelines during orientation. - Would expect a nurse to re-page the physician in 15 minutes if return call not received and if no response call EMS. - Would have expected Resident #4 to be transport out of the facility by 5:00 A.M. to 5:30 A.M. During an interview on 3/9/11 at 11:30 A.M., the administrator, with the DON present, stated: - The evening shift supervisor on the morning of 2/20/11, did not do the right thing; he/she should have called the DON or administrator to get direction if he/she was unsure and he/she flat out did not do it. - The appropriate time response from the time the physician is paged and no contact made until 9-1-1 called would be 10-15 minutes. During an interview on 3/9/11 at 1:40 P.M., Family Member A, who visits the resident daily, stated: - Staff left a message on an answering machine on 2/20/11. - His/her spouse made contact with facility staff around 5:30 A.M. - Informed the resident could not talk. - Spouse told the facility the best thing to do is take him/her to the hospital. During an interview on 3/9/11 at 2:13 P.M., the RN evening shift supervisor, on duty the morning of 2/20/11, said: - LPN E contacted him/her sometime after 4:00 A.M. and reported the resident unable to talk; physician paged and message left with no return call. - He/she instructed LPN E in 10-15 minutes if no return call from physician to call him/her back. - LPN E called him/her back and said the physician had not returned the page and he/she instructed LPN E to call the family because the family can say to send the resident to the hospital. - He/she was uncertain what time LPN E called and said the family said, "whatever you think." - Around 6:15 A.M. he/she told LPN E he/she thought the resident needed to go now to the hospital. - He/she assumed LPN E sent the resident to the hospital. - Facility instructed staff to go through the family and send a resident to the emergency room if unable to contact the physician in an urgent situation then call the DON. - He/she did not instruct LPN E to contact the DON. During an interview on 3/10/11 at 8:25 A.M., LPN E said: - The resident rang the call light around 4:00 A.M. and he/she answered the light. - He/she noticed the resident not talking, just made grunts and garbled speech, very different. - The resident nodded his/her head in response to questions. - Obtained the resident's vital signs and the resident's blood pressure which was slightly elevated from normal. - He/she was puzzled and questioned if the resident had a stroke. - Paged the physician with no response. - He/she called the evening shift supervisor around 4:10 A.M. to 4:15 A.M. and informed of symptoms and asked what to do. The evening shift supervisor instructed him/her to call the family and find out what they wanted. - The facility did not have a code status on him, so that meant he was a full code. - He/she had every intention of sending the resident out after contact with the physician and family but could not get ahold of either one. - Multiple calls made to the family with no response. - He/she did not recheck the resident's vital signs but monitored the resident while he/she cared for other residents and passed medications. - He/she wondered if he/she should send the resident out. - The family returned call around 6:10 A.M. and said "whatever you think." - Physician repaged with no response. - He/she did not call the RN evening shift supervisor back after he/she spoke with the family. - Report given to LPN A and both went to the resident's room and checked the resident. - Both felt the resident had a stroke. - LPN A assured LPN E he/she would get the resident out of here. During an interview on 3/10/11 at 9:15 A.M., LPN A the day charge nurse on 2/20/11 said: - Arrived on shift at 6:30 A.M. and received report from LPN E on the resident about 6:45 A.M. - LPN E reported something was wrong with the resident and round 4:00 A.M. the resident was unable to talk just moaned and groaned. - LPN E reported CNA I found the resident in this condition during routine bed check. - LPN E and I went to the resident's room to check on the resident. - Found the resident in bed alert, non-verbal, made grunts and moans, a complete difference from the day before. The day before, the resident's speech was understandable and not slurred, muffled, or garbled. In the past, the resident occasionally had a "hoarse/harsh voice" which made the words unclear and difficult to understand and the resident would have to repeat him/herself. - The resident had a worried look on his/her face with his/her eyebrows furrowed, so we left the room to discuss the situation. - LPN E told him/her the resident needed to go to the hospital, there was a significant change in condition. - LPN E reported he/she was unable to remember when the first page to the physician was placed but LPN E placed the second page done between 6:15 A.M. and 6:30 A.M. - LPN E reported the family's instruction was for staff to do whatever the physician wanted. - He/she wanted to allow time for the physician to respond. - The resident definitely had a change in condition. - Felt the resident going from verbal to non-verbal was a major change. - He/she called the hospital and had the physician paged around 8:30 A.M. to 8:45 A.M. After 10-15 minutes, Physician A informed of the resident's condition and an order received