Every finding on record at St Sophia Health & Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice. One resident had a wound identified on the sacral area with same-day documentation indicating there were no open areas and no treatment orders were obtained (Resident #9). One resident had a skin assessment identifying an open area with measurements, but no additional documentation or treatment orders for three days until the resident was transferred to the hospital for an unrelated change in condition (Resident #1). One resident had a dressing in place to an open area on the left knee with no documentation of a nursing assessment or treatment orders (Resident #8). Two residents had physician orders for skin treatments that were not documented as completed (Residents #6 and #7). The sample size was 10. The census was 161. Review of the facility's Physician Orders policy, reviewed 9/28/22, showed:Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines;Responsibility: Licensed Nurses, Nursing Administration & Director of Nursing;Procedure:-Physician Orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe Orders;-Orders must be Recorded in the Medical Record by the Licensed Nurse authorized to transcribe such Orders;-Physician Orders must be documented clearly in the Medical Record. The required components of a Complete Order:--Date and Time of Order;--Name of Practitioner Providing Order;--Name and Strength of Medication/Treatment;--Quantity/Duration;--Dosage/Frequency;--Route of Administration;--Indication/Diagnosis;--Stop Date, if Indicated;-Physician Orders that are missing required components, are illegible or unclear must beclarified prior to implementation.-Physician Order Sheet (POS) will be maintained with current Physician Orders as New Orders are received. Discontinued Orders will be marked as discontinued with the date, and all new Orders will be written in the appropriate area on the POS with the date the order was received;-Physician Orders will be transcribed to the appropriate Medication Administration Record (MAR/eMAR) or Treatment Administration Record (TAR/eTAR);-Medication will be ordered from the Pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy, if available;-Physicians and Physician Extenders will review and signature their Physician Orders at least every 30 days, or as required by State Regulations;-Pharmacy monthly review of the Physician Orders will be completed to assure appropriateness, accuracy, and completeness; -Telephone/ Verbal Orders:--Telephone/Verbal Telephone Orders may only be received by a Licensed Nurse;--Telephone/Verbal Orders should contain the required components;--Telephone/ Verbal Orders should be read back and verified with the prescriber;--The Licensed Nurse is required to transcribe the Order accurately in the Medical Record, Physician Order Sheet (POS) and on the appropriate MAR/eMAR or TAR/eTAR;--The Telephone/ Verbal Orders are required to be signed by the ordering Physician within 30 days; -Written/Faxed Orders:--Written/Faxed Orders requires a Physician Signature to constitute a valid Order;--The Written/ Faxed Orders should contain required components;--Written/ Faxed Orders that are missing required components, illegible or are unclear must be clarified prior to implementation;-The Licensed Nurse is required to record the Order in Point Click Care (Electronic medical record (PCC)) the POS and on the appropriate MAR/eMAR or TAR/eTAR;-The Written/Fax Order will be maintained in the Medical Record. Review of the facility's Skin Integrity Policy, revised 7/5/24, showed:-Purpose: To establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate;-Responsibility: Nursing Assistants, Licensed Nurses, & Nursing Administration;-Policy:-Only certified pressure relief mattresses shall be utilized;-Certified pressure relief seat cushions shall be available and utilized as per the care plan;-Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity;-Skin integrity risk factors will be evaluated upon admission and routinely, as per the care plan. Appropriate interventions will be initiated based on the risk factors identified;-Residents shall be repositioned frequently, as per the care plan, to provide pressure relief; -Incontinence care shall be provided timely after each episode of incontinence;-Lotion and moisture barrier products shall be available and applied as per the care plan. Minimize, as much as possible, any friction or vigorous rubbing of the skin while providing care;-Any skin abnormalities noted shall be communicated to the licensed nurse. The licensed nurseshall notify the provider as needed for appropriate skin care orders;-Encourage proper hydration and nutrition. Communicate with nutrition services as needed for additional nutritional needs;-Staff shall be educated on skin integrity best practices. 1.Review of Resident #9's care plan, revised 1/16/26, showed:-Focus: Activity Daily Living (ADL) self-care performance deficit related to dementia;-Goal: Resident will maintain current level of function with ADL's through the review date;-Interventions: Bed mobility-requires staff assistance to turn and reposition in bed. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/16/26, showed:-Mild cognitive impairment;-Dependent. A helper completed the activities for the resident, for toileting, personal hygiene, and shower/bath;-Diagnoses include end stage renal disease (ESRD), diabetes, non-Alzheimer's dementia, depression, and Schizophrenia (a chronic and severe brain disorder that affects a person's ability to interpret reality, causing disruptions in thought, processes, behaviors and emotions). Review of the resident's electronic Physician Order Sheet (ePOS), dated April 2026, showed no physician order for weekly skin assessments. Review of the resident's Medication Administration Record (MAR), dated April 2026, showed: -No order for weekly skin assessment;-No order for any treatment to the resident's sacral area. Review of the resident's medical record, showed a skin assessment, dated 5/1/26 at 9:49 A.M. No skin concerns at this time. Observation on 5/1/26 at 10:05 A.M., showed the resident lay in bed asleep. A linen cart was in the resident's room. Certified Nursing Assistant (CNA) F entered the resident's room. CNA F stated he/she had already checked on the resident this morning and provided care. CNA F washed his/her hands and put on gloves. CNA F informed the resident he/she was going to provide care to the resident and rolled the resident to the resident's left side. The CNA unfastened the resident's brief and removed it. The brief had blood on the inside around the sacral area. The brief stuck to that area as the CNA removed the brief. CNA F said it was not new. They had put cream on it, and it was getting better. The CNA wiped the area with a washcloth and put Calmoseptine cream (moisture barrier cream) on the resident. The CNA turned the resident to his/her back and placed a new brief on the resident. During an interview on 5/1/26 at 10:10 A.M., Registered Nurse (RN) H said he/she believed Resident #9 had an open area. The skin assessments were done weekly. Observations on 5/1/26 at 11:10 A.M., showed the Director of Nursing (DON) entered the resident's room. She washed her hands and placed gloves on. The DON turned the resident to his/her side and removed the resident's brief. The DON verified the open area and said, no stage but would call that area open. There was slough (soft, moist, yellowish or white tissue found in wounds, consisting of dead cells) over the top. It was unstageable, but not something that developed overnight. She would expect the skin assessment to be accurate, and it was not appropriate for the resident's skin assessment completed today to have shown no open areas. During an interview of 5/1/26 at approximately 11:55 A.M., the Regional Nurse Consultant (RNC) said she assessed the wound on the resident. She believed it could have been a Kennedy ulcer (specialized skin wounds that can appear, often on the sacrum or tailbone, in the final days or weeks of life as part of natural, unavoidable bodily decline). They could show up within hours. She in-serviced and educated nursing staff. Most were not aware of those types of ulcers. She also talked to hospice to see if they were aware of any open areas to make sure nothing was missed. She would expect any skin assessment completed to be accurate. 2.Review of Resident #1's face sheet, showed: -admission date, 4/1/26;-discharge date to hospital, 4/28/26;-Diagnoses included dementia, ESRD, Chronic Obstructive Pulmonary Disease (COPD, lung disease), and heart failure. Review of the resident's care plan, dated 4/16/26, showed:-Focus: ADL self-performance deficit:-Goal: Resident will maintain current level of function with ADLs through the review date;-Interventions: Bathing/showering, dressing, and toilet use one person assist. Review of the resident's ePOS, dated April 2026, showed:-An order dated 4/1/26. Complete skin observation tool form on day shift. Every day shift every Monday, Thursday;-No orders for skin treatments or wound treatments. Review of the resident's medical record, showed:-A skin assessment, dated 4/21/26, no new skin issues at this time;-A skin assessment, dated 4/25/26, Right Buttock Pressure, Length: 2.5 centimeters (cm), Width: 1.5 cm, Depth: Not Applicable (N/A), Stage: N/A. Review of the resident's Treatment Administration Record (TAR), dated April 2026, showed no orders for skin treatments or wound treatments. Review of the resident's medical record, showed no progress notes related to skin assessment or physician notification on 4/25/26. During an interview on 4/30/26, at 10:55 A.M., LPN E said if the resident had anything open on his/her right buttock, there should have been some orders, even for Calmoseptine cream. LPN E opened the resident's TAR and verified no orders in the medical record. During an interview on 4/30/26 at 11:19 A.M., LPN C said he/she completed the skin assessment on the resident. The open area was just a scab, not open. It was more like moisture. There was some discoloration where the scab had fallen off. LPN C states he/she let the physician and resident's family know and put in a nurse's note. During an interview on 5/1/26 at 11:22 A.M., the DON said if it was just a scab and before it was a scab, it had to be opened. If it was just scab, they still had to do something, like skin prep. There should have been something in there for orders. Initially even for one treatment, a scab would have been healed, and the skin assessment would have shown an open area. 3. Review Resident #8's care plan, revised 11/7/25, showed:-Focus: Resident has a pressure ulcer to his/her right thigh and is at increased risk for wound decline and infection;-Goal: Residents will pressure ulcer will show signs of healing and remain free of infection by/next review date;-Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown, inform the resident/family/caregivers of any new area of skin breakdown, administer treatments as ordered and monitor effectiveness, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of the resident's quarterly MDS, dated [DATE], showed:-Mild cognitive impairment;-Dependent. A helper completed the activities for the resident, for toileting, personal hygiene, and shower/bath;-Diagnoses include non-Alzheimer's dementia, depression, high blood pressure and malnutrition. Review of the resident's medical record, showed a skin assessment, dated 4/18/26. Dry skin bilateral lower extremities. No skin integrity issues noted. Review of the resident's wound notification form, dated 4/24/26, and signed by the wound nurse, showed:-Date: 4/24/26;-Time: 10:00 A.M.;-Wound location: Left knee;-Description of wound: Skin tear to left knee;-Stage (if applicable): Blank;-Was physician notified: Yes, Date/Time: 4/24/26 at 10:05 A.M.;-Family notified: Yes, Date/Time: 4/24/26 at 6:00 P.M. Review of the resident's medical record, showed no progress notes related to skin assessment or physician notification on 4/25/26. Review of the resident's ePOS, dated April 2026, showed:-Weekly Skin Assessment, every night shift every Wednesday;-No orders for wound treatments to the resident's left knee. Review of the resident's Treatment Administration Record (TAR), dated April 2026 , showed no left knee wound treatment orders. Review of the resident's medical record, showed a skin assessment, dated 5/1/26. Left knee (front), Skin tear, Length: 3.5 cm, Width: 2.5 cm, Depth: 0.1 cm, Stage: II (a partial-thickness skin loss involving the outer (epidermis) and part of the inner (dermis) skin layers). Review of the resident's ePOS, dated May 2026, showed an order, dated 5/1/26 at 11:52 AM., Left knee clean with normal saline or wound cleanser, pat dry. Apply xeroform and border gauze daily and as needed if soiled or dislodged. Review of the resident's TAR, dated May 2026, showed a treatment order on 5/2/26 8:00 A.M., Left knee. Clean with normal saline or wound cleanser, pat dry. Apply xeroform and border gauze daily and as needed if soiled or dislodged. One time a day for wound care. During an interview on 4/30/26 at 10:55 A.M., LPN E said nurses were responsible for skin assessments on shower days. He/She did some of them on Wednesdays. If they found anything, they would fill out a wound notification form. LPN E provided a wound notification form for Resident #8 dated 4/24/26. The nurse signed it and had 24 hours to assess the wound after receiving the form. Observation on 5/1/26 at 10:13 A.M., showed the resident in his/her room. The resident sat in his/her wheelchair. The resident had a foam dressing to his/her left knee, dated 4/30/26. Observation and interview on 5/1/26 at 11:22 A.M., showed the DON entered the resident's room. She verified the resident had a foam bandage, dated 4/30/26. The DON put gloves on and peeled back the foam bandage to see xeroform strip under the foam bandage. The DON said the resident should have had weekly skin assessments completed as ordered. The resident should have had orders for wound care if there was dated dressing. Any open area should have been noted. 4.Review of Resident #6's comprehensive MDS, dated [DATE] showed:-Severe cognitive impairment;- Substantial/maximal assistance. Helper does more than half the effort for shower/bathing;- Partial/moderate assistance. Helper does less than half the effort for personal hygiene;-Dependent. Helper does all the effort for toileting;-Diagnoses include aphasia (inability to express speech), stroke, seizures, and Schizophrenia. Review of the resident's care plan, revised 4/9/26, showed:-Focus: Resident has a wound to his/her sacrum that he/she is receiving treatment;-Goal: Residents will remain without complications over through the next review;-Interventions: Observe for signs of infection, document and alert physician as indicated, provide treatment per current order. Refer to physician orders for details., wound doctor to follow wounds. Review of the resident's medical record, showed:-A skin assessment, dated 4/23/26 at 7:08 A.M., Coccyx (other) wound. Area current with treatment in place. Followed by the wound nurse;-A skin assessment, dated 4/30/26 at 10:47 P.M, Sacrum, Pressure, Length: 2 cm, Width: 2 cm, Depth: 0.1 cm, Stage: II. Review of the resident's ePOS, dated April 2026, showed:-Weekly Skin Assessment, every night shift every Thursday;-An order, dated 4/3/26 and discontinued 4/24/26. Sacrum clean with wound cleanser, apply xeroform, cover with border dressing. Change daily and as needed if soiled or dislodged;-An order, dated 4/24/26 and discontinued 4/27/26. Sacrum clean with soap and water, pat dry. Apply zinc oxide daily and as needed if soiled or dislodged. Twice daily;-An order, dated 4/27/26. Sacrum clean with soap and water, pat dry. Apply zinc twice a day and as needed for skin protection. Twice daily. Review of the resident's TAR, dated April 2026, showed:-An order, dated 4/3/26 and discontinued 4/24/26. Sacrum clean with wound cleanser, apply xeroform, cover with border dressing. Change daily and as needed if soiled or dislodged.-Blank: 7:00 A.M. 4/3, 4/5, 4/6, 4/7, 4/10, 4/12, 4/13, 4/19, 4/22, 4/24/26;-An order, dated 4/24/26 and discontinued 4/27/26. Sacrum clean with soap and water, pat dry. Apply zinc oxide daily and as needed if soiled or dislodged. Twice daily;Blank: 7:00 A.M. 4/26 and 4/27/26;-An order, dated 4/27/26. Sacrum clean with soap and water, pat dry. Apply zinc twice a day and as needed for skin protection. Twice daily.Blank: 8:00 P.M. 4/30/26. On 5/1/26 at 12:20 P.M., Review of the resident's TAR, dated May 2026, showed:-An order, dated 4/27/26. Sacrum clean with soap and water, pat dry. Apply zinc twice a day and as needed for skin protection. Twice daily.Blank: 8:00 A.M. 5/1/26. Observation and interview on 5/1/26 at 10:56 A.M., showed LPN E entered the resident's room to perform the dressing change. LPN E said the area had opened up so he/she would get xeroform. The orders were in the POS to clean the area twice a day. He/She was not sure what transpired or why it was not completed as ordered. LPN E was not sure if that was the reason the area opened up. The resident did have a Foley catheter (a thin, flexible, sterile tube inserted through the urethra into the bladder) and had moisture associated damage which appeared to be sore at times. They would treat with the xeroform and bordered dressing. 5. Review of Resident #7's care plan, revised 1/19/26, showed:-Focus: Resident has diabetic wound of the right plantar, lateral foot and a diabetic wound of the left distal plantar foot;-Goal: Residents will have no complications related to ulcer through the review date;-Interventions: Monitor document wound, weekly treatment documentation, monitor document report any signs/symptoms of infection. Review of the resident's quarterly MDS, dated [DATE], showed:-No cognitive impairment;-Diagnoses included diabetes, paraplegia (paralysis affecting lower half of the body, depression, and anxiety. Review of the resident's medical record, showed a skin assessment, dated 4/23/26, Right antecubital (IV/Implanted port), Left buttock surgical incision, Other (specify) right stump. No new skin issues noted. Wounds are being treated by wound care. Review of the resident's ePOS dated April 2026, showed:-An order, dated 4/3/26, mupirocin external ointment, apply to affected area topically in the morning for infection;-An order, dated 4/3/26 and discontinued 4/27/26, left post thigh cleanser with wound cleanser, apply xeroform to surgical incision, pack Dakin's (mild, diluted antiseptic used to clean skin and prevent infections) soaked gauze, secure with ABD (abdominal pads), and secure with tape. Change daily and as needed if soiled or dislodged;-An order, dated 4/3/26 and discontinued 4/27/26, right plantar foot. Cleanse with wound cleanser, apply xeroform, cover with ABD, wrap with kerlix, and secure with tape. Change daily and as needed if soiled or dislodged;-An order, dated 4/29/26, left post thigh cleanse with Dakin's (antiseptic cleanser), apply collagen, 4x4 gauze and cover with ABD dressing daily and as needed if soiled or dislodged;-An order, dated 4/29/26, wound vac to left posterior thigh every shift for wound treatment;-An order, dated 4/30/26, left hip clean with Dakins solution, pat dry. Apply collagen and cover with bordered dressing every other day and as needed if soiled or dislodged;-An order, dated 4/30/26, right planter foot. Clean area with soap and water. Apply xeroform and ace wrap every other day and as needed. Review of the resident's TAR, dated April 2026, reviewed on 5/1/26 at 12:33 P.M., showed:-An order, dated 4/3/26, mupirocin external ointment, apply to affected area topically in the morning for infection;-Blank 4/5, 4/12, 4/17, 4/18, 4/22, 4/26, 4/29, and 4/30/26;-An order, dated 4/3/26 and discontinued 4/27/26, left post thigh cleanser with wound cleanser, apply xeroform to surgical incision, pack Dakin's soaked gauze, secure with ABD, and secure with tape. Change daily and as needed if soiled or dislodged;Blank: 7:00 A.M. 4/4, 4/5, 4/12, 4/17, 4/18, 4/22, 4/26, and 4/27/26;-An order, dated 4/3/26 and discontinued 4/27/26, right plantar foot. Cleanse with wound cleanser, apply xeroform, cover with ABD, wrap with kerlix, and secure with tape. Change daily and as needed if soiled or dislodged;Blank: 7:00 A.M. 4/4, 4/5, 4/12, 4/17, 4/18, 4/22, 4/26, and 4/27/26;-An order, dated 4/29/26, left post thigh cleanse with Dakin's, apply collagen, 4x4 gauze and cover with ABD dressing daily and as needed if soiled or dislodged;Blank: 8:00 A.M. 4/30/26;-An order, dated 4/29/26. Wound vac (a medical device that promotes healing by applying gentle suction to the wound) to left posterior thigh every shift for wound treatment;-Blank 7:00 A.M. 4/29/26 and 4/30/26; 7:00 P.M. 4/30/26;-An order, dated 4/30/26. Left hip clean with Dakins solution, pat dry. Apply collagen and cover with bordered dressing every other day and as needed if soiled or dislodged;Blank: 8:00 A.M. 4/30/26;-An order, dated 4/30/26. Right planter foot. Clean area with soap and water. Apply xeroform and ace wrap every other day and as needed;-Blank 8:00 A.M. 4/30/26. 6.During an interview on 4/30/26 at approximately 11:05 A.M., LPN G said nurses were responsible for skin assessment. If anything new was found, they would fill out the wound notification form. Then notify physician, management, and family. The physician should provide orders. This should be done on the same day. LPN G said he/she would not be surprised if a couple treatments or skin assessments were missed. He/She has been on vacation and just returned. 7. During an interview on 5/1/26 at 11:35 A.M., the Administrator said she would expect skin assessments to be done as ordered and accurate. A blank MAR/TAR in the medical record meant treatment was not given as required. She would expect a note as to why the treatment was not completed and for staff to follow physician orders. If a resident had a dressing, there should have been treatment orders in the medical record. If an open area was noted on the skin assessment, then physician notification should be documented with skin assessment. It should have been in there immediately. 2991034