to send the resident to the hospital. - LPN E reported he/she contacted the evening shift supervisor; LPN A did not call the evening shift supervisor. - The facility instructed staff to notify the resident's physician, the on-call staff, or management when there was a significant change in a resident. - The facility instructed staff to call the house physician if unable to contact the resident's physician or family. - Unsure if he/she could activate the Emergency Medical Service (EMS); would need to find out. - He/she felt since the resident was alert there was no need to, "jump on the gun so quickly." During an interview on 3/10/11 at 12:05 P.M., Family member B, who visits the resident daily, stated: - Staff left a message on an answering machine. - He/she made contact with facility staff around 5:30 A.M. or 5:45 A.M. - Staff said we think the resident had another stroke because he/she could not talk. - Staff asked him/her what they wanted to do and he/she told staff, "if you can't take care of him here then send to the hospital." - Does not recall staff mentioning anything about the physician. - Before the morning of 2/20/11, the resident talked all the time and his/her speech was very clear, was able to feed self, and ambulated with a roller walker. During an interview on 3/10/11 at 1:10 P.M., CNA I, the night shift CNA assigned to the resident's care on 2/19/11, stated: - He/she emptied the resident's urinal around 3:30 A.M., and the resident talked and joked with no problems understanding the resident's speech. - LPN E went to the resident's room around 4:00 A.M. - LPN E found me and asked if the resident acted funny earlier and I replied no. - LPN E and myself went back to the resident's room and the resident could not talk. During an interview on 3/8/11 at 4:30 P.M., and 3/10/11 at 9:00 A.M., Physician A said: - He/she did not remember the first time the facility notified him/her related to the resident's change in condition but thinks he/she spoke to someone on 2/20/11, through the hospital paging. - While at the hospital on the morning of 2/20/11, another physician told him/her that the facility earlier in the morning had repeatedly attempted to page him. He/she did not recall receiving any pages from the facility but would have to check the phone log. - The resident was assessed with [REDACTED]. - He/she was unsure if the five hour time delay from when staff assessed the change in condition to transport to the hospital would have made a difference in the resident's case because of the resident's history of stroke. - Sometimes, residents with a history of stroke may present symptoms of confusion and swallowing problems in the early morning. If staff called me every time a resident presented these symptoms, there may be a lot of false alarms. - The resident had a large stroke in 10/10. In a follow-up interview on 3/10/11 at 11:45 A.M., Physician A said he/she received the first page from the facility on 2/20/11 at 4:46 A.M. He/she thinks around 6:18 A.M., he/she received a second page and spoke to someone at the facility and gave order to send the resident to the emergency room . Those were the only two pages from the facility recorded. The next page he/she received about this resident was while he was at the hospital on [DATE]. He/she received many pages every day and it is hard to say which exact facility he spoke with. During an interview on 3/10/11 at 2:35 P.M., the speech language pathologist said: - The resident was not currently on the case load and last received therapy in 1/2011. - In January, described speech as one hundred percent intelligible, clear, appropriate, able to converse without difficulty, and able to make needs known. During an interview on 3/10/11 at 2:45 P.M., the physical therapist assistant said: - The resident was on case load and he/she worked with the resident the week prior to 2/20/11, during the morning and saw the resident frequently through the day. - Described speech as clear, intelligible, no work finding difficulty, and able to make needs known. - He/she never witnessed nor had reported to him/her of the resident experiencing slurred speech, difficulty with finding words, or unable to speak in the mornings or at anytime of day. Review of the American Heart Association's recommendations related to a stroke showed: - Stroke a life-and-death emergency and every second counts. - Stroke warning signs included the symptom of trouble speaking. - If symptoms of a stroke in progress, victims can benefit from new medications and treatments, clot-busting medications can reduce disability and save life. It is very important to take immediate action. - If any of the symptoms seen, immediately call 9-1-1. - Clot-busting medications must be administered within a three-hour window from the onset of symptoms to work best. #MO .