Based on observation, interview and record review, the facility failed to ensure a resident who was frequently incontinent of bowel and bladder received appropriate incontinence care and services to prevent prolonged exposure to urine when staff applied two adult briefs (incontinence products) following an incontinent episode. The resident's incontinent products became heavily saturated with urine, causing the resident discomfort (Resident #2). The sample size was 10. The census was 161. Review of the facility's Skin Integrity Policy, revised 7/5/24, showed:Purpose: To establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate;Responsibility: Nursing Assistants, Licensed Nurses, & Nursing Administration;Policy:-Only certified pressure relief mattresses shall be utilized;-Certified pressure relief seat cushions shall be available and utilized as per the care plan;-Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity;-Skin integrity risk factors will be evaluated upon admission and routinely, as per the care plan;-Appropriate interventions will be initiated based on the risk factors identified;-Residents shall be repositioned frequently, as per the care plan, to provide pressure relief; -Incontinence care shall be provided timely after each episode of incontinence;-Lotion and moisture barrier products shall be available and applied as per the care plan. Minimize, as much as possible, any friction or vigorous rubbing of the skin while providing care;-Any skin abnormalities noted shall be communicated to the licensed nurse. The licensed nurseshall notify the provider as needed for appropriate skin care orders;-Encourage proper hydration and nutrition. Communicate with nutrition services as needed for additional nutritional needs;-Staff shall be educated on skin integrity best practices. Review of Resident #2's care plan, revised 11/18/25, showed:-Focus: Activity of Daily Living (ADL) self-care and mobility performance deficit: Resident experiences fluctuations in abilities day to day and time of day;-Goal: Resident will maintain current level of function with ADLs through the review date;-Interventions: Personal Hygiene: One staff assist. Toileting: Dependent on staff for one to two assist. Bed mobility: Dependent on staff for one to two assist. Observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/16/26, showed:-Cognitively intact;-Dependent. A helper completed the activities for the resident, for toileting, personal hygiene, and upper and lower body dressing;-Substantial/Maximum assistance for resident to roll left and right;-Frequently Incontinent (seven or more episodes of urinary incontinence, but at least one episode of continent voiding) of bladder ;-Frequently Incontinent (two or more episodes of bowel incontinence, but at least one continent bowel movement) of bowel ;-Diagnoses included diabetes, anemia (decrease in number of red blood cells), high blood pressure, morbid (severe) obesity, and generalized muscle weakness. Observation on 4/30/26 at 11:27 A.M., showed Certified Nursing Assistant (CNA A) entered Resident #2's room to provide incontinence care. CNA A gathered towels to clean the resident and a brief, washed his/her hands, and put on gloves. The CNA removed the resident's brief and noted the top brief was dry, but there was a second brief under the first one, saturated with urine. CNA A said he/she checked on the resident earlier, but he/she did not know the resident was wearing two briefs. There was a line on the front of the brief that changed colors if it got wet. The CNA said he/she just looked at the top brief and thought the resident was dry. CNA A said it was from the night shift. CNA A finished with care, washed his/her hands, and left the room with the trash. During an interview on 4/30/26 at 11:35 A.M., the resident said he/she was not aware of the two briefs. This was the first time he/she had incontinence care today, but not the first time the CNA was in the room to check on the resident. The resident said he/she did not want to have a urinary infection. During an interview on 4/30/26 at 11:40 A.M., CNA A said this was not the first time he/she had seen a resident with two briefs. Sometimes he/she would find a second brief inside the first brief, like an insert or used as an incontinence pad. CNA A said residents should not have two briefs on because sitting in urine could cause skin breakdown or an infection like urinary tract infections. The CNA said he/she did not know the resident had two briefs on and just assumed the resident was still dry. During an interview on 4/30/26 at 11:45 A.M., Licensed Practical Nurse (LPN) B said he/she was not told about residents with two briefs. That should have been reported to the nurse. It was not sanitary and could have caused a skin break down. During an interview on 4/30/26 at 11: 50 A.M., LPN C said the residents should have been checked on frequently if they needed incontinence care. If a resident had two briefs, it could have caused skin breakdown, and staff could not tell if they were wet or soiled. During an interview on 4/30/26 at 12:15 P.M., CNA D said he/she would not place two briefs on a resident and would report to a nurse or supervisor if he/she found a resident with two briefs. It could have caused skin breakdown or infections. During an interview on 5/1/26 at 11:14 A.M., the Director of Nursing (DON) said the resident should not have had two briefs on them. This could have caused skin breakdown and prolonged staff having to provide incontinence care and change the brief. There should never have been two briefs on a resident. During an interview on 5/1/26 at 11:35 A.M., the Administrator said she would not expect a resident to wear two briefs. This could cause skin irritations or infections. There were some residents that it may have been care planned for, due to comfort. The staff should have been aware of that preference so they could have provided incontinence care. Resident #2 did not have that care planned, and the CNA was not aware if it was a preference. 29873882991034

Based on interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when Certified Nursing Assistant (CNA) F threw a metal fork at the resident after a verbal exchange between them. The resident (Resident #1) was struck in the arm. The sample size was 10. The census was 153. Review of the facility's Abuse and Neglect Policy, last reviewed 1/20/26, showed:Policy: The facility is committed to protecting the residents from abuse, neglect, misappropriation of property, and exploitation by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. This also includes freedom from corporal punishment, involuntary seclusion, physical and/or chemical restraints not required to treat a medical symptom.Definitions:Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident.Willful: Means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Physical Abuse/Corporal Punishment: Includes, but is not limited to: Hitting, Slapping, Punching, Biting, and Kicking. Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to: Pinching, Spanking, Slapping of hands, Flicking or hitting with an object.Deprivation of Goods and Services: Deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Example includes staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s) which result in care deficits to the resident(s).Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation including abuse that is facilitated or enabled through the use of technology. Examples include, but are not limited to:Keeping and/or distributing demeaning or humiliating photographs and/or recordings through social media or multimedia messaging;Photographs and/or recordings of resident that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perinea! care;Agitating a resident to solicit a response;Derogatory statements directed to the resident's face;Labeling resident's pictures and/or providing comments in a demeaning manner;Directing a resident to use inappropriate language;Showing the resident in a compromised position.Verbal Abuse: Use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Examples include, but are not limited to:Harassing a resident;Mocking, insulting, or ridiculing;Yelling or hovering over a resident, with the intent to intimidate;Threatening a resident, including but not limited to, depriving a resident of care or withholding a resident from contact with family and friends;Isolating a resident from social interactions or activities. Procedure:Screening: The facility will conduct background checks and all required federal and state pre-employment screenings on new hires prior to employment. Training: -Facility staff shall be provided education upon hire, and at least annually thereafter, regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, misappropriation of property, exploitation and the related reporting requirements and obligations.-Employees shall be trained in issues related to abuse prohibition practices such as:Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents;Staff rights to be free of reprisal and/or retaliation when reporting information related to any allegations;How to recognize signs of burnout, frustration and stress that may lead to abuse;What constitutes abuse, neglect, exploitation, and misappropriation of resident property;Appropriate implementation of trauma informed care principles, prohibiting further abuse, and making accommodations for the residents' safety and control of their environment after an allegation has occurred.-Training shall also include prohibiting staff from using any type of equipment (e.g. cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or audio/video recordings of residents that are demeaning or humiliating.Prevention:-Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse. There will be no negative repercussions for reporting against anyone who reports suspected abuse, neglect, involuntary seclusion, exploitation, or misappropriation of resident property. When an incident of resident abuse is suspected or determined, the incident must be reported to facility management regardless of the time lapse since the incident occurred.-Residents and/or their representatives shall be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents upon admission and at least annually thereafter.-Identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur.-Identification and monitoring of any potential features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility.-Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increased supervision, protection from retaliation, trauma informed care, resident accommodations, and follow-up counseling for the resident(s).-When a resident wishes to participate in a sexual relationship the facility should determine the capacity to consent and how a sexual relationship will be handled. The Administrator, DON and Physician shall collaborate to make a determination of capacity and document in the medical record. Review of the facility's investigation, showed:Date/ time alleged incident reported: 02/21/2026 2:30pm;Date/ time alleged incident occurred: 02/21/2026 2:00pm;Location of incident: 300 hall by the courtyard door;Name of person who reported alleged incident: Resident #1;Type of abuse: Physical: Fork thrown toward resident;Resident physically injured: No. The fork did make contact with the resident's arm. Resident had a heavy cotton/fleece blended hoodie. No discoloration noted on right arm. No injury noted;Do the injuries require medical attention? N/A;Were they any witnesses to the alleged incident? Resident and Employee;Name(s) and title/relationship of person(s) allegedly involved: CNA F;Summary of interviews with witnesses (List names and summary of their interviews): N/A;Summary of interviews with roommate/residents: N/A. Summary of interviews with staff: N/A No staff witnessed the incident.Summary of interviews with residents' family member/visitors/DPOA: N/ASummary of investigator's findings: The employee CNA F did throw a fork in the direction of the resident. The CNA stated that the resident was coming toward him/her after the resident was observed coming in from the courtyard smoking during an unscheduled smoking time. CNA F stated that he/she was fearful because the resident was approaching him/her in a threatening manner. The CNA's teammates were assisting others in rooms on 100 hall. He/She was alone and was trying to stop the resident from coming forward with his/her cane. The resident appeared to be motioning to raise his/her cane in an aggressive manner.Outcome of the investigation and any interventions/changes to plan of care/ corrective actions taken if appropriate) taken: Resident #1 stated that he/she is not aggressive and would not harm a woman. CNA F took the resident's forward motion toward him/her as with as aggressive with his/her cane. The resident's care plan was updated to address his/her. The employee, CNA F, was removed from the schedule/suspended pending investigation. He/She returned from suspension after participating in in-services regarding covering abuse/neglect and customer service. He/She understands that throwing an object towards a resident to stop perceived forward aggressive movement is not an appropriate action. He/She could have exercised other options such as walking in the opposite direction away from the resident. He/She could have addressed the safety matter later when additional staff were present to assist in the conversation. After further consideration with the incident, throwing an object at a resident would be considered abuse. The employee was terminated on 3/05/2026. Additional Comments: Resident #1 was interviewed after the incident and 72 hours following the incident. Resident stated that he/she felt safe and was not fearful. The resident had returned to his/her usual activities after the incident. He/She was monitored for any aggressive type of behavior toward other staff. Date Investigation Completed: 2/26/26 with additional corrective action completed on 3/5/26; Date Investigation Received: 3/15/26. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/26, showed:-No cognitive impairment;-Behavioral Symptom: Presence & FrequencyPhysical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited;Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others): Behavior not exhibited;Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds): Behavior not exhibited.-Diagnoses include anemia (decrease in the number of red blood cells, seizures, and high blood pressure. Review of the resident's care plan, initiated on 2/21/26 and created 2/26/26, showed:-Focus: Potential to be physically aggressive towards staff;-Goal: Will verbalize understanding of need to control physically aggressive behavior through the review date;-Interventions: Document observed behavior and attempted interventions in behavior log. Review of the resident's medical record, showed:-A progress note, dated 2/22/26 at 5:13 A.M., Resident slept throughout night. No distress noted. Normal sleep respirations. Will follow up from previous incident;-A progress note, dated 2/22/26 at 5:10 P.M., Resident remains on 72 hour observation for prior incident involving and employee resulting in resident being hit in his/her left arm with a fork. No apparent injury noted. Resident denies pain and discomfort when asked. Up ambulating around unit/facility with cane ad-lib. No aggressive behavers noted this shift. Resident appeared to be in good spirts talking and interacting with fellow residents;-A social services note by the Administrator, dated 2/24/26 at 6:59 P.M., Spoke with resident on yesterday and today regarding the incident that happened on 2/2/26. Resident #1 has participated in 72 hour monitoring for any ill-effects of the incident. Resident stated that he/she feels safe. He/She denied having any aggressive mannerisms toward the employee. He/She also denied going out to smoke at an unauthorized time. He/She stated that was wild that the CNA threw a fork at him/her for no reason. The smoking policy was attempted to be reviewed with the resident. However, he/she walked away;-A social services note by the social services assistant, dated 2/25/26 at 9:06 A.M., Spoke with resident today in regards of the incident that happened on 2/22/26 and stated that he/she feels safe and not sure on why the employee would throw something at him/her. I asked was something said between the both of them and he/she stated yes, that's what started it. That CNA F said something and he/she replied back to the CNA and he/she guess the CNA did not like what his/her respond was so the CNA threw a fork towards him/her. He/She also stated that he/she even went back to apologize to CNA F. As of today, resident is well and in good spirits and that he/she does not have any ill will towards CNA F. Will follow up with needs as directed. Observation and interview on 3/4/26 at 12:25 P.M., showed Resident #1 sat in his/her room. The resident states CNA F got mad because they were arguing back and forth. The CNA went behind the counter and grabbed a fork. The resident states he/she blocked it by holding up his/her arm. The resident showed where the fork hit him/her near his/her elbow. The resident said he/she normally does not say anything to the CNA. He/She was on the 300 hall in the courtyard area by 300 hall. The resident states overall he/she feels safe and forgives CNA F. The resident feels shocked that the CNA threw the fork and did not think nurses were supposed to do that. The resident was just standing in the hall. The CNA was walking away. It happened on the 300 hall. The resident reports that he/she went and apologized to the CNA after the incident, but the CNA did not apologize to him/her. During an interview on 3/4/26 at 12:30 P.M., CNA M stated he/she would consider throwing a fork or any item at a resident abuse. He/She is familiar with the resident and the resident is not aggressive or threatening. The resident does not raise his/her voice to anyone residents or staff or have known behaviors. During an interview on 3/4/26 at 12:32 P.M., Licensed Practical Nurse (LPN) said Resident #1 was pretty chill/relaxed. He/She would consider throwing anything including a fork at a resident abuse. During an interview on 3/4/26 at 12:35 P.M.,CNA G said he/she heard about the incident with Resident #1 and CNA F but was not here when the incident occurred. He/She would consider throwing anything at the resident abuse. The resident is very calm and CNA G said he/she is really surprised CNA F still works at the facility. The resident does argue sometimes but CNA G said he/she was not here so cannot say what happened. He/She said it does take a lot for the resident to yell and normally he/she just walks away. During an interview on 2/4/26 at 2:05 P.M., CNA L said he/she was not here when the incident happened between the resident and CNA F. He/She has worked with CNA F before and never seen the CNA act like that. He/She has also never seen the resident heated. During an interview on 3/4/26 at 2:35 P.M., CNA F states the incident happened on 2/21/26 around lunch time. He/She was passing lunch trays so around 1-2ish and was assigned the 300 hall. While he/she was passing trays, he/she noticed there was few residents outside smoking unsupervised. CNA F said he/she asked them who let them outside and they informed him/her it was the front desk. One of them, Resident #1 started screaming and cussing and started to walk towards the CNA with his/her cane. CNA F said when the resident is frustrated he/she does yell. He/She thought the resident was serious when the resident was yelling at him/her. CNA F said as the resident was coming towards him/her, he/she threw the metal fork at the resident. It was the fork from the tray he/she was holding. CNA F said he/she called over to the nurse, Registered Nurse (RN) E and the supervisor to let them know. After the incident, they took the resident back to his/her hall and the CNA was sent home. CNA F said he/she was [NAME] back last Wednesday but is not near the resident. CNA F said the resident never apologized but said he/she did apologize to the CNA. The resident was standing close, hand distance. The fork never hit the resident; the fork hit the floor. It did not hit the resident's elbow. During an interview on 3/4/26 at 3:00 P.M., the Administrator said the resident had on a heavy fleece so the fork did not cause any harm. The fork did hit the resident's left arm. The Administrator said the resident can have a temper when he/she does not get his/her way. CNA F was only allowed back after he/she was in serviced on abuse/neglect and also on customer service/throwing forks. During an interview on 3/4/26 at 3:56 P.M., RN E said he/she was at the nurse's station and heard the commotion and looked up when the incident occurred. The commotion was CNA F and Resident #1. They were down the hall and having a verbal exchange. CNA F was trying to pass trays and the resident was kind of standing over him/her. Certified Medication Technician (CMT) I was at the nurses station and went over to CNA F. The CMT took CNA F back towards the nurses station. That is when the resident followed. The resident and CNA F were still yelling and going back and forth. CNA F took the fork from the tray and threw it at the resident. The resident was coming up the hall when it happened. RN E does believe the fork hit the resident's arm. The resident was going off and yelling and kind of calling CNA F out of his/her name. However, it was not an appropriate interaction between the resident and CNA F. RN E does feel like that does classify as abuse because something was thrown at a resident. RN E was surprised that CNA F was brought back as quickly as he/she was after the incident After CNA F threw the fork, the Assistant Director of Nursing (ADON) was already coming down the hall and walked CNA F out. RN E said this is the first time he/she has ever seen CNA F act like that. There have been no complaints from residents in the past about CNA F. Resident #1's normal behavior can be aggressive and intimidating. He/She's always yelling at staff. RN E said he/she is not sure if CNA F knew he/she hit the resident with the fork. The interaction or exchange was inappropriate, and the CNA should not have been going back and forth with a resident like that. The CNA should have walked away. Even if residents are yelling at them, staff should never be yelling at residents. During an interview on 3/5/26 at 9:50 A.M., the Administrator said the interaction between CNA F and Resident #1 was not appropriate. She would have expected CNA F to go different way and get someone's attention. There were other rooms for the CNA to go to step aside and go calm down. She said throwing/yelling is abuse. CNA F told the Administrator he/she knew it was wrong to say that. The CNA also had to have one on one in-service on abuse neglect and customer service before he/she came back. During an interview on 3/5/26 at 10:57 A.M., ADON B stated he/she did not see the incident between CNA F and Resident #1. He/She heard about it after the fact. ADON B is not quite sure what happened, but the resident was trying to hit the CNA. ADON B would consider the incident abuse in that context. ADON B said the resident had on a sweatshirt that kept the fork from hitting the resident. During an interview on 3/13/26 at 1:30 P.M. CMT I verified he/she witnessed the incident between Resident #1 and CNA F. The incident occurred on 2/21/26. CMT I said the smokers go outside in the courtyard which is at the start of the 300 hallway where CNA F was passing lunch trays. CMT I said it really bothered CNA F when they go outside without supervision so the CNA always says something. The day of the incident, CNA F was passing trays and saw Resident #1 and a couple other residents outside so CNA F started fussing at Resident #1. CNA F said you know you are not supposed to be out here right now. You cannot be out here without supervision. Resident #1 said back to the CNA, Who are you the superintendent? CNA F kept going and said you do this every day and we say something to you every day. CMT I said at this point, he/she was nurses station with RN E and did not know what was going to happen so he/she went down the hall to grab CNA F and take the CNA back to the nurses station. As CMT I was pulling CNA F away, CNA F grabbed a fork off the floor and threw it at Resident #1. CMT I does not know if CNA F felt threatened because the resident had a cane but the resident was pretty far back. CMT I said when the fork got thrown, CNA F was at the nurses station and Resident #1 was in the middle of the hallway going towards the nurses station. CMT I does not believe the fork hit the resident. CNA F was still going back and forth with Resident #1 so that is why CMT I went to bring the CNA to the nurses station. Resident #1 does not have history of behaviors but they had history of getting into it the past with the same scenario but that was just a quick verbal exchange, nothing like this. CMT I does feel that was abuse. CNA F could have walked away. Staff was supposed to redirect. He/She should have said nothing and just walked away. The resident apologized to CNA F the same day. CMT I did not see the ADON. After the incident, CNA F removed himself/herself off the floor. The incident got reported to someone and the CNA was taken off the floor. CMT I said this was the first time that he/she knows of something happening with CNA F. 2785045

Based on interview and record review, the facility failed to ensure staff implemented their Abuse Prevention Policy by not conducting a thorough investigation as required, when two residents had a physical altercation (Residents #7 and #8). The staff was unsure how many incidents between the two residents had occurred, the date they occurred, and was unsure of any history. The sample size was 10. The census was 153.Review of the facility's Abuse and Neglect Policy, last reviewed 1/20/26, showed:Policy: The facility is committed to protecting the residents from abuse, neglect, misappropriation of property, and exploitation by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. This also includes freedom from corporal punishment, involuntary seclusion, physical and/or chemical restraints not required to treat a medical symptom.Definitions: Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. Willful: Means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse/Corporal Punishment: Includes, but is not limited to: Hitting, Slapping, Punching, Biting, and Kicking. Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to: Pinching, Spanking, Slapping of hands, Flicking or hitting with an object. Training: -Facility staff shall be provided education upon hire, and at least annually thereafter, regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, misappropriation of property, exploitation and the related reporting requirements and obligations.-Employees shall be trained in issues related to abuse prohibition practices such as:Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents.Staff rights to be free of reprisal and/or retaliation when reporting information related to any allegations.How to recognize signs of burnout, frustration and stress that may lead to abuse.What constitutes abuse, neglect, exploitation, and misappropriation of resident propertyAppropriate implementation of trauma informed care principles, prohibiting further abuse, and making accommodations for the residents' safety and control of their environment after an allegation has occurred.-Training shall also include prohibiting staff from using any type of equipment (e.g. cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or audio/video recordings of residents that are demeaning or humiliating.Prevention:-Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse. There will be no negative repercussions for reporting against anyone who reports suspected abuse, neglect, involuntary seclusion, exploitation, or misappropriation of resident property. When an incident of resident abuse is suspected or determined, the incident must be reported to facility management regardless of the time lapse since the incident occurred.-Residents and/or their representatives shall be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents upon admission and at least annually thereafter.-Identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur.-Identification and monitoring of any potential features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility.-Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increased supervision, protection from retaliation, trauma informed care, resident accommodations, and follow-up counseling for the resident(s).-When a resident wishes to participate in a sexual relationship the facility should determine thecapacity to consent and how a sexual relationship will be handled. The Administrator, DON and Physician shall collaborate to make a determination of capacity and document in the medical record. Review of the facility's investigation showed:Date/ time alleged incident reported: 2/28/2026 at 4:45 P.M,; Date/ time alleged incident occurred: 2/28/2026 at 4:00 P.M.; Location of incident: Resident #8's room;Name of person who reported alleged incident: Nurse Supervisor Type of abuse:Physical: Resident #7 put her hands around Resident #8's neck in a choking motion. Resident #8 attempted to stop Resident #7 from shaking him/her. During the shaking, the inner cannula [a removable, insertable tube used within a tracheostomy tube (surgically created opening (stoma) in the neck leading into the trachea (windpipe) to establish an airway) to maintain a clear airway by allowing for the safe removal and cleaning of accumulated secretions] on Resident #7 was dislodged.Resident physically injured: No injury noted to Resident #8's neck. No complaints of pain. No injury noted to Resident #7. The inner cannula was cleaned and reinserted by the nurse;Do the injuries require medical attention? The inner cannula trach cleaned and reinserted; Were there any witnesses to the alleged incident? Roommate of Resident #8;Name(s) and title/relationship of person(s) allegedly involved: Resident #8 and Resident #7. Summary of interviews with witnesses (List names and summary of their interviews): Roommate of Resident #8 stated that Resident #7 came in to see him/her. The roommate had been talking to Resident #7 earlier about something so he/she came back to the room to finish the conversation. Resident #8 said something like our room is so popular now. The roommate stated that Resident #8 said it jokingly in his/her opinion. Resident #7 did not seem to think that and stood up from his/her chair and started choking Resident #8. Resident #8 then grabbed Resident #7. The roommate then called for help. A staff member came in and separated the two. The roommate stated that he/she did not understand why Resident #7 thought that Resident #8 said mean something. They were friends.Summary of interviews with roommate/residents: Please see roommate's statement above. Summary of interviews with staff: CMT heard someone call for help. He/She went into the room and saw Resident #8 and Resident #7 in an altercation. The CMT separated the two residents and directed Resident #7 to leave the room. Resident #7 went toward the nurse's station where he/she was assessed by the nurse. Summary of interviews with residents' family member/visitors/DPOA: Resident #7's family was interviewed on 3/3/26 by phone by Assistant Director of Nursing (ADON) B and the Administrator. The family member stated that he/she was informed of the incident but believed Resident #7 who said the other person started it and provoked Resident #7. The family member also stated that he/she believed Resident #7 who said that he/she had been without his/her inner cannula and tracheostomy for several days. It was shared that Resident #7 is not a good historian. Also, the resident has a history of removing his/her inner cannula and manipulating his/her trach. The family member stated that he/she was not convinced that Resident #7 would do that. (See nurse's notes). Summary of investigator's findings: A physical altercation between Resident #8 and Resident #7 occurred. Resident #7 initiated physical contact by attempting to choke Resident #8 (putting his/her hands around his/her neck). Resident #8 grabbed his/her upper body and started shaking Resident #7 to get loose. During the shaking, the inner cannula was dislodged. Staff came and separated the two. Both were assessed. Upon examination by nurse practitioner, Resident #8 had no observable signs of pain or injury. Outcome of the investigation and any interventions/changes to plan of care/corrective actions taken if appropriate) taken: Resident #8 participated in follow-up interviews. He/She stated that he/she felt safe and had not experienced any further issues with Resident #7. Resident #8 returned to his/her usual activities. It was reported that Resident #7 had been removing and re-inserting his/her inner cannula repeatedly over a period of a few days. Resident #7 also stated that he/she had no further issues with Resident #8. Additional Comments: Both residents have diagnosis that contribute to them being poor historians and are both subject to embellishing details. Both resumed their usual daily routines. Resident #7 was transferred to the hospital on 3/32026 secondary to removing inner cannula again and manipulation of trach. Date Investigation Completed: 3/6/26Date Investigation Received: 3/15/26 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/4/26, showed:-No cognitive impairment;-Diagnoses included multiple sclerosis (MS, a disease in which one's immune system attacks the protective barrier of nerves), left tibia (shinbone) fracture, depression, post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event), seizures, and asthma. Review of the resident's care plan, dated 8/27/25, showed:-Focus: Resident has experienced a traumatic event in the past, that currently affects their mental and psycho-social well-being. Resident has a history of sexual, physical, and emotional abuse. He/She also reports PTSD related to finding survivors as prior employment for 911 hazmat team;-Goal: Interventions will minimize exposure to trauma triggers and promote de-escalation should triggering occur;-Interventions: Identify any known triggers, provide calm environment, teach visualization and relaxation techniques, notify physician of any significant changes with psycho-social wellbeing. Review of the resident's medical record, showed:-A progress note, dated 2/28/26 at 3:45 P.M., Resident standing in the hallway informed staff they were fighting in Resident #8's room. CMT reported he/she saw resident peer choking resident . Resident stated he/she told resident to get the fuck out of her room and male/female peer started choking him/her. Resident was assessed and separated by CMT. Resident neck was slightly redden denies pain or discomfort. No bruising noted to neck. Call placed to physician. Made aware of altercation orders received for psychiatry consult. -A progress note, dated 2/28/26 at 10:27 P.M., Resident remain on follow up. Resident been pleasant this shift. Resident show no issues or altercation with anyone at this time. Resident in bedroom with call light in reach.-A progress note dated 3/1/26 at 9:28 P.M., Resident remain on follow up. Resident been pleasant this shift. Resident show no issues or altercation with anyone at this time. Resident in bedroom with call light in reach.-A progress note, dated 3/2/26 at 11:57 P.M., Resident remains on observation related to altercation, no complaints pain or discomfort voiced. No further altercations noted, no behaviors seen. Resident remained in room all shift. Physician aware.-A progress note, dated 3/3/26 at 4:26 P.M., Residents in hallway stated they are fighting this writer observed resident sitting in her wheelchair with another resident standingover her, Resident informed this writer that resident standing over her choke her because I told her to get the F out of my room. Resident was assessed neck was slightly redden skin was intact resident ask to put call light on if someone comes into her room that he/she does not want in his/her room. Physician was made aware of altercation. Orders received for Psychiatry Consult. Message left on resident's family.-A progress note, dated 3/3/26 at 11:11 P.M., Resident remains on observation related to altercation, no complaints pain or discomfort voiced. No further altercations noted, no behaviors seen. Resident remained in room all shift. Physician aware. Review of the medical record, showed a provider note, signed 3/2/26 at 11:51 A.M., which included: -Chief Complaint: Request from staff related to altercation with another resident on 2/28/26 per staff note;-History Of Present Illness:Staff report that on 2/28/2026 the resident was found standing in the hallway and informed staff that he/she was in a fight with another resident. The incident was observed by a staff member. The resident stated 'he/she told resident to get the f**k out of his/her room' and the other resident started choking him/her. The two residents were separated by the staff member that observed the encounter and reported that this resident had a slightly reddened neck but denied pain and/or discomfort at the time. The staff observed no bruising noted to the neck. The staff contacted the physician and an order to consult Psychiatry was ordered. The resident was seen in his/her room. He/She was wearing a gown when he/she came out of the bathroom. The resident was able to ambulate to the bed from the bathroom and he/she was not wearing appropriate footwear and did not have on his/her boot. When asked what happened, he/she reported He/She decided to put his/her hand on me and that he/she accidently pulled his/her tracheostomy out. The resident reports that he/she was pushed up against the wall by the other resident and hit his/her Head, Left shoulder, and Right knee. He/She reports that he/she has been nauseated and having loose stools since the encounter and endorses that it is likely related anxiety due to potentially seeing the other resident after the encounter. He/She has no injury palpated or visualized on the head, or bilateral shoulders, or left elbow. He/She has full range of motion (ROM) of both arms. He/She had a light bruise (fading purple) to the right lateral knee area that is fading and appears to be improving. He/She has full ROM of the knee and is able to ambulate as evidenced by his/her ability to ambulate independently from the bathroom to the bed. He/She was advised to take his/her as needed anxiety medication and to drink small sips of water more frequently to stay hydrated. He/She report that the Zofran (nausea medication) he/she was given earlier had just dissolved in his/her mouth. The resident reports no other concerns at this time. The Psychiatry Nurse Practitioner (NP) was advised of the altercation in person at the facility. The ADON was advised that the resident was concerned about his/her pain medication The staff report no other concerns at this time. Resident denies fever, chills, chest pain, and/or shortness of breath.-Plan:Acute Stable Altercation with Another Resident with bruise Right lateral knee, improving; Continue Separate each resident Continue Psych Consultation;Continue Behavior monitoring every shift for behaviors;Continue Leave right lateral knee open to air;Chronic Controlled Anxiety;Continue Antidepressant Medication Monitoring every shift;Resident counseled and encouraged to take small sips of water more frequently to remain hydrated;Acute on Chronic Pain;Continue Document pain using 1-10 pain scale every shift. Risk for falls, malnutrition, and skin breakdown;Plan discussed with Nursing. Observation and interview on 3/5/26 at 11:40 A.M., showed Resident #8 in his/her room. The resident sat in his/her wheelchair and had a large boot cast to left foot. The resident states there were two different incidents with Resident #7. The first time Resident #7 came in cursing and the nurse made him/her leave. The next time Resident #7 was in his/her room, he/she came in to talk to the roommate. Resident #8 said when he/she said something to Resident #7, Resident #8 blocked him/her from the door. He/She then hopped out of his/her wheelchair and pushed the resident against the wall and went for his/her airway. Resident #8 said he/she pinched his/her nipple and could not breathe. Resident #8 said if he/she cannot breathe, then neither can Resident #7, so he/she grabbed the resident's tracheostomy and pulled it out. Resident #8 says he/she does not trust Resident #7. Resident #7 went to the hospital and is still there. Resident #8 does not want the resident back on this hall and does not feel safe in his/her room, at lunch, or smoke breaks. Resident #8 said the resident also got him/her with their elbow to his/her temples and has had a headache since the incident. 2. Review of Resident #7's medical record, showed:-admission 1/22/26;-Diagnoses included diabetes, muscle weakness generalized, bipolar disorder, and chronic respiratory failure. Review of the resident's care plan, initiated 2/28/26 and created 3/4/26, showed:-Focus: Potential to be physically aggressive related to anger and poor impulse control;-Goal: Will demonstrate effective coping skills through the review date;-Interventions: Administer medications as ordered, Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and interpret needs, when becomes agitated intervene before agitation escalates. If response aggressive, staff to walk calmly away and approach later. Review of the resident's medical record, showed:-A progress note, dated 2/28/26 at 3:26 P.M., Resident in hallway informed this writer that resident were fighting. This writer observed resident standing over other resident with her inner cannula in his/her hand. Resident states other resident involved told him/her to get the F out of his/her room. This writer ask resident to leave the room. Inner cannula was reinserted at this time with supervision. No respiratory distress noted. Oxygen Saturation (O2, measures the percentage of oxygen-carrying hemoglobin in the blood, with normal levels for healthy individuals typically between 95% and 100%) at 97% at room air.-A progress note, dated 2/28/26 at 3:44 P.M., This writer observed resident in Resident #8's room in verbal altercation. Resident stated that resident told her to get the fuck out of his/her room and he/she became angry and try to choke resident. Behavior was redirected and ask to leave the room. He/She was holding his/her trach in his/her hand. He/She informed this writer that Resident #8's roommate invited him/her into their room. Voiced no complaints of discomfort. No aggressive behavior noted at this time. Resident stated, that resident told him/her to get the fuck out of my room and do not like for people to holler at me this why I tried to choke him/her. Also, he/she informed this writer that he/she had been invited into the room by resident's roommate. Resident was escorted out the room by this writer and ask not to go back in the room at this time compliant with this writer.-A progress note dated, 2/28/26 at 11:18 P.M., Resident remain on follow up resident to resident. Resident been pleasant this shift. Resident show no issues or altercation with anyone at thistime. Resident in bedroom with call light in reach.-A progress note dated, 3/1/26 at 10:21 P.M., Resident remain on follow up resident to resident. Resident been pleasant this shift. Resident show no issues or altercation with anyone at thistime. Resident in bedroom with call light in reach.-A progress note, dated 3/3/26 at 2:46 P.M., This nurse was talking to resident in the hallway when I noticed his/her voice box was not in place and that the opening was closing. The resident was asked about his/her tracheostomy being out. He/She stated he/she was ok and that he/she did not need it because he/she was breathing fine. Informed resident that it was not ok and that he/she would still have to be assessed by doctor. Resident hesitant to say when it was removed but did say it was during an altercation with another resident. Talked to floor nurse and that nurse that handled the altercation to inquire about tracheostomy. The nurse that handled the altercation stated that it was the inner cannula that came out and was replaced and resident was assessed at that time there was not decannulation (permanent removal of a tracheostomy tube once a patient can breathe independently). Resident assessed after noticing inner cannula out and decannulation was noted. When this nurse returned to office to contact the doctor, the resident's guardian was calling and was upset that he/she had not been informed of tracheostomy being out and spoke with the nurse that had contacted him/her the night of the altercation who was also in the office. The nurse was trying to inform the guardian that it was not out when the nurse called him/her but guardian stated only thing he/she wanted to hear was that the resident was being sent out to hospital. The guardian asked us to allow him/her that grace because he/she was upset and could not hear {process} what we were saying.-A progress note, dated 3/3/26 at 3:19 P.M., ADON reported that resident's guardian would like for resident to be sent to hospital for evaluation due to decannulation of tracheostomy a couple of days ago. Resident's O2 Saturation 98% room air at this time. No acute distress noted.-A progress note, dated 3/3/26 at 3:29 P.M., Call placed to ambulance service to transport resident to hospital emergency room for evaluation. Estimated time of arrival, one hour, awaiting arrival of Emergency Medical Services (EMS) to facility.-A progress note, dated 3/3/26 at 5:31 P.M., Ambulance services at facility to transport resident to hospital. ADON aware and stated that physician is also aware of resident's condition and guardian's request that resident be sent to hospital for evaluation.-A progress note, dated 3/3/26 at 7:39 P.M., This nurse spoke with guardian. Informed him/her that resident had been sent to hospital, vitals. He/She was not in distress. Informed him/her that when he/she called we had just become aware of decannulation. He/She inquired as to why he/she had not been notified if tracheostomy out for days. Advised we were still trying to determine at what point he/she pulled it out. Per nurse that assessed resident, his/her tracheostomy was still in place and inner cannula was replaced. He/She spoke of resident's history behind why tracheostomy was needed and previous issues with another facility. Said he/she spoke with hospital and had the resident admitted . Wanted more info about when it came out and spoke of resident improvement with activity of daily living (ADLs). Review of the medical record, showed a provider note, signed 3/2/26 at 4:13 P.M., which included: Chief Complaint / Nature of Presenting Problem: Request from staff related altercation with another resident on either 2/28/2025 or 3/1/2026. History Of Present Illness:The staff report no concerns related to the resident at this time. Staff report the resident was in Resident #8's room in a verbal altercation with a resident and he/she was told to get the f**k out of the room and he/she became angry. The resident tried to choke Resident #8 and staff redirected the behavior. While leaving the room, he/she was holding his/her tracheostomy in his/her hands. No injuries noted on the resident and he/she was separated from the other resident. The resident was seen sitting in his/her wheelchair in the doorway of his/her room. When asked about the incident he/she reported I don't want to talk about it. I already gave my statement. The incident was discussed with the Psychiatry NP this morning. The resident denies any concerns at this time. Denies fever, chills, chest pain, and/or shortness of breath. Physical ExamGeneral: no acute distress, appears obese, well developed, cooperative;Head: Normocephalic (normal shape and size); Eyes: extraocular movements intact, conjunctiva and sclera are normal;Ears: hears without difficulty;Neck: Tracheostomy status, site clean/dry; Mouth: Mucous membranes are moist; Cardiac: Appears well perfused, no chest pain;Pulmonary: nonlabored breathing, normal effort, no shortness of breath, no distress, tracheostomy statusAbdomen: differed;Musculoskeletal: Unsteady gait uses a wheelchair for mobility, no edema;Skin: tracheostomy to neck, no edema, no rash, no lesions, warm and dry;Neurological: Responds appropriately, Awake, Alert, Verbal, oriented to person, place, and situation;Psychiatric - mood stable, cooperative. Plan: Acute Controlled Behavior (Altercation with another resident, no injury) behavior concerning, aggressive behavior. Continue Separate residents;Continue may be seen by Psychiatrist/Psychologist as needed;Chronic Controlled Bipolar disorder Schizoaffective disorder;Psychiatrist/Psychologist as needed;Continue Behavior monitoring every shift;Continue Antipsychotic medication side effect monitoring every shift; Plan discussed with Nursing. During an interview on 3/11/26 at 2:00 P.M., Resident #7 stated he/she was still in the hospital. The resident reports he/she got in a fight with Resident #8 last week and Resident #8 pulled out his/her tracheostomy. He/She just had the strings hanging. Resident #7 said there was a history due to Resident #8 recently had tried to take his/her door dash food. Staff intervened and told Resident #8 not to touch that, it was not his/hers. Last Saturday, he/she was in the room talking to Resident #8's roommate. Resident #8 came in pissed that he/she was in there and started cussing the resident out. Resident #7 said the next thing he/she knows, he/she is out of his/her wheelchair, and up in the air with the tracheostomy hanging by a thread. The resident said staff intervened but the nurse did not assess his/her tracheostomy site. The resident said he/she was fine with no signs/symptoms of distress like shortness of breath. It was just his/her guardian that made him/her go to the hospital on 3/3/26. The site closed so he/she no longer has his/her tracheostomy. The resident reports he/she got evaluated at the hospital and they are going to do a Bilevel Positive Airway Pressure machine (Bipap machine, a non-invasive ventilator used to assist breathing by delivering pressurized air through a mask, with higher pressure during inhalation and lower pressure during exhalation) which he/she thinks will be much easier to handle. The resident said his/her guardian is not telling the resident much but he/she feels fine to go back to the facility. He/She has friends there and feels safe. The resident says he/she is fine. 3. Observation and interview on 3/4/26 at 11:10 A.M., showed Resident #8 was not in his/her room. The resident's roommate was in their room. The roommate reported there was a recent incident with another resident down the hall, Resident #7. He/She was in here talking with Resident #7 when he/she just started going off on Resident #8. Resident #8 was trying to joke with him/her. Resident #7 did not seem to like that and threatened Resident #8, so he/she told Resident #7 to get out. That is when Resident #7 backed Resident #8 into a corner. The roommate states he/she called for help and staff came in to assist. The roommate states he/she has no problems with Resident #8. Resident #8 is wonderful. They get along great. Both of them were in wheelchairs and have MS, so they understand each other and their struggles well. The roommate states he/she feels safe. 4. During an interview on 3/4/26 at 11:30 A.M., Licensed Practical Nurse (LPN) H states he/she is not aware of two incidents between Resident #7 and Resident #8. LPN H is only aware of one incident and was just told to keep them separated. 5. During an interview on 3/4/26 at 1:00 P.M., the Administrator stated she only knew of one incident with Resident #7 and Resident #8 that occurred on 2/28/26. She was not sure of any incident on 3/3/26. Resident #7 was in the hospital. She was planning to move one of the residents but not sure which one. They both eat and smoke at similar times. The facility staff could keep them on separate sides and may have to look at smoke times. If there was second incident, the staff definitely should have said something. She said the first incident happened in Resident #8's room. 6. During an interview on 3/4/26 at 2:00 P.M., LPN H reviewed the progress notes and said this was the first he/she has heard of two incidents if there were two incidents. There should not have been a history between the two of them. After the first incident, staff should have been listening out for them and Resident #7 should not have been allowed to get back into Resident #8's room. 7. During an interview on 3/4/25 at 2:05 P.M., Certified Nursing Assistant (CNA) L said he/she knows Resident #7 was in Resident #8's room, Saturday 2/28/26. He/She was helping Resident #8's roommate. Resident #7 should not have been in that room again if they have history of altercation. 8. During an interview on 3/5/26 at 9:50 A.M., the Administrator said she believes there were two incidents between Resident #7 and Resident #8 but they both happened in one day on 2/28/26. The altercation was an all-day thing. It was same day but later that day. She should have been made aware of more than one incident between the two residents. Resident #7 should not have been in Resident #8's room after the first incident. She would expect staff to follow the abuse/neglect policy. 9. During an interview on 3/5/26 at 10:57 A.M., ADON B stated there was only one incident with Resident #7 and Resident #8. They did have problems before that. Resident #8 reported prior that some words had been said like an inappropriate conversation, but nothing physical had happened, just inappropriate words. 27939082794304