Based on interview and record review, the facility administrator failed to interact with five of nine sampled residents (Resident #1, #2, #3, #4, and #5) in a manner that maintained the residents' dignity. The facility census was 70. 1. Review of the Resident #1's current care plan, dated 3/26/10, and reviewed on 6/24/10, showed staff did not identify any behavior issues for the the resident. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/25/10, showed the following: - No memory problems. - Independent with daily decision making. - No behaviors. - Totally dependent on staff for bed mobility, transfers, toilet use, personal hygiene and bathing. - Did not ambulate. Review of the resident's social service note, dated 8/25/10, showed the resident was alert and oriented to person, place, and time. The resident was usually pleasant and cooperative. He/she did have times of increased anxiety. The resident was his/her own responsible party. Review of the resident's current physician order [REDACTED]. During an interview on 9/29/10 at 9:50 A.M., Resident #1 said he/she was very upset about an incident that happened 9/28/10, with the administrator. The resident said he/she was in the beauty shop to get his/her hair fixed. There were three other residents in the beauty shop at the same time. The beautician had already put two or three rollers in his/her hair. At that point, the administrator came into the beauty shop and told the resident he/she owed the facility twenty dollars and could not get his/her hair done. The resident told the administrator he/she had ten dollars to pay the beautician but the administrator said he/she could not get his/her hair fixed until he/she paid the facility. The resident said the administrator's tone of voice was very bossy and not friendly. It was like she had the authority and could tell me what to do. The resident said he/she did not end up getting his/her hair fixed. The beautician took the rollers out of his/her hair and took him/her back to his/her room. It really upset him/her when the administrator got onto him/her in front of the beauticians and other residents. The resident said he/she was embarrassed and humiliated. He/she cried and cried after the incident. The resident said he/she had never had any run-ins with the administrator before this incident. During an interview on 9/29/10, at 10:20 A.M., the beautician said on 9/29/10, Resident #1 was in the beauty shop. The beautician had the resident in the chair with rollers in his/her hair. The administrator came into the beauty shop and in front of other residents and the beautician, told the resident he/she owed the facility twenty dollars. The resident told the administrator she would get her money, but wanted to get his/her hair done. The beautician said he/she offered to fix the resident's hair for nothing, but the administrator told the beautician to take the curlers out of the resident's hair. Resident #1 started crying. The beautician removed the rollers from the resident's hair and took the resident back to his/her room. The resident was so upset he/she to cried all the way back to his/her room. The other residents in the beauty shop were also upset. During an interview on 9/30/10, at 10:30 A.M., Certified Nurse Aide (CNA) B said he/she worked the day the resident came back from the beauty shop. The resident was very excited that morning about getting his/her hair fixed. The resident got up early to shower and get his/her hair washed before the beauty shop appointment. When the resident came back to his/her room from the beauty shop, he/she was crying and "very, very upset." The resident told CNA B he/she was embarrassed because the administrator got onto him/her about owing money in front of the beauticians and other residents. The CNA said he/she tried to fix the resident's hair to give it some body and curl. CNA B said it was not like the resident to get that upset. The resident was usually easy-going and happy. 2. Review of Resident #2's readmission data collection tool completed by the facility nurses, dated 6/16/10, showed the resident was alert and oriented to person, place, time and situation. The resident was able to understand verbal communication. The resident's comprehension was quick. His/her short- and long-term, as well as situational memory, was intact. The resident did not have behavioral symptoms but was on antidepressant and antipsychotic medications. The resident was anxious and agitated. Review of the resident's physician progress notes [REDACTED]. The resident was adamant about going home. The resident had anxiety and high irritability, no emotional lability (frequently changing), depression, no sleep disturbances, anhedonia (psychological condition characterized by inability to experience pleasure in normally pleasurable acts) and not desire to keep living. The resident was alert and oriented to time, person, and place. The physician noted the resident had depression and mood disorder. The physician did not feel the resident was able to make his/her own medical decisions and was not medically stable to return home. Review of the resident's physician progress notes [REDACTED]. The examination showed the resident was alert and oriented, his/her memory was adequate, he/she had marginal judgment and poor insight. Review of Resident #2's MDS, dated [DATE], showed the following: - Short-term memory problems and no long-term memory problems. - Modified independence with daily decision making. - No behavioral symptoms. - Indicators of depression, anxiety, or sad mood included persistent anger with self or others, repetitive anxious complaints/concerns, and sad, pained or worried facial expressions. - The resident was independent with all activities of daily living. - [DIAGNOSES REDACTED]. During an interview on 9/29/10 at 10:40 A.M., Resident #2 said the only staff