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to follow physician orders for a resident's Peripherally Inserted Central Catheter (PICC, flexible tube that delivers long term intravenous (IV) treatments through a vein) line (Resident #9). The dressing was ordered to be changed weekly. The date on the dressing was worn off and illegible. The sample size was 10. The census was 153. Review of the facility's Physician Orders Policy, reviewed 9/8/22, showed:-Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, and Director of Nursing (DON).-Procedure: Physician Orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe Orders.Orders must be Recorded in the Medical Record by the Licensed Nurse authorized to transcribe such Orders.-Physician Orders must be documented clearly in the Medical Record. The requiredcomponents of a Complete Order:-Date and Time of Order-Name of Practitioner Providing Order-Name and Strength of Medication/Treatment-Quantity/Duration-Dosage/Frequency-Route of Administration-Indication/Diagnosis-Stop Date. if indicated-Physician Orders that are missing required components, are illegible or unclear must beclarified prior to implementation.-Physician Order Sheet (POS) will be maintained with current Physician Orders as New Orders are received. Discontinued Orders will be marked as discontinued with the date, and all new Orders will be written in the appropriate area on the POS with the date the order was received.-Physician Orders will be transcribed to the appropriate Administration Record(Medication Administration Record (MAR) or Treatment Administration Record (TAR) 1. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/26, showed:-Cognitively intact;-admission 1/29/26;-Diagnoses include end stage renal disease, pressure ulcer sacral region stage 4 ( severe, full-thickness wound over the tailbone, characterized by extensive tissue loss with directly exposed or palpable bone, tendon, or muscle), diabetes, depression, muscle weakness, and cognitive communication deficit. Review of the resident's care plan, showed:-Focus: PICC Line;-Goal: Will have no adverse effects from the use of a peripherally inserted central catheter;-Interventions: Dressing changes should be performed on a weekly basis or when dressing is dirty, wet, or loose. Ensure insertion site is clean and protected with sterile dressing. Review of the resident's electronic Physician Order Sheet (ePOS), showed:-An order, dated 1/29/26, change IV dressing on left brachial vein (PICC) every week. Every night shift every Thursday. Review of the resident's February MAR, showed:-Change IV dressing on left brachial vein (PICC) every week. Every night shift every Thursday;-Marked as completed on 2/5/26, 2/12/26, 2/19/26, 2/26/26. Review of the resident's March MAR, showed:-Change IV dressing on left brachial vein (PICC) every week. Every night shift every Thursday. -Due to be completed on 3/5/26, 3/12/26, 3/19/26, and 3/26/26. Review of the medical record, showed:-A progress note, dated 3/4/26 at 14:16, PICC line dressing changed with no difficulty. Remains patent and intact. No abnormalities to report at this time. IV therapy continues. An observation on 3/4/26 at 11:55 A.M., showed the resident lay in bed. The resident had a PICC line to his/her left upper arm. The dressing date was not legible. The dressing appeared to be coming off and not adhering to the skin at the corners. The resident said he/she was not sure when the dressing was last changed, but he/she gets his/her antibiotics through the PICC line. During an interview on 3/4/26 at 12:02 P.M., Assistant Director of Nursing (ADON) A said Resident #9's PICC dressing should be changed once a week. The dressing date should not have a one in front of it. It should be dated for last week. ADON A stated he/she will go check the resident's PICC line dressing after lunch. During an interview on 3/5/26 at 9:20 A.M., ADON A states he/she changed the dressing yesterday and the dressing was old. The date was hard to read. He/She thinks it may have been 2/12 but not sure. It could have been January. The date should have been 2/28 and it was not. He/She said staff should not have been charting the dressing change as done when it was not done. He/She would expect the dressing change to be done weekly as ordered. The night shift is responsible for completing the dressing change and he/she plans to in-service staff. During an interview on 3/5/26 at 9:50 AM., the Administrator said she would expect staff to follow physician orders. She would have expected the PICC line to be changed weekly and staff should not document a medication/treatment as done if it has not been done. During an interview on 3/5/26 at 10:00 A.M., the Registered Nurse Consultant (RNC) said he/she would expect staff to follow physician orders. The PICC dressing should have been changed weekly as ordered. Any treatment or medication should not have been charted as done if not done.

Based on observation, interview and record review, the facility failed to ensure a resident with pain received prescribed opioid pain medications as ordered by the physician for four days (Resident #8). The sample size was 10. The census was 153. Review of the facility's Physician Orders Policy, reviewed 9/8/22, showed:-Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, and Director of Nursing (DON).-Procedure: Medications will be ordered from the Pharmacy to ensure prompt delivery. Medications available from the Emergency Drug Supply (E-Kit) or Automatic Dispensing Unit (ADU) shall be utilized for the first dose until a supply arrives from Pharmacy if available. Review of the facility's Pain Management Policy, reviewed 11/15/22, showed:Policy: The Facility will use a systematic approach to Pain Management; Recognition, Evaluation, Treatment, & Monitoring of Pain. Individuals experiencing Pain may receive Pharmalogical/Non-Pharmalogical Interventions to assist in Pain Management. The Facility will provide Employees Education on Pain Management & Opioid Overdose. Responsibility: Nursing Personnel, Nursing Administration, and DON. Procedure: Recognition: Evaluate/Prevent: Recognize when Resident is experiencing Pain and identify circumstances when Pain can be anticipated. '-Evaluate Resident for Pain on admission and Routine Evaluations.-Manage/Prevent Pain, consistent with the Comprehensive Evaluation and Plan of Care, Current Professional Standards of Practice, & Resident's Goals/Preferences. Pain Evaluation: Nursing will complete a Pain Evaluation Tool, appropriate for the Resident's Cognitive Status, to assist with Evaluation of a Resident's Pain.-Evaluation of Pain by the Licensed Nurse or Medical Provider.-History of Pain & Treatment-Ask the Resident to Rate the Intensity of his/her Pain using a numerical scale, Verbal or Visual Descriptor that is appropriate and preferred by the Resident.-Reviewing the Resident's Current Medical Conditions (e.g., pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, CVA, venous and arterial ulcers, and multiple sclerosis).-Identifying Key Characteristics of Pain: Duration Frequency Location Timing Pattern (e.g., constant, or intermittent) Radiation-Obtaining Descriptors of Pain (e.g., stabbing, aching, pressure, spasms).-Identifying activities, Resident care or treatment that precipitate or exacerbate Pain and those that reduce or eliminate Pain.-Impact of Pain on Activities of Daily Living (e.g., sleeping, social activities, physical activity and mobility, emotions, intimacy, appetite, and mood, etc.). Current Prescribed Pain medications, Dosage, Frequency, Treatments, and Modalities. Pain Management and Treatment: Based on the Evaluation, Nursing in collaboration with the Physician/Prescriber, other Health Care Professionals, the Resident and/or the Resident's Representative will Develop, Implement, Monitor, and Revise as necessary intervention's to Prevent/manage Resident's Pain beginning at Admission.-The Interventions for Pain Management will be incorporated into the components of the Comprehensive Care Plan, addressing medical conditions that may be associated with Pain Management Goal.The Interdisciplinary Team, the Resident and/or the Resident's Representative will collaborate and discuss realistic, and measurable goals for Treatment.-Pharmacological interventions will follow a systematic approach for selecting Medications/Doses to Manage Pain. The Practitioner and IDT Team is responsible for developing a Pain Management Regimen that is specific to each Resident who has Pain/Potential for Pain. General Principles for Analgesics: Evaluate the Resident's medical condition, current medication regimen, cause and severity of the Pain and course of Illness to determine the most appropriate Analgesic for Pain Therapy.-Consider evidence-based practice tools to assist in the Evaluation of the Resident's Pain.-Consider Administering Medication Routinely instead of PRN or combining longer acting medications with PRN Medications for breakthrough Pain.-Utilize the most effective and least invasive route for Analgesic Administration (e.g., oral, rectal, topical, injection, infusion pump and/or transdermal).-Use lower doses of Medication initially and titrate slowly upward until comfort is achieved.-Reassess and adjust the Medication Dose to optimize the Resident's Pain relief while monitoring the effectiveness of the Medication and work to minimize or manage side effects.-Review Medical Conditions which may require several Analgesics and/or adjuvant medications; Documentation will clarify the rationale for a Treatment Regimen and acknowledge associated risks.-Opioids will be Prescribed and Dosed in accordance with current professional standards of practice and manufacturers guidelines to optimize their effectiveness and minimize their adverse consequences.-Nursing will Notify Practitioner if the Resident's Pain is not controlled by the current Treatment Regimen.-Referral to a Pain Management Clinic for other Interventions that need to be Administered under the close supervision of Pain Management Specialists will be considered for Residents with Advanced, Complex, or poorly controlled Pain.Monitoring, Reevaluation, & Care Plan Revision: Nursing will reassess Resident's Pain Management for effectiveness and/or adverse consequences (e.g., constipation, sedation, anorexia, change in mental status, delirium, respiratory depression, pruritus, nausea, vomiting, addiction and falling or drowsiness) at established intervals.-If Re-Evaluation findings indicate Pain is not adequately controlled, the Pain Management Regimen and Plan of Care will be revised as indicated.-If Pain has resolved or there is no longer an indication for Pain Medication, the Interdisciplinary Team will work to discontinue or taper Analgesics (as needed to prevent withdrawal symptoms). Review of the Resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/4/26, showed:-No cognitive impairment;-Diagnoses include multiple sclerosis (MS, a disease in which one's immune system attacks the protective barrier of nerves), left tibia (shinbone) fracture, depression, post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event), seizures, and asthma. Review of the resident's care plan, dated 8/27/25, showed:-Goal: Resident has a history of pain related to neuropathy, bilateral lower extremity pain, right ankle pain with edema noted;-Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date;-Interventions: Administer analgesia (pain relief) as per orders, Identify and record previous pain history and management of that pain and impact on function, monitor/record/report to nurse resident complaints of pain or requests of pain treatment, notify physician if interventions are unsuccessful or if current complaint is significant change from residents past experience of pain, encourage resident to try different pain relieving methods. Review of the resident's Pain assessment dated , 2/28/26 showed:-Current Pain Level: No pain-Effects of Pain on Activities of Daily Living (ADLs):-Sleep and Rest: Yes;-Social Activities: Yes;-Appetite: Yes;-Physical Activity and Mobility: Yes;-Emotions: Yes;-Intimacy: No.Medications/Treatments/Modalities:Describe all methos of alleviating pain and their effectiveness: Voiced no complaints of pain/discomfort.Comments: Continue to monitor. Review of the resident's electronic Physician Order Sheet (ePOS), showed:-An order, dated 11/19/25, Oxycodone Oral Tablet 5 milligram (mg). Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Review of the resident's March Medication Administration Record (MAR), showed:-Oxycodone 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Scheduled: 0000, 0400, 0800, 1200, 1600, and 2000.-Medication shown as given on 3/1/26 at 0000 and 0400. -Medication shown as not administered (NA) see nurses note:-3/1/26 0800, 1200, 1600, 2000;-3/2/26 0000, 0400, 0800, 1200, 1600, 2000;-3/3/26 0000, 0400, 0800, 1200, 1600, 2000;-3/4/26 0000, 0400, 0800, 1200, 1600, 2000;-3/5/26 0000, 0400, 0800. Review of the resident's medical record, showed:-A progress note, dated 3/1/26 at 20:55, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Medication needs prescription.- A progress note, dated 3/1/26 at 20:56, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Medication needs new prescription.- A progress note, dated 3/1/26 at 21:54, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Not in stock. -A progress note, dated 3/1/26 at 23:09, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Not in stock.-A provider note by the Nurse Practitioner (NP), dated 3/2/26, The Assistant Director of Nursing (ADON) was advised that the resident was concerned about her pain medication as the nurse told her she did not have it only Tylenol and that the script had been sent in, but the nurse cannot pull it. The staff report no other concerns at this time.-A progress note, dated 3/2/26 at 05:50, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Med not in stock.-A progress note, dated 3/2/26 at 11:12, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Medication not available due to new pharmacy change 3/2/26.-A progress note, dated 3/2/26 at 14:01, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Pharmacy change occurring unable to give medication awaiting new scripts.-A progress note, dated 3/2/26 at 17:23, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Pharmacy change requiring new e-prescriber scripts to be sent to new pharmacy awaiting medication. -A progress note, dated 3/3/26 at 09:03, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Resident pain medication not available awaiting medication from new pharmacy.-A progress note, dated 3/3/26 at 11:50, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Pharmacy change awaiting medication from pharmacy.-A progress note, dated 3/3/26 at 16:31, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Facility changed pharmacy awaiting medication to facility.-A progress note, dated 3/3/26 at 20:14, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. awaiting medication to facility.-A progress note, dated 3/4/26 at 09:07, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Not available.-A progress note, dated 3/4/26 at 11:24, Oxycodone Oral Tablet 5 mg. Give 2 tablet by mouth every 4 hours for pain related to left tibia fracture. Not available. An observation and interview on 3/4/26 at 11:40 A.M., showed the resident in his/her room. The resident sat in his/her wheelchair and had boot to his/her left foot. The resident reported he/she has been out of pain pill Oxycodone for several days since the facility switched pharmacies. He/She is hurting without his/her pain pill because of the broken foot. An observation and interview on 3/5/26 9:30 A.M., showed the resident in the main hallway. The resident sat in his/her wheelchair, crying. The resident was not wearing his/her boot. The resident stated he/she is just overwhelmed and in a lot of pain. He/She just wanted to go outside to get some fresh air and was told to wait due to the rain. He/She asked for pain medication overnight and was given anxiety medication. During an interview on 3/5/26 at 9:45 A.M., Certified Medication Technician (CMT) J said he/she has been giving the resident Tylenol as needed. They just switched pharmacy, so they are trying to get the resident's oxycodone approved. They switched Monday and have been working on it. The resident does not seem like he/she is in pain. He/She just asked for anxiety medication not pain medication. During an interview on 3/5/26 at 9:48 A.M., Licensed Practical Nurse (LPN) K said they just got a new pharmacy. Oxycodone is not in new system. The resident does seem like he/she is in pain. The resident gets pain medication scheduled several times a day every day. LPN K was not sure how long he/she has been out. They switched pharmacy on Friday. The resident asked for anxiety medication and then had to give Tylenol for headache. During an interview on 3/5/26 at 9:50 A.M., The Administrator said the resident or any resident should not be out of pain medications for 4 days. She would expect staff to notify the Administrator, supervisor, DON and ADON to get the medication at the facility. During an interview on 3/5/26 at 10:00 A.M., the Registered Nurse Consultant (RNC) said they started with the new pharmacy officially on Monday after the pharmacy brought some medications on Friday to start the process. Stock medications should be in pyxus (an automatic medication dispensing system) . If someone is out of pain medication, staff had to call to get the medication or a different medication for pain relief. The RNC would expect to wait less than 24 hours to receive pain medication once requested. The prescription for the resident's pain medication was received yesterday. The RNC verified 3/4/25 was the date the pharmacy received the new prescription which is also the day the RNC reports she was made aware of the issue to get it fixed. For pain medications, the facility had to have a valid script to have in e-kit for pain medications. The RNC said if the resident has been out since 3/1/26 that is four days and was not acceptable. Due to signature issue, they had to have a brand new prescription, but it is not ok for the resident to have to wait all week. The medication is supposed to arrive today. During an interview on 3/5/26 at 10:57 A.M., ADON B said he/she was aware the resident was out of ordered Oxycodone. The medications have been getting transferred from the pharmacy. ADON B said he/she has been working on getting the resident's medication since Sunday, but could not pull the medications from the Pyxis.

Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 39 residents (Resident #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41 and #42). The facility census was 160.1. Record review of the facility-maintained Accounts Receivable (A/R) Aging Report, dated [DATE], showed the following residents with personal funds held in the facility operating account. Review showed Resident #42's name did not show on the A/R Report due to the facility refunding $1,834.00 on [DATE], four days prior to running the Accounts Receivable Report on [DATE]. Resident - Amount Held in Operating Account#1 $40.80 #2 $197.00#3 $4,940.38#5 $1,099.00#6 $1,114.80#7 $50.00#8 $253.09#9 $1,888.00#10 $5.47#11 $174.00#12 $2.00#14 $1,646.62#15 $165.53#16 $1.08#17 $654.38#18 $92.00#19 $5.10#20 $1,917.01#21 $917.00#22 $698.06#23 $912.20#24 $123.41#25 $50.00#26 $2,974.90#27 $37.52#28 $391.00#29 $23.94#31 $153.00#32 $90.08#33 $701.00#34 $11,395.00#35 $191.00#36 $1,464.00#37 $72.00#38 $25.00#39 $1,578.04#40 $137.55#41 $1,143.21#42 $1,834.00Total $39,158.17 Record review of the facility maintained paperwork showed the facility processed paperwork to generate check #16339, dated [DATE] in the amount of $1,834.00, made payable to Resident #42.Record review of the facility-maintained paperwork showed the facility did not provide the Personal Fund Account Balance Report for expired Resident #5, #7, #8, #11, #15, #16, #17, #18, #19, #23, #25, #27, #28, #29, #36, #37, #38, #40 and #41 to the Missouri HealthNet Division Third Party Liability Unit until [DATE], one day after the department started a case managed investigation.During an interview on [DATE] at 1:43 P.M., the Business Office Manager (BOM) said Resident #42 had a credit balance in the amount of $1,834.00 as a result from the resident paying for 07/2025 and 08/2025 and should not have. The credit balance was brought to the BOM's attention on [DATE], but he/she had not looked into the refund. He/She said the previous BOM left on [DATE] and did not process the resident's refund. During email correspondence dated [DATE] at 1:23 P.M., the BOM said the refund requests were sent to home office for Resident #1, #2, #3, #6, #10, #14, #20, #21, #24, #26, #31, #32, #33, #34 and #39.During an interview on [DATE] at 2:51 P.M., the BOM said he/she was working with corporate to verify why Resident #9, #12, #22 and #35 had bad debt write-offs instead of receiving refunds.2787398

Based on observation, interview, and record review, the facility failed to follow acceptable nursing practice when facility staff left a pain medication in one resident's room at the bedside (Resident #7). The resident had not been assessed safe to self-administer medications. The medication was the resident's Morphine Sulfate Extended Release (Schedule Class II Opioid pain medication). During a skin assessment observation for the same resident, a white tablet identified as Oxycontin (Schedule Class II Opioid pain medication) was found under the resident, in his/her bed. The resident did not have a physician order for Oxycontin 10 mg. The sample was 14. The census was 160.Review of the facility's Oral Medication Administration Policy, dated 12/2017, included:-Purpose: To administer oral medications in a safe accurate, and effective manner.-Review and confirm medication orders for each individual resident on the Medication Administration Record prior to administering medications to each resident. Discuss with resident and determine if there is a need for any as needed medication such as for pain.-Administer medication and remain with the resident while medication is swallowed. Caution with residents who have difficulty swallowing. Do not leave medications at bedside, unless specifically ordered by prescriber. Review of the facility's Controlled Substance policy, dated 12/2017, showed:-Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.-Procedures: All controlled substances are stored and maintained in a locked cabinet or compartment. Review of Resident #7's medical record, showed:-admission date 11/3/25;-Diagnoses include depression, diabetes, right above knee amputation, and paraplegia (lower body paralysis);-No order or assessment to self-administer medications. Review of the resident's electronic physician order sheets (ePOS), showed:-An order dated 1/24/26, for Morphine Sulfate Extended Release (ER) 60 milligram (mg). Give 1 capsule by mouth every 12 hours for osteoarthritis.-No order for Oxycontin 10 mg. Review of the resident's February 2026 medication administrator record, showed Morphine Sulfate ER 60 MG (Morphine Sulfate). Give 1 capsule by mouth every 12 hours for osteoarthritis. Scheduled for 9:00 A.M. and 9:00 P.M. Last dose given 2/19/25 9:00 A.M. dose. Observation on 2/19/26 at 9:45 A.M., showed the resident lay in bed with no staff present in the room. On the bedside table, a medication cup with a round brown pill sat next to a small cup of water. The resident said that was his/her medication. The resident picked up the medication cup and swallowed the pill. During an interview on 2/19/26 at 9:55 A.M., Licensed Practical Nurse (LPN) A said he/she does not know why there would be medication at bedside. He/She gave the resident their morphine earlier this morning and the resident took the medication. The resident must of spit it back out. During an interview on 2/19/26 at 10:00 A.M., Certified Medication Technician (CMT) B said he/she has not given Resident #7 his/her medications yet this morning. CMT B is not sure what medication that the resident just took but must have been from the nurse. The resident medications should not be left in the room. Nursing should stand there and watch them take their medications. Observation on 2/19/26 at approximately 11:15 A.M., showed Assistant Director of Nursing (ADON) C entered the resident's room to complete a skin assessment. ADON C rolled the resident to his/her left side. Under the resident was a small round white pill. ADON C said that it must be his/her morphine and put the pill on the bedside table. He/She completed the skin assessment and then left the room with the white pill. Observation and interview on 2/19/26 at 11:30 A.M., showed ADON C at the nurse medication cart. ADON C crushed the medication found under the resident and disposed of it. ADON C opened the medication cart and the narcotic box. He/She said that medication was not Morphine but Oxycontin. Further observation in the medication narcotic box showed the resident was not prescribed Oxycontin. ADON C is not sure how the medication would have been in the resident's bed. Another resident on the unit has a card of Oxycontin located in the narcotic box. The resident's morphine was a small brown pill that matched the medication he/she had at his/her bedside earlier that morning. ADON C said a nurse may have pulled both medications at the same time and then gave Resident #7 the wrong medication. During an interview on 2/19/26 at 12:45 P.M., the Director of Nursing (DON) and Administrator said they would expect the nurse to check the resident's mouth if they believe the resident is known for spitting out medications or pocketing them in their mouth. They would not expect any controlled medications to be in the resident's bed or the resident to have any medications not prescribed to him/her. During an interview on 2/19/26 at 2:05 P.M., ADON D said nurses should sign out narcotic medications as they are pulled. Nursing staff should make sure residents take the medication before they leave the room. Resident #7 is not known to pocket or spit out medications. 2737849

Based on observation, interview and record review, the facility failed to ensure all residents were treated in a dignified manner when staff did not offer a resident (Resident #2) a chance to leave his/her room after his/her roommate (Resident #3) expired at approximately 1:47 A.M. The resident was left in his/her room with the roommate for almost four hours until the funeral home picked up the roommate's remains at approximately 5:09 A.M. The sample was 9. The census was 165. Review of Resident #3's medical record, showed:-A progress note dated [DATE] at 1:47 A.M., Emergency Medical Services (EMS) calls the code and gives a time (of death) 1:47 A.M. EMS departs from the facility;-A progress note, dated [DATE] at 5:09 A.M., funeral home here for the departure. Review of Resident #2's medical record, showed:-Cognitively intact;-Diagnoses include quadriplegia (paralysis of all 4 limbs), malnutrition, diabetes, and general muscle weakness. During an interview on [DATE] at 3:47 P.M., the Administrator said staff should have taken Resident #2 to an empty room after Resident #3 passed. Observation and interview on [DATE] at 10:00 A.M., showed Resident #2 lay in bed. The resident was located in the bed furthest from the door. The resident said the night/morning after Resident #3 died, the staff closed the privacy curtain between his/her bed and his/her roommate and left the room. The resident thinks they closed the room door too. The resident said his/her roommate was over there for a while after he/she died. No one came in and asked him/her if he/she wanted to leave the room or if he/she was ok. Resident #2 said he/she did not like that. It made him/her really upset and uncomfortable, especially since he/she just lost his/her son recently. During an interview on [DATE] at 10:33 A.M., Licensed Practical Nurse (LPN) H said if a resident's roommate passes, he/she would ask the roommate to come out of the room or at least offer them the option to come out of room. He/She would expect any nurse or aide to offer that. During an interview on [DATE] at 10:45 A.M., Certified Nursing Assistant (CNA) I said if a resident passes away, staff will take the roommate out of the room. Especially if family comes to visit the resident that passed away. He/She is not sure what happened when Resident #3 died. During an interview on [DATE] at approximately 3:30 P.M., the Administrator and Director of Nursing (DON) said they would expect staff to ask resident's roommate to leave the room after the roommate passed away. The DON said it is not dignified to leave them in the room or to have the family see the deceased loved one with the roommate still in the room. 2719769

Based on interview and record review, the facility failed to ensure services provided met professional standards when staff failed to obtain a repeat weight as requested by the dietician for one resident (Residents #9) after the resident was noted to have significant weight loss. The facility also failed to ensure requested labs from an outside provider were completed and followed up on timely for one resident (Resident #4). The sample was 9. The census was 165.1.Review of Resident #9's medical record, showed diagnoses include diabetes, aphasia (difficulty communicating), dysphagia (difficulty swallowing), dementia, and delusional disorder. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: Resident has nutritional problem or potential nutritional problem related to multiple comorbidities and age/diagnosis process;-Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight within 5-10% of usual weight no signs/symptoms of malnutrition, and consuming at least 75% of at least 2-3 meals daily through review date;-Interventions: Monitor/document/report as needed any signs/symptoms of dysphagia, registered dietician to evaluate and make diet change recommendations as needed. Review of the resident's Weight Summary, showed:-On 11/10/25, 192.5 pounds (lbs);-On 12/6/25, 187.2 lbs;-On 1/5/26, 166.2 lbs;-No further weighs documented. Review of the resident's Registered Dietician progress note, dated 1/9/26 at 11:48 A.M., showed WEIGHT WARNING: Value: 166.2 lbs. Requesting reweight. During an interview on 1/22/26 at 12:18 P.M., Certified Nursing Assistant (CNA) C said he/she is the restorative aide and responsible for obtaining and documenting the weights. The dietician reviews them and sends an email to the Administrator, Director of Nursing (DON), Dietary Manager, and Assistant Director of Nursing (ADON) if the dietician wants anyone reweighed. The ADON will then email CNA C to inform him/her. He/She was supposed to reweigh the resident and thought he/she had reweighed him/her. The resident was on his/her list. He/She will go ahead and reweigh the resident now since he/she cannot find the weight. Observation on 1/22/26 at 12:30 P.M., showed the resident's weight measured 163.7 lbs. During an interview on 1/22/26 at approximately 3:30 P.M., the Administrator and DON said if the dietician requests a weight be repeated, they would expect that to be completed and documented within 24-48 hours of the request. The reweights are communication from the dietician through risk management or emails. The dietary supervisor or ADON are responsible to share the information with the restorative aide. 2. Review of #4's medical record, showed:-Diagnoses include liver cancer, generalized muscle weakness, and Alzheimer's disease;-An order, dated 1/2/26 and marked as complete on 1/6/26, Complete Blood Count (CBC, blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets)/Comprehensive Metabolic Panel (CMP, checks liver and kidney function). May discontinue after results have been faxed. Review of the resident's progress notes, showed:-On 1/6/26 at 5:29 P.M., contacted oncologist office listed on appointment sheet. Transferred to voicemail, informed that labs were drawn and pending. Left callback number for any further questions. Will fax final labs per request if received prior to appt on 1/7/26.-On 1/07/26 at 9:10 A.M., this nurse called to follow up with oncologist office regarding lab work. Spoke with the Nurse Coordinator, informed CBC and CMP drawn but still pending, was unsure if lab work needed for appointment this morning.Review of the resident's lab results report, received date 1/6/26 at 11:26 A.M. and reported 1/7/26 at 11:48 A.M., show: CMP hemolyzed (a blood sample has been rejected because red blood cells burst, releasing hemoglobin into the liquid portion (serum/plasma) and rendering it pink/red, often making test results inaccurate). Call to reschedule. During an interview on 1/22/26 at 11:45 A.M., ADON L said the resident's lab results are done by an outside provider so that is why they are not in the computer. The resident needed a CBC and CMP. During an interview on 1/22/26 at 1:01 P.M., the social worker at the oncology office said after the resident's appointment in December, the office sent orders with the resident and the CNA who accompanied the resident. The nurse at the office also called and faxed the orders. The resident was last seen in the office on 12/18/25 and labs were ordered to be completed between Christmas and New Year. The resident was supposed to have an appointment on 1/7/26. The appointment was cancelled by the facility for transportation issues. The labs requested were not completed until 1/15/26 and they were drawn at their office. They never received any results from the facility and were not aware of any concerns with the specimen being hemolyzed. During an interview on 1/22/26 at approximately 3:30 P.M., the Administrator and DON said they would expect staff to follow up on lab results that were hemolyzed or not completed. The labs should have been redrawn prior to the office having to complete them on 1/15/26. They would also expect any new orders or appointments to be entered in the medical record when a resident returns from an outside provider appointment. 27161722717219

Based on observation, interview and record review, the facility failed to ensure staff followed their Enhanced Barrier Precautions (EBP) policy when a staff member assisting with wound care did not wear an item of personal protective equipment (PPE), which was the gown, for one resident (Resident #5). Further review of the medical record, showed the resident was not ordered to be on EBP Precautions despite multiple open areas. The sample was 9. The census was 165. Review of the facility's Enhanced Barrier Precautions policy, last reviewed 5/15/24, showed:-Policy: The facility may expand the use of PPE and refer to the use of gowns and gloves during high-contact care activities that provides opportunities for transfer of multi-drug resistant organisms (MDROs) to hands/clothing. The use of gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for facility residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection/colonization.-Responsibility: Direct Care Employees, Housekeeping/Laundry, Nursing Administration, & Director of Nursing (DON).-Procedure: Examples of High-Contact Resident Care Activities requiring Gown & Glove Use for EBP included: Dressing; Bathing/Showering; Providing Hygiene; Changing Linens; Changing Briefs or Toileting; Wound Care: Skin Opening requiring a Dressing.-Steps:--Post signage on the door/wall outside of the resident' s room indicating the use of Enhanced Barrier Precautions;--Post signage in the resident room with information on use of Enhanced Barrier Precautions & required PPE (e.g., Gown & Gloves). Enhanced Barrier Precautions signage should include information on high contact resident care activities that require the use of gown and gloves;--PPE should be available inside of the resident' s room. Review of the resident's medical record showed diagnoses include hemiplegia (weakness on one side of the body) following stroke left side and high blood pressure. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus (initiated 12/24/25): Resident has pressure ulcer (wound caused by prolonged pressure or shearing) to sacrum (tailbone area) related to immobility and episodes of bowel and bladder;-Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date;-Interventions: Administer treatments as ordered and monitor for effectiveness, Follow facility policies/protocol for the treatment/prevention of skin breakdown.-The resident's care plan has no mention EBP precautions for the resident. Review of the resident's electronic physician order sheet (ePOS) and January 2026 Treatment Administration Record (TAR), showed no order for EBP precautions. Observation on 1/22/26 at 10:10 A.M., showed Licensed Practical Nurse (LPN) A and LPN B at the treatment cart outside of the resident's room. LPN A gathered wound care supplies, entered the resident's room, and set the items on a disposable pad placed on the resident's bedside table. LPN A and LPN B wash their hands. LPN B placed on gloves and stood at the resident's bedside. LPN A placed on gloves and a gown from a shelf that hung on the resident's door. LPN A placed an extra gown on the bed and pointed to LPN B. LPN B did not put on the gown. Both staff assisted to roll the resident to his/her left hip to expose a large, open wound to the buttocks area. The extra gown fell off the bed and onto the floor. LPN A removed the old dressing and cleansed the wound. LPN A removes his/her gloves, used hand sanitizer and placed on new gloves. LPN B stood across on the other side of the bed and held the resident's hips to keep the resident on his/her side and stable. LPN A placed the ordered treatment to the wound. LPN A cleaned up the trash, removed his/her gown and gloves and washed his/her hands. He/She removed the trash from the room. LPN B assisted the resident to be positioned on his/her right side and then exited the room. During an interview on 1/22/25 at approximately 3:30 P.M., the DON and Administrator said they would expect staff to follow their policy. They would also expect both nurses to wear appropriate PPE for EBP. 2719769

Based on observation, interview and record review, the facility failed to ensure medical records containing protected health information (PHI) were not accessible to individuals who do not have the right to view the protected health information, for one resident (Resident #23) when staff provided an after-visit summary for Resident #23 to the family of a different resident. The facility census was 159.Review of the Know Your Rights statement, posted at the front entrance of the facility showed resident rights included confidentiality. Medical, personal, social or financial affairs should be considered privileged information. During an interview on 12/31/25 at 1:30 P.M., the family member for Resident #10 said a couple weeks ago on December 17th, the resident's nurse handed him/her the after-visit summary for Resident #23. The family member told the staff person about the mistake, and the staff person told the family member that he/she did not care and did not want the paperwork back and the family member could do whatever he/she wanted to with the documents. The family member still has the after-visit summary for Resident #23's doctor visit that includes the resident's name, date of birth , and follow-up testing that was recommended and he/she would provide a copy to the surveyor. Review of the record provide by Resident #10's family member, showed an after-visit summary dated December (the rest of the date not legible). Only the front page of a multi-page record was provided. The front page of the record included the resident's full name, medical record number, date of birth , referrals for an MRI of the spine and the pain clinic, and results of an x-tray completed during the visit. Review of Resident #23's medical record, showed no after-visit summary dated December matching the record sent, available in his/her medical record. During an interview on 12/31/25 at 3:40 P.M., the Administrator and Director of Nursing (DON) said only the residents, their guardian, and power of attorney (POA) should have access to a resident's medical record. The Administrator said if staff find out they accidentally gave someone's medical records to the wrong family member she would expect them to take the paperwork back. Management then must notify the legal team and notify the family. 2697454

Based on observation, interview and record review, the facility failed to provide a homelike environment for two residents sampled (Resident #10 and Resident #12) by not keeping Resident #10's room swept daily and having a bedside table with screws sticking out of the table. The facility staff also left two plates stacked by the air conditioning unit in Resident #12's room over a period of two days. The plates had dried food on them. In addition, the facility failed to ensure a sufficient number of plates were available to provide a homelike environment, providing Styrofoam plates in place of dining plates (Residents #6 and #7). The facility census was 159.Review of the facility's Resident's Rights Policy, last reviewed 4/26/23, showed the facility shall treat Residents with kindness, respect, and dignity and ensure Resident Rights are being followed:-Upon admission to the Facility the Resident and/or Resident Representative will be informed of the residents' bill of rights. Resident/Resident representative will sign the residents' bill of rights acknowledgement;-A copy of the residents' bill of rights will be posted in the facility; Area visible to residents and families;-Employees will receive education and training on resident rights upon hire and annually.-The Administrator/Designee will process concerns with resident rights. Review of the Know Your Rights statement, posted at the front entrance of the facility showed resident rights included be treated with consideration and respect, with full recognition of dignity and individuality. 1. Review of Resident #10's medical record, showed:-Moderate cognitive impairment;-Diagnoses include stroke, aphasia (inability to understand or express speech), hemiplegia (paralysis on one side of the body), and schizophrenia. Observation on 12/30/25 at 10:45 A.M., showed the resident lay in bed asleep. The resident's call light on the floor near the top of his/her bed. The resident's bedside table had two screws sticking up out of the table. There was trash on the floor under his/her bedside table and trash along the wall to the resident's right side. On 12/31/25 at 11:42 A.M., the resident's room was in the same condition as the previous day. Observation on 12/31/25 at 3:11 P.M., showed the resident lay in bed asleep. The resident's room was cleaned with no trash on the floor. The bedside table still had two screws sticking out the top. During an interview on 12/31/25 at 3:15 P.M., Floor Tech B said the floor techs are responsible for the main area and hallways in the facility. The housekeeping staff should be sweeping rooms daily as well as cleaning resident rooms daily. During an interview on 12/31/25 at 3:20 P.M., the Housekeeping Supervisor said screws on bedside table are not homelike. The resident has an older bedside table that is not used anymore. 2. Review of Resident #12's medical record, showed:-Cognitively intact;-Diagnoses include diabetes, high blood pressure, and hemiplegia. Observation on 12/30/25 at 11:35 A.M., showed staff in the resident's room to provide wound care. The resident has two dirty plates on the air conditioning unit. The top plate has dried food and dried ketchup on the plate. During an interview on 12/30/25 at 11:45 A.M., the resident said the plates were from meals served the previous day. Observation on 12/31/25 at 11:50 A.M., showed the resident in his/her room. The two plates remained in the same location. The resident also had an untouched Styrofoam plate wrapped on his/her bedside nightstand. The resident says that it is from the night before and was brought cold when it was supposed to be warm. During an interview on 12/31/25 at 3:20 P.M., the Housekeeping Supervisor said she expects staff to clean rooms every day. If plates are in the room, she expected her staff to take them or tell nursing. Trash should be taken in the morning and then she expected staff to go back and check room before they left. They have been shorthanded lately. They only had one staff person for the 100-hall yesterday. 3. Review of Resident #6's medical record, showed:-Diagnoses included high blood pressure, vitamin D deficiency, and muscle weakness;-A care plan, in use at the time of the investigation, showed: The resident has nutritional problems or potential nutritional problems related to food choice. Interventions included dietician will meet with the resident twice a day and discuss resident's likes and dislikes. During an interview on 12/30/25 at 2:02 P.M., the resident said staff have been serving on Styrofoam for a long time. They do not have enough plates. They will come and get residents' plates before we are done eating so they can wash them for the next meal. Half of the time he/she does not even eat the food because it is cold and it sweats because of the plastic wrap. He/She usually must ask staff to microwave it. He/She keeps his/her own peanut butter and jelly so he/she can make a sandwich. Observation at this time, showed the resident had a Styrofoam plate wrapped in plastic wrap sitting on his/her bed. The plate contained a taco, refried beans and corn. Review of Resident #7's medical record, showed:-Diagnoses included high blood pressure, diabetes, gastric ulcer, and muscle weakness;-A care plan, in use at the time of the investigation, showed: The resident has diabetes and is at risk for abnormal blood sugar. Interventions included encourage resident to practice good general health practices, compliance with dietary restrictions. During an interview on 12/30/25 At 1:40 P.N., the resident said the food is terrible. He/She is not sure what is going on in the kitchen. The facility needs more money to spend on dietary. Observation at 1:57 P.M., showed staff brought lunch to the resident on a Styrofoam plate. Staff served a taco, refried beans, and corn. The plate was wrapped in plastic wrap. The resident touched it and said it is cold and the taco shell is soggy from being wrapped in plastic. He cannot eat that stuff. Staff always serve their food on Styrofoam, unless residents eat in the main dining room. Staff have been serving food this way for months. He/She does not like Styrofoam, he/she is not a kid. Plus, plates would help keep the food warm and would be easier to eat off of. Observation on 12/31/25 At 9:07 A.M., in the main dining room, showed meal service in progress, staff serve meals from the steam table on Styrofoam plates, wrap them in plastic, and placed them on carts to be sent to the halls. The Dietary Manager (DM) said they are using Styrofoam plates because they ran out of regular plates, that is what they must do. They do not have enough plates. Observation on 12/31/25 at 12:06 P.M., showed dietary staff prepped lunch and set up the steam table. Tour of the kitchen and dining room service station showed approximately 60 plates available and a large stack of Styrofoam plates. No dirty plates were in the dish washing area in the kitchen or other plates in storage. At 12:13 P.M., a dietary aide (DA) who stood at the steam table and served food said this is all the plates they have. They order them and then they go missing. It has been about 2 months since more plates were ordered, and they are already gone. Staff serve on regular plates until they run out. Observation at this time showed dietary staff serving food to residents in the main dining room on regular plates. At 12:34 P.M., all residents in the main dining room were served lunch. Dietary staff began to serve trays for the 100-hall. The DM came in and asked one of the dietary staff to search the hall for plates. At 12:38 P.M., approximately halfway through the 100-hall cart, dietary staff ran out of plates and switched to Styrofoam. At 12:45 P.M., a dietary staff person who had left to search for plates returned from the halls with 4 regular plates and one divided plate. He/She took them to the dishwasher. At 12:48 P.M., staff finished the 100 hall trays and started to serve the 200-hall trays on Styrofoam. At 12:58 P.M., the plates that were washed were placed on the back serving station. Dietary staff prepared the 300 and 400 hall trays. The four regular plates that were located and washed were used for the 300/400-hall cart, then the rest of the meals were served on Styrofoam. During an interview on 12/31/25 at 2:25 P.M., the Administrator provided an invoice for plates that were ordered recently and said she is looking for the prior order because she just started in November and cannot locate the last time plates were ordered by the prior administrator. Review of the invoice, dated 12/30/25, showed two cases of 12 plates ordered, to equal 24 plates. During an interview on 12/31/25 at 3:40 P.M., the Administrator and Director of Nursing said residents should be provided with a homelike environment. This includes a homelike dining service. They would expect there to be enough dishes so each resident could eat off real plates instead of Styrofoam.26865782699782