he/she had problems with was the administrator. The administrator talked down to the residents. The administrator has gotten onto him/her a couple of times and shook her finger in the resident's face. The resident said he/she has lived in the facility for about seven months. He/she did not like to go to the dining room for meals. The administrator told the resident he/she had to go to the dining room for meals or she would tell the physician the resident was not following the rules and the physician would not let the resident go home. The resident said he/she felt like this was a threat. The administrator also told the resident, he/she could not give gifts to other residents and if he/she tried, the facility would send it back to the resident. The resident said the administrator told him/her the state said he/she could not give the gifts. It made the resident want to fight when the administrator threatened and bossed him/her. During an interview on 9/30/10 at 10:25 A.M., CNA A said the administrator told Resident #2 he/she could not eat in his/her room. The CNA did not know why the resident could not eat in his/her room, because other residents were allowed to eat in their room. During an interview on 9/29/10 at 10:20 A.M., the beautician said one day, she observed Resident #2 go into the office next to the beauty shop. The administrator saw the resident in the office and in a "short tone" scolded the resident and "got all over him/her" for being in the office. The resident said he/she wanted to mail a package. The administrator then saw the beautician and her tone completely changed and she offered to wrap and mail the resident's package. 3. Review of Resident #3's admission data collection tool completed by the facility nurses, dated 7/26/10, showed the resident was alert and oriented to person, place, time, and situation. The resident's memory was intact and he/she had quick comprehension. Review of the resident's social progress note, dated 7/29/10, showed the resident was in the facility for skilled services after a [MEDICAL CONDITION]. The resident was alert and oriented. The resident had a history of [REDACTED]. Review of the resident's admission MDS, dated [DATE], showed the following: - Responsible for self. - No memory problems. - Modified independence with daily decision making. - Indicator of depression, anxiety, sad mood was repetitive health complaints. - Behavioral symptom was socially inappropriate/disruptive but he/she did not exhibit this behavior the seven days prior to the assessment date. - Wheelchair is his/her primary mode of locomotion. - [DIAGNOSES REDACTED]. During an interview on 9/30/10 at 11:25 A.M., Resident #3 refused to talk to the surveyor in his/her room. The resident said he/she would never complain about anything ever again. The resident said he/she got in trouble for complaining. The surveyor asked the resident who he/she got in trouble with and the resident said it was the administrator. The resident again said he/she was not going to complain anymore. When the surveyor asked the resident if he/she was afraid, the resident said yes. The resident then asked the surveyor to not say anything because he/she would get in trouble. 4. Review of Resident #4's readmission data collection tool completed by the facility nurses, dated 7/2/10, showed the resident was alert and oriented to person and place. The resident was independent with decision making and did not have any memory problems. The resident's comprehension was quick. The resident took [MEDICAL CONDITION] medications. He/she was anxious and cooperative. Review of the resident's social service progress notes written by the facility administrator and dated 7/25/10, showed the resident went to the hospital last month for behaviors and had returned to the facility. The note showed the resident continued to seek attention through behaviors. Review of the resident's MDS, dated [DATE], showed the following: - Responsible for self. - No memory problems. - Independent with daily decision making. - Repetitive health complaints. - Independent with all cares. - [DIAGNOSES REDACTED]. During an interview on 9/29/10, at 9:25 A.M., Resident #4 sat in his/her room reading the newspaper. The resident said the lady who runs the place (administrator) screams and yells at him/her. The resident said the administrator has come to his/her room and yelled and shook her finger at him/her. The resident said he/she could not talk to the administrator because she would not listen. The resident said he/she talked to the social service director (SSD) if there were any problems. The resident said it upset him/her when the administrator yelled at him/her. The resident did not have any family to help him/her. 5. Review of Resident #5's MDS, dated [DATE], showed the following: - No memory problems. - Moderately impaired cognitive skills for daily decision making. - Indicator of depression, anxiety, sad mood was crying/tearfulness. - No behaviors noted. - [DIAGNOSES REDACTED]. Review of the resident's psychological services progress note, dated 9/20/10, showed the treatment goal was stabilization of depressed mood. The resident was alert and oriented to person, place, time, and situation. The resident's mood was depressed. The resident showed no evidence of perceptual disturbances, paranoia, or delusional thinking. Review