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, when the narcotic count sheet for one resident was lost, resulting in 30 narcotic pain pills with no reconciliation (Resident #12). The census was 159. Review of the Controlled Substance Storage Policy, revised 03/2017, showed:-Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.-Procedures:-The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances.-A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule 11, III, IV, and V medications, including those in the emergency supply. Review of Resident #12 medical record, showed:-Diagnoses included opioid dependence with opioid-induced mood disorder, sleep apnea, and hemiplegia left sided (weakness on one side of the body);-An order dated 9/18/25, for Oxycodone (narcotic pain medication) 20 milligram (mg). Give 1 tablet by mouth every 6 hours for pain. Review of the resident's December 2025, medication administration record (MAR), showed staff documented the administration of Oxycodone 20 mg:-At 12:00 A.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 6:00 A.M. on 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 12:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25 ;-At 6:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, and 12/22/25. During an interview on 12/31/25 at 2:15 P.M., the Pharmacy Technician said on 12/15/25, the pharmacy sent the resident's 30-day supply, 120 tablets of Oxycodone 20 mg divided on four cards of 30 tablets each and their records show it was received by the facility on 12/15/25. Review of the resident's Controlled Substance and Narcotic Sheets, on 12/31/25 at 2:30 P.M., showed three of the four sheets with accurate reconciliation of medication given. One Oxycodone 20 mg 30 tablet count sheet unavailable for review with no reconciliation for the tablets administered:-At 12:00 A.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 6:00 A.M. on 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 12:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25 ;-At 6:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, and 12/22/25.During an interview on 12/31/25 at 2:30 P.M., Licensed Practical Nurse (LPN) A said narcotic medications are signed in when they are delivered from the pharmacy. The resident receives four cards of Oxycodone 20 mg. Each card is accounted for on the Controlled Substance Sheet. Reconciliation is completed at the beginning and end of each shift and any discrepancies are reported to the Director of Nursing (DON). LPN A does not recall any recent discrepancies and has not had any residents report not receiving their pain medication. During an interview on 12/31/25 at 2:40 P.M., the DON said she cannot find that narcotic sheet that is missing. The narcotic sheets should all be accounted for and she expects staff to sign out any controlled medication administered as well document the administration of the medication on the MAR. During an interview on 12/31/25 at 3:40 P.M., the Administrator said there should there be an accurate reconciliation of narcotics.

Based on observation, interview and record review, the facility failed to provide care in a manner to prevent the risk of accidents and injury for one resident who was transferred without using a mechanical lift as ordered and according to the resident's plan of care (Resident #1). The census was 170. Review of the facility's Total Lift Transfer policy, dated 11/28/22, showed the facility will utilize a total lift device on residents who are unable to assist with transfers:-Full Body Lift: A lifting device used to provide safety of the resident/employees during transfers.-Procedure: Measure resident for appropriate sling size according to manufacturer. Position the sling under the resident with the base of the sling at the base of the resident's spine, top of the sling at the top of the head, cross straps prior to hooking the straps of the lift. Match the corresponding colors on each slide of the sling & observe that all sling loops are securely connected. Standing next to the Resident, press the up button on the lift controls to slowly raise the Lift to the height necessary to clear the surface. Standing next to resident use the down button on the lift control to slowly lower the resident to the desired surface, guide/steady as necessary. Detach the Sling from the lift ensuring the bar of the Lift does not touch Resident. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/19/25, showed moderately impaired cognition and dependent on all transfers - helper does all of the effort, resident does none to complete the activity. Review of the resident's electronic health record, showed:-An order dated 9/9/25, to use Hoyer Sling (a mechanical total lift device), appropriate with resident's weight size; use Hoyer lift for all transfers;-Diagnoses included hemiplegia and hemiparesis (weakness or paralysis on one side of the body), history of falling, unsteadiness of feet, dementia, and legal blindness. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Limited physical mobility;-Goal: Will remain free of complications related to immobility, including fall-related injury;-Interventions: Use Hoyer sling appropriate with resident's weight size, use Hoyer lift for all transfers. Does not walk. Observation on 11/5/25 at 11:43 A.M., showed Certified Nurse Assistants (CNAs) B and C transferred the resident, using a gait belt, from wheelchair to bed. CNA B leaned the resident forward while he/she sat on the wheelchair and placed the gait belt around the resident's waist. The wheelchair was positioned parallel to the bed, approximately one foot away from the edge of the bed. CNA B stood at the resident's left side while CNA C stood on the right side. The wheelchair was not locked. Both CNAs lifted the resident by holding onto the gait belt with one hand with their other hands pushing on the wheelchair's arm rest. CNA B instructed the resident to stand up. Both of the resident's knees were bent, did not straighten, and appeared contracted and he/she did not stand up. The resident's feet did not touch the floor while staff carried the resident by the gait belt from the wheelchair to the bed. The resident showed discomfort, moaning and yelling during the transfer. During an interview on 11/6/25 at 11:01 A.M., CNA J said at the start of the shift they receive a full report from the previous shift's staff of all the residents assigned to them, including transfer method. If he/she was not sure of the resident's care and transfer status, he/she would ask the nurse prior to transferring or providing care. Any orders should be followed, including transfer orders. During an interview on 11/6/25 at 11:15 A.M., Licensed Practical Nurse (LPN) A said CNAs received reports and complete a walk-through with the previous shift staff prior to starting their shift. Staff were expected to follow the transfer orders for the resident. Resident #1 was to be transferred using a Hoyer lift at all times. During an interview on 11/6/25 at 12:01 P.M., the interim Director of Nursing (DON) said CNAs received report from previous shift and from their nurse. They were expected to follow the resident's care plan and their Kardex (quick reference tool for a resident's care plan). The CNAs should not transfer the resident without using the Hoyer lift, as ordered, for resident's safety. During an interview on 11/6/25 at 2:46 P.M., the Administrator and the Regional Director of Operation said they expected the staff to follow the appropriate transfers for all residents as ordered and according to their care plan. 2657487

Based on interview and record review, the facility failed to ensure nursing staff working in the facility were licensed to practice in the state of Missouri, when a Licensed Practical Nurse (LPN) on duty, who obtained their nursing license in a different state was working as a LPN in the facility with no Missouri nurses license. This had the potential to affect all residents. The census was 170.Review of the facility's current Human Resources (HR) General Position Information, showed graduated practical nurses (GPN, an individual who had graduated from nursing school to work as an LPN but had not yet passed the nursing boards) may only work for maximum of 90 days following graduation date. Review of Nursys Quick Confirm License Verification Report (the national database for nurse licensure verification, discipline, and practice privileges, created and operated by the National Council of State Boards of Nursing), showed LPN D not listed as licensed in the state of Missouri. He/She was only licensed and authorized to practice in Illinois state, with license original issue date of 10/29/25. Review of LPN D's employee file, showed:-A Certificate of Completion in the Practical Nursing Program, program completed on 6/16/25;-LPN D started employment on 6/25/25 as a full-time LPN-GPN (Graduate Practical Nurse). Review of the facility's staffing schedule dated 10/1/25 through 11/6/25, showed the following dates LPN D was scheduled to work as a GPN or LPN: 10/5 through 10/7, 10/10, 10/14, 10/22, 10/24 through 10/26, 10/29 through 10/31, 11/3 and 11/4/25. During an interview on 11/5/25 at 3:24 P.M., LPN D said he/she was employed by the facility since June 2025 as a GPN. He/She passed the licensure examination a couple weeks ago and started working as an LPN at the facility right after that. He/She was providing care and administering medications to residents with tracheostomies (a hole surgically recreated in the airway for individuals who cannot breath through the mouth and nose), tube feedings, and administering insulin medications. He/She also provided wound care treatment to his/her assigned residents. He/She was rarely monitored or paired with an experienced nurse. During an interview on 11/6/25 at 12:01 P.M., the interim Director of Nursing (DON) said GPNs were expected to work with another nurse at all times. There should be oversight from a licensed nurse every day they work. HR was responsible for checking and reviewing the employees' credentials. The DON expected HR to follow-up the GPN's status. LPN D resigned on 11/5/25, due to the phone call and questions from the state surveyor. During an interview on 11/6/25 at 2:46 P.M., the Administrator and the Regional Director of Operation (RDO) said they were not aware that LPN D was not licensed in Missouri. The Administrator and the DON both started their employment on 11/3/25 and were not made aware of the situation. They expected the HR staff to make sure all employee credentials were checked and verified. The RDO said HR should track the 90-day mark of the GPNs. GPNs should be precepted or working with another nurse until officially licensed. During an interview on 11/7/25 at 9:55 A.M., Regional HR said he/she was not aware of LPN D's status. The facility had 2 HR personnel prior to him/her taking over the position temporarily. He/She expected the facility HR to verify the applicants background and if they were authorized to work in the state. He/She expected the facility HR to collect the school's transcript records, copy of the NCLEX (National Council Licensure Examination) registration and authorization to test with the date of testing. A GPN can work until licensed or for 90 days after graduation, whichever comes first. 2657062

Based on interview and record review, the facility failed to ensure staff implemented their Abuse Prevention Policy by not conducting a thorough investigation and report to the state survey agency as required, when two residents had a physical altercation (Residents #24 and #25). The sample was eight. The census was 171.Review of the facility's Abuse Prevention Policy, dated 10/21/22, showed the following:-Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual;-Definition: -Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident;-Investigation:-1. The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect and provide protection to any alleged victims to prevent harm during the continuance of the investigation;-2. The Administrator, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required. -Reporting:The facility will report any knowledge of actions by court of law against any employee, which would indicate unfitness for service as a nurse aide or other staff member to the [NAME] nurse's aide registry or licensing authorities; 2. Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, are reported immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency, and local law enforcement as required);3. Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident;4. Findings will be reviewed by the Interdisciplinary Team. -Implementation of this policy:-1. All staff and others who may have unsupervised access to residents will read and have maintained in their facility personnel file, this signed Abuse Prevention Policy. -2. The components of this Abuse Prevention Policy and Procedure, specific to prohibition of abuse, neglect, misappropriation, involuntary seclusion and misappropriation of property, the reporting requirements and investigative procedures shall be reviewed with each employee during orientation, and again no less than annually. -3. All residents/family members will be made aware of the prohibition of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of resident's property upon admission. -4. This subject and these items shall be reviewed no less than annually at resident council, family council, and general staff meeting. -5. All residents and family member will be interviewed during other times, for example, at care planning conferences to determine whether complaints or suspected events of abuse or neglect have been reported and investigated. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/8/25, showed the following:-Moderate cognitive impairment;-No behaviors;-Supervision with activities of daily living (ADLs);-Diagnoses of high blood pressure, dementia and anxiety disorder. Review of the resident's care plan, dated 10/16/25, showed the following:-Focus: Resident can be physically and verbally aggressive towards other residents;-Interventions: Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Review of the resident's nurse's notes, dated 10/16/25 at 6:00 P.M., showed nursing observations, evaluation, and recommendations were reported to the resident's physician and psych Nurse Practitioner (NP). The resident to be sent out to hospital emergency room for a psychiatric evaluation treatment and medication review. Review of the resident's nurse's notes, showed no additional documentation regarding the resident-to-resident altercation. During an interview on 10/29/25 at 9:57 A.M, the resident said he/she was fine but did not remember any altercation. Review of Resident #25's admission MDS, dated [DATE], showed the following:-No cognitive impairment;-No behaviors;-Supervision with ADLs;-Diagnoses of congestive heart failure, high blood pressure, diabetes and dementia. Review of the resident's care plan, dated 10/16/25, showed the following:-Focus: Resident can be physically and verbally aggressive towards residents;-Interventions: Document observed behavior and attempt interventions in behavior log. Send resident to hospital for evaluation. Review of the resident's nurse's note, dated 10/16/25 at 6:18 P.M., showed nursing observations, evaluation and recommendations are the resident's physician wants resident sent to hospital for psychiatric evaluation treatment and medication adjustment. Review of the resident's nurse's notes, showed no additional documentation regarding the resident-to-resident altercation. During an interview 10/29/25 at 10:01 A.M., the resident said he/she was fine and did not have any problems with any resident. During an interview on 10/29/25 at 9:59 A.M., Licensed Practical Nurse (LPN) C said he/she was not at the facility when the altercation happened, but Resident #24 had a mark under his/her right eye afterwards. During an interview on 10/22/25 at 8:53 A.M., Family Member E said the resident was punched in the eye. The resident had a black eye as a result. During an interview on 10/29/25 at 11:45 A.M., the Activity Director (AD) said he/she saw Resident #25 grab Resident #24 and they both fell to the floor. AD said they call for a stat call (call for immediate assistance). The Director of Nursing (DON) and Assistant Director of Nursing came to assist. The AD said he/she was not asked to write a statement regarding the incident. The AD said he/she did not see any bruising at that time on either resident. During an interview on 10/30/25 at 12:45 P.M., Certified Nurse Aide (CNA) A said he/she was charting at the nurse's station. CNA A heard something, looked up and saw Resident #25 attack Resident #24. CNA A saw Resident #25 hit Resident #24 but did not remember where he/she was hit. CNA A said the two residents fell to the floor. He/She and other staff helped separate the residents. A stat call was made and other nursing staff came to assist. The DON came and assessed the residents. CNA A said he/she did not remember writing a statement regarding the incident. CNA A said they monitor the residents and keep them separated. During an interview on 10/30/25 at 12:15 P.M., the Regional Director of Nursing (RNC) said the DON is currently in the hospital. The RNC said the incident was not reported and there is no documentation of an investigation. The RNC expected the facility's Abuse Prevention Policy to be followed as written. The Administrator was present at that time and said he agreed with the RNC. The Administrator did not know why the policy was not followed. The Administrator said he is responsible for ensuring the policy is followed. The Administrator said he was aware of the incident but did not know why the incident was not reported. The Administrator said he is responsible for reporting abuse and neglect allegations. The Administrator did not know why the investigation was not started. The Administrator said he is responsible for ensuring the investigation is started. 2649607

Based on observation, interview and record review, the facility failed to follow the facility's policy, and notify the physician and the Registered Dietician (RD) of an 11.5-pound (lb) weight loss in 56 days for one resident (Resident #17). The sample was eight. The census was 171. Review of the facility's Weight Variances Policy, dated 3/31/21, showed the following:-Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian. Recommendations from Registered Dietitian to include but not limit to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes; -Residents receiving supplements shall be monitored for acceptance by the Dietary Manager/Nursing Staff. Residents at risk for unintentional/unplanned weight variance may be monitored with weekly weights. Weights shall be reviewed by the Registered Dietitian for review and assessment;-Responsibility: Nursing Personnel, RD, Dietary Personnel and Dietary Manager;-Procedure:Residents shall be weighed, and weights reported monthly to the Registered Dietitian. If significant, insidious, or unintentional/unplanned weight variances are identified or, if low body weight or malnutrition is identified, a Registered Dietitian consult shall be notified. The Registered Dietitian shall assess the resident and submit a request for monitoring and/or intervention. Once the order is obtained nutrition intervention is communicated to Dietary Manager and/or designee through nursing and/or Nutrition Management.Residents assessed at risk may be weighed weekly.Residents shall be assessed for progress monthly or as needed by the Registered Dietitian and adjustments to care made according to resident progress. Resident progress shall be reviewed with the Director of Nursing and Dietary Manager. All progress or any changes made shall be documented in the medical records and care plan updated accordingly. Review of the facility's Notification of a Change in Condition Policy, dated 4/26/23, showed the following: -Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, per Standards of Practice and Federal and/or State Regulations; -Responsibility: All Licensed Nursing Personnel, Nursing Administration and Director of Nursing; -Procedure: -1. Guidelines for Notification of Physician, Resident Representative (not all inclusive); -Significant Change or Unstable Vital Signs; -5% Weight Gain/Loss in 30 days; -2. Document in the Interdisciplinary Team (IDT) Notes: Resident Change in Condition; Physician/Physician Extender Notification; Notification of Resident Representative. Review of Resident #17's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/25, showed the following:-No cognitive impairment;-No behaviors;-Independent with most activities of daily living;-Diagnoses of high blood pressure, diabetes and asthma;-120 lbs;-No weight loss. Review of the resident's weights, showed the following:-8/29/25: 119.5 lbs;-9/4/25: 119.5 lbs. Review of the resident's care plan, dated 9/23/25, showed the following:-Additional diagnoses included dehydration, unspecified severe protein-calorie malnutrition and gastro-esophageal reflux disease (GERD, a common condition in which the stomach contents move up into the esophagus);-Focus: The resident has a nutritional problem or potential nutritional problem and a diagnosis of malnutrition. Resident has an order for glucerna supplements (diabetic supplement);-Interventions: Monitor, record and report to the physician as needed any sign or symptoms of malnutrition or significant weight loss: three pounds in one week, more that 5% in one month, more than 7.5% in three months and more than 10% in six months. Provide and serve diet as ordered;-Goal: The resident will maintain adequate nutritional status as evidenced by maintaining baseline weight, no signs/symptoms of malnutrition and consuming at least 75% of at least three meals daily through review date. Review of the resident's progress notes, dated 9/30/25 at 11:31 P.M., showed the charge nurse was notified resident was admitted to hospital for hypoglycemia (low blood sugar) and hypotensive (low blood pressure). Review of the resident's weights, showed the following:-10/2/24: 116.5 lbs. Review of the progress notes, showed:-No note of readmission;-10/4/25, a physician progress note, with insulin orders;-10/7/25 at 3:06 P.M., the resident remained on therapy. The resident eats a regular texture diabetic diet. Resident eats all meals in room per choice;-10/8/25 at 5:02 P.M., resident complained of increased pain, swelling to the back of head, dizziness and hypotensive. Resident transported to hospital;-10/10/25 at 8:52 P.M., resident returned to facility. Physician reinstated previous medications. Review of the resident's weights, showed the following:-10/5/25: 115 lbs;-10/10/25: 116 lbs. Review of the resident's Order Summary Report, showed the following:-10/11/25, Glucerna Shake two times a day for nutrient supplement. Review of the resident's progress notes, dated 10/17/25 at 1:35 P.M., showed the resident stated to nurse he/she had persistent nausea and vomiting. Resident transported to hospital. Review of the resident's Medication Administration Record (MAR), showed the Glucerna Shake was discontinued on 10/21/25. Review of the resident's Order Summary Report, showed the following:-10/22/25, for regular diet, regular texture and thin consistency. Review of the resident's weights, showed the following:-10/22/25: 112 lbs. Review of the resident's October, 2025 Consumption Record, showed the following:-Breakfast: 10/7, 10/11, 10/15-16, Blank; -Lunch: 10/12 and 10/14, Blank; -Dinner: 10/12 and 10/14, Blank. Review of the resident's nurse's note, dated 10/22/25 at 3:55 P.M., showed the resident returned to facility via ambulance following transfer from the hospital from a change in condition resulting from diabetic ketoacidosis (a life-threatening complication of diabetes that occurs when the body does not have enough insulin to use glucose for energy (DKA)). Upon arrival patient is alert and oriented name, time and place and ambulating with assistive device around the facility. The resident's vital signs were obtained and stable. Report was obtained from emergency medical services. The resident was treated for DKA and condition improved and cleared to return to the facility. The resident oriented to his/her surroundings and plan of care was reviewed. The resident's call light is within reach, bed in lowest position, safety maintained, and fluids offered. The resident will continue to be monitored for any changes in condition. Review of the resident's hospital discharge record, dated 10/22/25, showed a recommendation the resident would benefit from oral nutritional supplements. Will provide Ensure High Protein Shake twice a day to better meet nutritional needs. Review of the resident's nurse's notes, showed no documentation of notification to the resident's physician or RD regarding the resident's return, weight loss or recommendation. During an interview on 10/29/25 at 1:14 P.M., the resident said he/she has had weight loss and has a concern regarding the weight loss. The resident said he/she has not seen the RD. The resident said he/she would like to see the RD to help with the weight loss and get back on track. During an interview on 10/30/25 at 8:05 A.M., the Restorative Aide (RA) B said the resident's monthly weights are completed by the 5th of the month. RA B said he/she would report any significant weight loss or gain to the Director of Nursing (DON). RA B said the resident's weight does go up and down. Observation on 10/30/25 at 8:17 A.M., showed RA B weighing the resident. The resident's weight was 108 lbs. The resident had a 9.62% weight loss in 56 days. During an interview on 11/5/25 at 12:18 P.M., the MDS Coordinator said when a resident returns to the facility from the hospital, the return is discussed in the stand-up meeting. The charge nurse or the Assistant Director of Nursing (ADON) should review the resident's hospital records for any orders or recommendations. During an interview on 10/30/25 at 8:35 A.M., the RD said he/she has only been with the facility for a couple of months. The RD said the facility did not make him/her aware of the resident's weight loss. The RD expected the facility to notify him/her to put a plan of action in place to assist with the weight loss. During an interview on 10/30/25 at 12:08 P.M., Physician D said the resident has been back and forth to the hospital and can be non-compliant with care. The resident eats well but will refuse meals and has an unstable blood sugar (level of sugar in the bloodstream). The facility should have identified the weight loss and put interventions in place and the RD should have been notified. During an interview on 10/30/25 at 8:52 A.M., the Regional Nurse Consultant (RNC) said he/she was not familiar with the resident. The facility should have looked at the resident's weights during the stand-up morning meeting and put interventions into place to prevent the weight loss, which included contacting the RD and the resident's physician. The Administrator was present at that time and agreed with the RNC. During an interview on 11/6/25 at 10:26 A.M., the DON said he/she has only been with the facility for about four days. The DON said the charge nurse and the unit manager should be reviewing the resident's hospital records for orders and any recommendations. The DON said the following day he/she or the ADON will review the hospital records as a follow up. The charge nurse should be contacting the resident's physician and if necessary the RD. The DON said the meal consumptions should be documented in the EHR by the charge nurse. The Administrator was present and agrees with the DON. 2648439

Based on interview and record review, the facility failed to ensure staff consistently notified physicians when blood glucose/sugar levels (the concentration of glucose in the blood) exceeded the parameters ordered by the physician or the parameters in accordance with the facility's policy. In addition, the facility failed to ensure staff consistently documented blood glucose levels on the Medication Administration Record (MAR) and/or failed to ensure staff documented explanations when they used the codes NA (not administered, see nurses notes), NI (no insulin required) or HD (hold, see nurses notes) on the MAR. The facility identified 48 residents with routine blood glucose monitoring. Of those 48, eight were sampled and problems were found with four (Residents #8, #15, #16 and #17). The census was 170.Review of the facility's Notification Of A Change In A Resident's Condition policy, approved on 11/1/18 and last reviewed on 4/28/21, showed:-Policy: The attending physician and the Resident Representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations;-Responsibility: All Licensed Nursing Personnel-Procedure: Guidelines for Notification of Physician/Resident Representative:--Significant Change or Unstable Vital signs. Glucometer reading below 70 or above 200 unless specific parameters given by physician for reporting;-Document in the Interdisciplinary Team (IDT) Notes: Resident Change in Condition. Physician Notification. Notification of Resident Representative. Review of the facility's Licensed Practical Nurse (LPN) and Registered Nurse (RN) job descriptions, revised 5/2022, showed:-Essential Function of the LPN and RN: Assesses and documents the resident's condition and nursing goods. Accurately and promptly implements physician's orders. Administers medications;-Reports to: Director of Nursing (DON). 1. Review of Resident #8's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/25, showed:-Adequate hearing;-Unclear speech - slurred or mumbled words;-Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time;-Ability To Understand Others: Usually understands - misses some part/intent of message but comprehends most conversation;-Moderately impaired cognition;-Diagnoses of high blood pressure, renal (kidney) disease, diabetes mellitus (low/high blood glucose levels) and stroke;-Received insulin injections six out of the last seven days. Review of the resident's care plan, showed:-7/18, Focus: Diabetes Mellitus and has an order for insulin. Goal: Will have no complications related to diabetes. Interventions: Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. Review of the resident's physician's order sheet (POS), showed:-Order Date 8/4/25: Insulin lispro (fast acting insulin), inject per sliding scale (the amount of insulin administered is determined by the blood glucose level) if 200-250 = 2 units (u), 251-300 = 4u, 301-350 = 6u; 351-400 = 8u. Subcutaneously (injection is given in the fatty tissue, just under the skin) before meals at 7:30 A.M., 11:00 A.M. and 4:00 P.M. Call physician if blood sugar is less than 70 or greater than 400;-Order Date 9/13/25: Lantus SoloStar (long-acting insulin) inject 32 units (u) subcutaneously between 4:00 P.M. and 9:00 P.M. daily. Review of the resident's MAR, dated 8/1/25 through 8/312/25, and the resident's progress notes, showed:-Order Date 7/28/25 Discontinue (DC) Date 8/4/25: Lantus SoloStar. Inject 24u at 3:00 P.M.:-8/2 and 8/3, the nurse documented NA (NA/not administered, see nurse's note). Review of the resident's nurse's notes/progress notes, showed no documentation why NA had been documented on the MAR;-Order Date 8/4/25 DC Date 8/17/25: Lantus SoloStar. Inject 24u between 4:00 P.M. and 9:00 P.M. Staff initialed the insulin had been administered as ordered;-Order Date 8/17/25 DC Date 9/13/25: Lantus SoloStar. Inject 28u between 4:00 P.M. and 9:00 P.M. Staff initialed the insulin had been administered as ordered; -Order Date 7/20/25 DC Date 8/4/25: Insulin Lispro. Inject per sliding scale if 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, ; 351-400 = 8u. Subcutaneously before meals at 7:30 A.M., 11:00 A.M. and 4:00 P.M. No order when to notify the physician: -Order Date 8/4/25 No DC Date: Insulin Lispro. Inject per sliding scale if 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, ; 351-400 = 8u. Subcutaneously before meals at 7:30 A.M., 11:00 A.M. and 4:00 P.M. Call physician if blood sugar is less than 70 or greater than 400:-8/6 at 7:30 A.M., the nurse documented a blood glucose level of 54. Review of the progress notes showed no documentation the physician had been notified;-8/9 at 4:00 P.M., the nurse documented a blood glucose level of 541 and NA. Review of the progress notes showed no documentation the physician had been notified or if the resident received insulin;-8/30 at 4:00 P.M., the nurse documented NI (no insulin required), but did not document the blood glucose level. Review of the Weights and Vitals Summary located in the EMR, showed on 8/30 at 4:05 P.M., the blood glucose level was 343. Per the sliding scale parameters, the resident should have received 6u of insulin. There was no documentation showing the resident received the insulin. Review of the resident's MAR, dated 9/1/25 through 9/30/25, and the resident's progress notes, showed:-Order Date 8/4/25 No DC Date: Insulin Lispro per sliding scale. -9/9 at 11:00 A.M., the nurse documented the resident received 8u of insulin, but did not document the blood glucose level;-9/16 and 9/17, at 7:30 A.M., the nurse documented NA, but did not document the blood glucose levels;-9/20 at 11:00 A.M., the nurse documented NA, but did not document the blood glucose level;-9/25 at 7:30 A.M., the nurse documented NA, but did not document the blood glucose level; -Order Date 8/17/25 DC Date 9/13/25: Lantus SoloStar. Inject 28u in the evening (4:00 P.M.-9:00 P.M.). Nurses initialed the insulin was administered as ordered from 9/1 through 9/13;-Order Date 9/13/25 No DC Date: Lantus SoloStar. Inject 32u in the evening (4:00 P.M.-9:00 P.M.):-9/16, 9/21, 9/23 and 9/29. Nurses documented NA. Review of the progress notes showed no documentation why NA was documented;-9/24 at 4:00 P.M.-9:00 P.M. Staff documented the blood glucose level was 433 and NA. Review of the progress notes showed no documentation the physician was notified or if insulin had been administered. During an interview on 10/1/25 at 12:40 P.M., the resident said he/she was diabetic and received routine insulin and blood glucose monitoring. His/Her blood glucose level can go high, and the facility does not always contact the physician when that happens. During an interview on 10/3/25 at 2:00 P.M., the DON said she could not find documentation the nurse contacted the resident's physician for the blood glucose level of 433 on 9/24/25. 2. Review of Resident #15's admission MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses of high blood pressure, renal (kidney) insufficiency and diabetes mellitus;-Received insulin injections seven out of the last seven days. Review of the resident's care plan, showed:-9/4/25, Focus: Diabetes Mellitus and has an order for insulin. Goal: Will have no complications related to diabetes. Interventions: Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. Review of the resident's POS, located in the EMR, showed:-Order Date 9/12/25: Insulin aspart (fast acting insulin). Inject per sliding scale(70-140 = no insulin, 141-180 2u, 181-220 = 4u, 221-260 = 6u, 261-300 = 8u, 301-350 = 10u, three times a day for diabetes. No order to call the physician if the blood glucose level exceeds the parameters);-Order Date 9/13/25: Insulin Glargine (long-acting insulin). Inject 6u twice a day. Review of the resident's MAR, dated 9/1/25 through 9/30/25, and the resident's progress notes, showed:-Order Date 8/19/25 DC Date 9/12/25: Insulin aspart per sliding scale (200-250 = 2u, 251-300 = 4u, 301-350 = 6u, 351-400 = 8u. No order to call the physician if the blood glucose level exceeded the parameters) at 7:30 A.M., 11:00 A.M. and 6:00 P.M.: -9/3/25 at 4:00 P.M., the nurse documented a blood glucose level of 409 and NI. Review of the progress notes showed no documentation the physician had been notified or if insulin had been administered;-Order Date 9/12/25 No DC Date: Insulin aspart per sliding scale (70-140 = no insulin, 141-180 2u, 181-220 = 4u, 221-260 = 6u, 261-300 = 8u, 301-350 = 10u, three times a day at 8:00 A.M., 2:00 P.M. and 10:00 P.M. for diabetes. No order to call the physician if the blood glucose level exceeded the parameters);-9/16 and 9/25 at 8:00 A.M., the nurse documented NA and no blood glucose level. Review of the progress notes showed no documentation why NA had been documented and no blood glucose levels documented; -9/19, 9/22 and 9/25 at 2:00 P.M., nurses documented a blood glucose level of 350 on 9/129, 354 on 9/22 and 384 on 9/25 and documented NI on each date. Review of the progress notes showed no documentation why no insulin was required and no physician notification;-Order Date 8/19/25 DC Date 9/12/25: Insulin Glargine 6u two times a day at 7:00 A.M.-10:00 A.M. and 3:00 P.M.-6:00 P.M. Nurses documented the insulin was administered as ordered:-Order Date 9/12/25 No DC Date: Glargine 6u two times a day at 8:00 A.M. and 5:00 P.M.:-9/16 and 9/25 at 8:00 A.M., nurses documented NA. Review of the progress notes showed no documentation why the Glargine insulin was not administered. 3. Review of Resident #16's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses of high blood pressure and diabetes mellitus;-Received insulin injections seven out of the last seven days. Review of the resident's care plan, showed:-7/9/25, Focus: Diabetes Mellitus and uses insulin. Goal: Will have no complications related to diabetes. Interventions: Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. Review of the resident's POS, showed:-Order Date 2/27/25 DC Date 9/28/25: Humalog (brand name for lispro) 18u subcutaneous three times a day;-Order Date 2/27/25 DC Date 9/28/25: Lispro insulin. Inject as per sliding scale at 8:00 A.M., 12:00 P.M. and 5:00 P.M. If 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, 351-400 = 8u. If blood glucose level is above 400, call the physician;-Order Date 6/9/25 DC Date 9/28/25: Lantus SoloStar insulin inject 30u every morning and 40u every evening;-Order Date 7/30/25 DC Date 9/18/25: Trulicity (an injectable diabetes medication) 3 milligrams (mg) subcutaneous weekly on Tuesdays at 8:00 A.M. Review of the MAR, dated 8/1/25 through 8/31/25, and the resident's progress notes, showed:-Order Date 2/27/25 DC Date 9/28/25: Lispro insulin. Inject as per sliding scale at 8:00 A.M., 12:00 P.M. and 5:00 P.M. If 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, 351-400 = 8u. If blood glucose level is above 400, call the physician:-8/2 at 12:00 P.M. The nurse documented a blood glucose level of 428 and HD (hold, see nurses notes). Review of the progress notes showed no physician notification;-Order Date 7/30/25 DC Date 9/18/25: Trulicity (an injectable diabetes medication) 3 milligrams (mg) subcutaneous weekly on Tuesdays at 8:00 A.M.:-8/19 at 8:00 A.M., the nurse documented NA. Review of the progress notes showed no documentation why the Trulicity was not administered. Review of the MAR, dated 9/1/25 through 9/30/25, and located in the EMR, showed:-Order Date 7/30/25 DC Date 9/18/25: Trulicity (an injectable diabetes medication) 3 milligrams (mg) subcutaneous weekly on Tuesdays at 8:00 A.M.:-9/9 at 8:00 A.M., the nurse documented NA and HD. Review of the progress notes showed no documentation why the Trulicity was not administered and/or held;-9/16 at 8:00 A.M., the nurse documented NA. Review of the progress notes showed no documentation why the Trulicity was not administered;-Progress note, dated 9/25/25 at 7:38 P.M., the resident was sent to the hospital for confusion and elevated respiratory rate. His/Her blood glucose level was 233. 4. Review of Resident #17's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses of high blood pressure and diabetes mellitus;-Received insulin injections seven out of the last seven days. Review of the resident's care plan, showed:-9/23/25, Focus: Diabetes Mellitus and has orders for insulin. Goal: Will have no complications related to diabetes. Interventions: Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. Review of the resident's POS, showed:-Order Date 9/4/25. Insulin Degludec (long-acting insulin). Inject 22u subcutaneously in the afternoon;-Order Date 9/4/25. Insulin Lispro. Inject 5u subcutaneously before meals;-Order Date 9/4/25: Insulin Lispro. Inject per sliding scale if: 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, 351-400 = 8u before meals for blood glucose control. No order when to notify the physician. Review of the resident's MAR, dated 9/1/25 through 9/30/25, showed: -Order Date 9/4/25: Insulin Lispro. Inject per sliding scale if: 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, 351-400 = 8u before meals at 7:30 A.M., 11:00 A.M. and 4:00 P.M. for blood glucose control:-9/16, 9/25, 9/26 and 9/27 at 7:30 A.M., no blood glucose levels documented;-9/20 and 9/22, at 11:00 A.M., no blood glucose levels documented;-9/25 at 4:00 P.M., no blood glucose level documented. Review of the resident's progress notes, showed:-9/30/25 at 1:21 P.M.: Resident is (on) leave of absence (LOA) at physician's follow-up appointment;-9/30/25 at 5:24 P.M.: Resident remains at physician's appointment;-9/30/25 at 11:31 P.M.: Charge nurse was notified that resident was admitted to the hospital for hypoglycemia (low blood glucose) and hypotension (low blood pressure) 4. 5. During an interview on 10/2/25 at 12:54 P.M., LPN D said if there are orders to call the physician for a low/high blood glucose level, he/she would contact the physician if a blood glucose level is 60 or below, or above 400. If the physician has ordered parameters of when to be notified and a blood glucose level exceeded those parameters, he/she would contact the physician and document it in the progress notes. Any time he/she documents an NA or HD, he/she would document the reason in the progress notes. The blood glucose levels should be documented on the MAR. 6. During an interview on 10/2/25 at 1:19 P.M., LPN G said if a sliding scale insulin does not have orders to notify the physician, he/she would contact the physician and ask for orders. When a physician is contacted for a low or high blood glucose level, it should be documented in the progress notes along with any new orders received. Any time insulin is not administered as ordered, the physician should be notified and the reason why it was not given documented in the progress notes. If there were no parameters to call a physician, he/she would call if a blood glucose level was below 60 or above 450. 7. During an interview on 10/3/25 at 2:00 P.M., the DON said she identified a problem in September with staff failing to notify physicians when blood glucose levels exceeded parameters, not consistently documenting blood glucose levels, and documenting NA and NI with no explanation as to why in the progress notes. She provided the inservices, dated 9/19 and 9/22, that showed the following topics were discussed: Blood sugar requirements/protocols, insulin administration, emphasis on requirements for narrative progress notes when glucose is out of range to include physician notification. Apparently, the problem has not been corrected. She expected staff to follow the physicians' orders and notify physicians when blood glucose levels exceeded the ordered parameters. If sliding scale order does not specify when to contact the physician, she expected staff to either follow the facility policy or contact the physician and ask when they want to be notified. When nurses contact the physicians, they should document it in the progress notes. When nurses document NA or NI, there should be an explanation documented in the progress notes. She does not know why this is not being done. 2597610