of the resident's physician orders, dated 10/1/10 through 10/31/10, showed the resident's [DIAGNOSES REDACTED]. During an interview on 9/30/10 at 11:00 A.M., Resident #5 said the administrator called him/her a troublemaker. The resident said the administrator was mad and hateful when she said it. The resident said the administrator told residents to be careful what they said to the ombudsman. The resident said the ombudsman was his/her friend and helped him/her a lot. The resident said in the past, the administrator called him/her a "fat cow." The resident became tearful when he/she told this to the surveyor. The resident said Resident #2 wanted to give him/her a Christmas present. The administrator told Resident #2 he/she could not give him/her a gift. Resident #5 said Resident #2 was his/her friend. 6. During an interview on 9/29/10 at 10:25 A.M., the SSD said she has worked at the facility for about three years. The role of the SSD was to be an advocate for the residents and to try and resolve any issues they may have. On 9/30/10, at 10:40 A.M., the SSD said she tried to intercede on the resident's behalf before it got to the administrator. It seemed like problems between the residents and the administrator occurred when the SSD was not at the facility. Review of the voluntary statement provided by the facility SSD, dated 10/1/10, showed residents informed her they felt threatened or "scolded" by the facility administrator. Resident #2 told the SSD, the administrator threatened him/her because the resident did not want to eat in the dining room. The resident said the administrator told him/her if he/she did not go to the dining room for meals it would keep the resident from being able to return to his/her own home. The reason Resident #2 did not want to eat in the dining room was due to him/her having trouble getting to the bathroom in time. Resident #3 told the SSD that after he/she had a discussion with the administrator, he/she would never say anything again because he/she just gets in trouble. The SSD documented she encouraged the resident to continue voicing any concerns and the resident repeated several times, "Nope, I'm not going to say anything. It won't do anything but get me in trouble." Resident #4 said he/she felt like the administrator treated him/her like a kid and gave the example of the administrator shaking her finger in the resident's face. The administrator has said you have to be stern with psychiatric patients. The reason these resident complaints were not addressed in the grievance logs was because they were to be considered psychiatric issues. 7. During an interview on 10/1/10, at 2:45 P.M., the administrator said she has worked in two psychiatric facilities in the past. The administrator denied threatening or speaking harshly to residents. She said she never speaks to residents without another staff person present. The administrator verified she spoke to Resident #1 about owing the facility money in the beauty shop in front of other resident's and the beautician. The administrator said she probably should not have done this in front of other residents. The administrator said she wanted Resident #2 to eat in the dining room so staff could monitor her fluid intake. The resident had a fluid restriction in the past and it was easier for staff to monitor the resident's intake, if he/she ate in the dining room. If a resident had a problem with the administrator, they could go to the SSD with their concerns. The ombudsman has not reported any concerns to her recently. The administrator asked the ombudsman to bring any concerns to her instead of the SSD, because she did not think the SSD followed up on resident grievances. During an interview on 10/5/10, at 1:40 P.M., a former director of nursing (FDON) said she left her position for personal reasons. She said the administrator did talk to residents without always having someone else with him/her. Review of a statement provided by the regional resident advocate showed the resident advocate received multiple complaints from several residents at the the facility. The residents gave permission for the resident advocate to speak with the facility SSD about their concerns. On 9/3/10, the regional resident advocate and the local resident advocate met with the facility administrator. The administrator wanted the resident advocates to bring complaints to her instead of the SSD. The administrator voiced concerns that the resident advocate was frequently in the facility and saw the same residents each week. She was concerned that the resident advocates saw "psychiatric residents" whose complaints would never be resolved because of their illness and would always complain. After this meeting, residents started to refuse to grant permission for the resident advocates to report their complaints. They told the resident advocates it would not help to complain and they stated they were afraid of retaliation. The residents told the resident advocates the administrator, "Jumps them, reams them, threatens them, makes derogatory remarks about them, humiliates them in front of people, jumps down people's throats, demeans them, and calls them liars." The previous statements were the resident's words. The residents stated the administrator said she would make it right and then when everyone leaves, she reverses it. MO