Based on observation, interview and record review, the facility failed to ensure residents had oral care supplies (toothbrush, toothpaste and mouthwash) for their use in their rooms and failed to ensure staff provided oral care to residents. Twenty-three residents were sampled. Of those 23, five were interviewed and three said they did not have oral care supplies and staff did not offer to provide oral care (Residents #18, #8 and #15). The census was 170.Review of the facility Oral Hygiene policy, approved on 4/28/22 and last reviewed on 7/21/22, showed:-Policy: The Facility will provide Oral Hygiene to Residents as directed in the Plan of Care. Oral Care will include cleansing the Oral Cavity and removing Food/Debris; This may reduce Odor, Infection and provide Comfort;-Responsibility: Nursing Assistant (Certified Nursing Assistant (CNA), Licensed Nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)), Nursing Administration, and Director of Nursing (DON);-Equipment Includes: Toothbrush, Toothpaste and Mouthwash. Review of the facility Certified Nurse Aide job description, revised on 1/2024, showed:-Essential Functions of CNAs: Provides Residents with hygiene supports including nail care, light hair or other grooming, oral hygiene, bathing, and incontinence care;-Reports to: Director of Nursing. 1. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/14/25, showed:-admission date of 8/8/25;-Adequate hearing;-Clear speech - distinct intelligible words;-Makes self understood: Understood;-Ability to understand others: Understands - clear comprehension;-Cognitively intact;-No behavioral symptoms (physical, verbal or other);-Rejection of care: Behavior not exhibited;-Oral hygiene: Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Review of the resident's medical diagnoses located in the electronic medical record (EMR), showed diagnoses of muscle weakness, chronic kidney disease and high blood pressure. Review of the resident's care plan, located in the EMR, showed: -9/9/25, Focus: Activity of daily living (ADLs) deficit. Goal: Will maintain current level of function with ADLs. Intervention: One person assistance with ADLs. During observation and interview on 9/30/25 at 1:17 P.M., the resident was on his/her bed. The resident said staff do not offer to brush his/her teeth in the morning. Staff have not provided him/her with a toothbrush, toothpaste or mouthwash since coming to the facility about six weeks ago. He/She would like to have the supplies because he/she wants a fresh mouth. The resident gave permission for the surveyor to check his/her cabinet drawers. No toothbrush, toothpaste or mouthwash was found, During observation and interview on 10/1/25 at 1:18 P.M., CNA H said he/she was assigned to the resident today. He/She did not offer the resident oral care because the resident is able to do pretty much everything on his/her own. The resident said he/she could if he/she had the supplies. The CNA looked in the resident's cabinet drawers and could not find a toothbrush, toothpaste or mouthwash. The CNA said he/she always brushes his/her own teeth every morning, and oral care should be offered to the residents every day. 2. Review of Resident #8's admission MDS dated [DATE], showed:-admission date of 7/1/25;-Adequate hearing and vision;-Unclear speech - slurred or mumbled words;-Makes self understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time;-Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation;-Moderately impaired cognition;-No behavioral symptoms;-Rejection of care: Behavior not exhibited;-Functional limitation in range of motion: Impairment in one upper and one lower extremity;-Oral hygiene: Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of the resident's medical diagnoses, located in the electronic medical record EMR, showed diagnoses of end stage renal (kidney) disease, muscle weakness and diabetes. Review of the resident's care plan, located in the EMR, showed:-7/18/25, Focus: Activities of daily living deficit. Goal: Will maintain current level of function with ADLs. Intervention: One person assistance with ADLs. During observation and interview on 9/30/25 at 1:17 P.M., the resident (Resident #18's roommate) sat in his/her room in a wheelchair feeding himself/herself lunch. The resident said staff do not offer to brush his/her teeth in the morning. He/She had been at the facility for about two or three months and had not had his/her teeth brushed once. The resident gave permission for the surveyor to check his/her cabinet drawers. No toothbrush, toothpaste or mouthwash was found. During observation and interview on 10/1/25 at 1:18 P.M., CNA H said he/she was assigned to the resident today. He/She did not offer the resident oral care because the night shift was getting the resident up this morning, and all he/she did was assist with the transfer. He/She thought the night shift provided the resident with oral care. The resident said he/she does not and has never had a toothbrush, toothpaste or mouthwash for oral care since being admitted . The CNA looked in the resident's cabinet drawers and could not find a toothbrush, toothpaste or mouthwash. The CNA said he/she always brushes his/her own teeth every morning, and oral care should be offered to the resident's every day. 3. Review of Resident #15's admission MDS dated [DATE], showed:-admission date of 8/18/25;-Adequate hearing;-Clear speech - distinct intelligible words;-Makes self understood: Understood;-Ability to understand others: Understands - clear comprehension;-Cognitively intact;-No behavioral symptoms;-Rejection of care: Behavior not exhibited;-Oral hygiene: Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Review of the resident's medical diagnoses located in the EMR, showed diagnoses of diabetes, altered mental status and muscle weakness. Review of the resident's care plan, located in the EMR, showed:-9/4/25, Focus: ADL self-care performance deficit. Goal: Will maintain current level of function with ADLs. Intervention: One person assistance with all ADLs. During observation and interview on 9/30/25 at 7:30 A.M., the resident said he/she has his/her own teeth. Staff do not offer him/her oral care in the morning. He/She would like to have his/her teeth brushed. He/She gave permission to open his/her cabinet drawers. No toothbrush, toothpaste or mouth wash was observed. He/She said no one had given him/her those items since coming to the facility. 4. During an interview on 10/2/25 at 1:10 P.M., CNA E said he/she always brushes his/her own teeth every morning and then uses mouthwash so his/her breath won't smell. Oral care should be offered to all the residents every day. 5. During an interview on 10/2/25 at 1:12 P.M. Certified Medication Technician F said he/she brushes his/her own teeth every morning. Oral care should be part of the resident's morning routine every day. 6. During an interview on 10/2/25 at 1:19 P.M., LPN G said he/she brushes his/her teeth every morning, so his/her breath is not bad. Oral care should be offered to the residents every morning. 7. During an interview on 10/2/25 at 1:45 P.M., the DON said she expects staff to provide oral care to each resident every morning. Each resident should have a toothbrush, toothpaste and mouthwash in their rooms. MO2597610

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #45), assessed to be at risk for aspiration, was served pureed meat and thickened liquids in accordance with physician's orders. The resident recently returned from a hospitalization after aspirating at the facility, resulting in aspiration pneumonia (an infection caused by inhaling something other than air into your lungs) for which he/she received intravenous antibiotics. The facility staff failed to monitor the resident in the dining room, as assessed in the Minimum Data Set (MDS), which showed the resident required supervision and touching assistance for eating. Observation showed the resident chewing on a milk-soaked paper napkin without staff intervention, which could have resulted in choking. The resident's care plan failed to identify the resident's risk of aspiration and the level of assistance and supervision required for eating. The sample was 33. The census was 166. The administrator was notified on 1/27/25 at 1:09 P.M. of an Immediate Jeopardy (IJ) which began on 1/23/25. The IJ was removed on 1/27/25, as confirmed by surveyor onsite verification. Review of the facility's policy, entitled Physician Orders, dated 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines. Review of the facility's Tray Identification and Tray Cards policy, revised 3/20/24, showed: -Policy: Physician diet orders may be communicated to the Dietary Manager by nursing staff upon admission, using electronic medical record Nutrition Management or otherwise communicated by Nursing. A tray card shall be printed to be used by the personnel as tray identification during meal service. Changes in dietary orders shall be communicated in the same manner. All additions and changes shall be updated in a timely manner; -Procedure: -A tray card shall be printed in a timely manner and provide to the nutritional services personnel. Tray card to include but not limit to name of resident, type of diet, texture of diet, type of liquids; -The Dietary Manager shall audit tray cards/diet orders against the medical records as needed. Review of Resident #45's medical record, showed: -Diagnoses included history of transient ischemic attack (TIA, temporary blockage of blood flow to the brain), unspecified sequelae (aftereffects) of cerebral infarction (stroke), hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body) and hemiparesis (a condition characterized by weakness or paralysis on one side of the body) following cerebral infarction affecting left non-dominant side; frontal lobe and executive function deficit, other symptoms and signs involving cognitive functions and awareness; -An order, dated 8/31/23, for mechanical soft texture diet. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Severe cognitive impairment; -Able to make self understood; -Supervision or touching assistance required for eating. Review of the resident's care plan, revised 1/24/25, showed: -Focus: Impaired cognitive function/dementia or impaired though process; -Focus: Activities of daily living (ADLs) self-care performance deficit; -Focus: History/potential for behavior problem. Update on 1/24/25: Resident chews on linens; -Interventions included: Encourage and redirect patient from chewing on linens; -Focus: The resident has nutritional problem or potential nutritional problem and is on a supplement; -Interventions included: Provide, serve diet as ordered. Monitor intake and record every meal; -The care plan did not identify the resident's risk of aspiration and the level of assistance and supervision required for eating. Review of the resident's nurse's note, dated 1/18/25 at 11:30 P.M., showed Licensed Practical Nurse (LPN) E documented during report, the resident had emesis (vomiting) multiple times. In the middle of report, resident was heard gurgling, lung sounds mirrored crackling, oxygen declining. Reached out to physician and hospice. Was told by hospice to send resident to emergency room (ER) for aspiration. Resident left facility at 7:55 P.M. to hospital. Review of the resident's nurse's note, dated 1/19/25 at 1:50 A.M., showed LPN E documented the resident arrived back via Emergency Medical Services (EMS). Resident was still gurgling with audible breathing and per EMS, resident threw up multiple times on the way to facility. Hospice notified of status and agreed resident needs to go back out to hospital. Resident vomited a large piece of what appeared to be meat. Resident's oxygen still low, but no longer loud audible breathing. EMS took resident back to hospital at 2:54 A.M. During an interview on 1/29/25 at 8:50 A.M., LPN E said after the resident returned to the facility from the hospital on 1/18/25, he/she had an episode of emesis and threw up a chunk of meat. LPN E could tell the meat was ground up, but it was stuck together in a ball. The resident was on a mechanical diet at the time of the incident. He/She requires assistance and supervision while eating. Someone should be sitting down next to him/her while he/she eats. The resident has confusion and will put anything in front of him/her in his/her mouth. Review of the resident's hospital discharge summary, dated 1/21/25, showed: -Presenting history: Patient initially aspirated on evening of 1/18/25 on a hamburger patty at the nursing home. Chest x-ray showed bilateral lower lobe infiltrates (increased density in the lower lobes of both lungs, which can be caused by various conditions including infection (like pneumonia), fluid buildup (pulmonary edema), blood clots, or inflammation). Patient was given intravenous antibiotics and fluids and admitted for further medical management; -Clinical swallow evaluation, dated 1/20/25, showed recommendations of mechanically altered diet/minced and moist/nectar thick (mildly thick) liquids. Patient is at risk for aspiration due to recent aspiration event, stroke with history of dysphagia (swallowing disorder) and results observed during this assessment; -Discharge diagnosis: Aspiration pneumonia; -Precaution orders: Aspiration precautions. Review of the resident's physician order summary, showed an order, dated 1/21/25, for mechanical soft texture diet/pureed meat texture, nectar consistency liquids. Observation on 1/23/25 at 1:28 P.M., showed the resident seated by the nurse's station, chewing on a towel. Certified Medication Technician (CMT) A gave the resident a cup of un-thickened water. The resident took a couple sips of water and began coughing. CMT A waited until the resident stopped coughing, then gave the resident another sip of un-thickened water. During an interview on 1/23/25 at 1:52 P.M., CMT A said the resident chews on things like towels as a behavior and it seems to soothe him/her. He/She used to receive a mechanical-soft diet, but went out to the hospital last week for aspiration. He/She returned to the facility on a pureed diet. He/She still receives thin liquids. Observation on 1/24/25 at 8:05 A.M., showed Dietary Aide (DA) F poured un-thickened 2% milk into the resident's cereal and left the carton of milk on the table. The resident knocked over the carton of milk, which spilled all over the paper napkin on the table. No staff was observed to supervise the resident. At 8:18 A.M., the resident picked up the milk-soaked napkin and put the napkin in his/her mouth. The resident began chewing on the napkin and made swallowing gestures. Staff were not aware the resident was chewing on the napkin until the surveyor notified Registered Nurse (RN) B at 8:21 A.M. Upon being made aware the resident had something in his/her mouth, RN B approached the resident and asked him/her what he/she had in his/her mouth. The resident looked at RN B and did not verbally respond while he/she continued to chew on the napkin in his/her mouth. RN B did not ask the resident to open his/her mouth. As Certified Nurse Aide (CNA) C was walking by, RN B asked CNA C what the resident had in his/her mouth. CNA C said the resident was eating breakfast. RN B told the surveyor the resident was chewing his/her food. The surveyor asked RN B to look inside the resident's mouth. RN B asked the resident to open his/her mouth and observed the napkin inside his/her mouth, then removed it. CNA C said the resident does this all the time. At 8:23 A.M., CNA C brought the resident a breakfast plate consisting of mechanical-soft sausage. CNA C fed the resident the mechanical-soft sausage. Review of the resident's dietary slip showed mechanical soft diet, with no documentation regarding pureed meat or nectar thick liquids. During an interview on 1/24/25 at 8:27 A.M., CNA C said the resident requires feeding assistance and reaches for things he/she should not have. He/She receives a mechanical soft diet so he/she can chew his/her food. He/She does not require pureed food and can have regular liquids. During an attempted interview on 1/24/25 at 9:08 A.M., the resident was unable to respond to specific questions related to his/her recent hospitalization or medical condition. During an interview 1/27/25 at 8:23 A.M., RN B said he/she does not know the resident, and does not know his/her cognitive status, dietary orders, or level of assistance required for eating. On 1/24/25, after being made aware the resident had something in his/her mouth, RN B assumed the CNA saw what he/she had in his/her mouth and assumed he/she was chewing on cereal. During an interview on 1/24/25 at 1:10 P.M., CNA G said the resident is confused. He/She recently had an incident where he/she choked on his/her food and was sent out to the hospital. He/She can feed him/herself but needs to be supervised at all times while eating because he/she will put things in his/her mouth that he/she shouldn't. During an interview on 1/27/24 at 7:53 A.M., the Dietary Manager (DM) said the resident has always required feeding assistance. He/She has been on a mechanical diet for a while now. Last week, the resident just kept choking and choking during breakfast, possibly on sausage. Assistant Director of Nurses (ADON) T made an executive decision to give the resident pureed meat at that meal, instead of mechanical. The order for pureed meat and thickened liquids is new and happened after the incident last week. Thickened liquids include all liquids served to the resident, such as milk, coffee, and water. The kitchen has thickened milk cartons that can be given to residents who should have nectar-thick liquids, and this is what should have been used for the resident at breakfast on 1/24/25. Residents with orders for thickened liquids should receive liquids as ordered because of choking risk. Dietary slips are generated from the physician orders entered by nursing in the electronic medical record (EMR). When there is a change to a resident's diet orders, nursing gives her a form. She cannot find a form to notify her of the changes to the resident's diet, but the orders are in the EMR. The diet slip observed with the resident's breakfast on 1/24/25 must have been an old slip. Dietary and nursing staff should check the diet slips to ensure residents are served the correct foods. During an interview on 1/27/25 at 8:10 A.M., ADON T said he/she may have recently made a nursing judgment to downgrade the resident's diet to pureed meat one day because he/she was pocketing his/her food. He/She cannot remember the exact day this occurred. The resident should receive the correct diet in accordance with physician orders due to risk of choking. He/She puts things other than food in his/her mouth all the time and needs a lot of supervision. On 1/24/25, the staff should have been paying attention to the resident, keeping a close eye on him/her. When the nurse was notified the resident had the napkin in his/her mouth, the nurse should have checked the resident's mouth because the resident is confused. During an interview on 1/27/25 at 8:30 A.M., the MDS Coordinator said he/she does not know the resident well. When asked to define supervision for eating, as indicated on the resident's MDS, the MDS Coordinator said supervision means staff need to be there to guide the resident, encourage them, and assist to a certain point. Staff should make sure the resident is safe with eating and not exhibiting behaviors. During an interview on 1/27/25 at 7:23 A.M., the Medical Director said the resident just came back from the hospital. He believes the facility made him aware of the hospital's new orders for the resident to receive a mechanical soft diet and nectar-thick liquids. He is not sure if the instruction for pureed meat on the current physician order came from hospice or the hospital's speech therapist, but he expected the orders to be followed. Pureed meat could be helpful with the resident's swallowing. Nectar-thick liquids means all liquids should be thickened, including water. The resident is confused and has poor safety awareness. He/She should be supervised while eating. It would be fine for staff to just be in the dining room with the resident, if they are keeping an eye on him/her. When given a description of the observations made on 1/24/25, the Medical Director said it was problematic for the resident to have put the napkin in his/her mouth, whether he/she has a swallowing issue or not. When the nurse was notified of the behavior, the nurse should have checked the resident's mouth, without prompting. Staff should have had a more watchful eye on the resident. The resident should have received thickened liquids and pureed meat at his/her meal. During an interview on 1/27/25 at 8:59 A.M., the Administrator said the resident is confused and recently went out to the hospital for aspiration pneumonia. Before the hospitalization , the resident received a mechanical diet. When he/she returned to the facility, the admitting nurse should have reviewed the orders from the hospital, verified them with the physician, then entered the orders into the EMR. The EMR is integrated so new dietary orders would have gone to the dietary department, and the new orders would have been generated on the dietary slips. Sometimes dietary staff will generate bulk slips at one time to be used throughout the week, but the dietary slips should be printed daily so the current orders are reflected on the dietary slips. Changes to a resident's diet should be communicated to the floor staff from daily huddles and the report sheets. Nectar-thick liquids applies to all liquids given to a resident. Nectar-thick liquids allow for more time to go down to prevent aspiration because thin liquids can go down too fast. The resident should have received thickened liquids with meals and pureed meat at breakfast, not mechanical-soft sausage. The resident needs supervision while eating. He/She has poor safety awareness. He/She can pick up his/her utensil but needs encouragement and at times, staff may have to pick up his/her utensil for him/her to get started eating. He/She chews on his/her tongue and the behavior of putting things in his/her mouth is recent. Because he/she has this behavior, staff should be around at meals to keep an eye on him/her. When informed of the observations made on 1/24/25, the Administrator said she expected staff to be supervising the resident. When the nurse was made aware of the resident having something in his/her mouth, the nurse should have checked his/her mouth right away. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

See Event ID 6YPW12. Based on observation, interview and record review, the facility failed to provide protective oversight to one of three sampled residents identified by the facility as at risk for elopement. Resident #8, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia (a serious mental health condition that affects how people think, feel and behave) and was assessed to have moderate cognitive impairment. The resident had a known history of elopement and was admitted to the facility due to elopements while at home. During routine rounds, staff who were assigned to the resident failed to visibly check for confirmation of the resident's whereabouts. The resident left the building without staff knowledge and remained out of the building for approximately four hours before staff realized the resident was missing. The resident was found 12 hours later, approximately two miles away from the facility and had to cross a busy intersection to arrive at the location he/she was found. The census was 160.

Based on observation, interview and record review, the facility failed to provide protective oversight to one of three sampled residents identified by the facility as at risk for elopement. Resident #8, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia (a serious mental health condition that affects how people think, feel and behave) and was assessed to have moderate cognitive impairment. The resident had a known history of elopement and was admitted to the facility due to elopements while at home. During routine rounds, staff who were assigned to the resident failed to visibly check for confirmation of the resident's whereabouts. The resident left the building without staff knowledge and remained out of the building for approximately four hours before staff realized the resident was missing. The resident was found 12 hours later, approximately two miles away from the facility and had to cross a busy intersection to arrive at the location he/she was found. The census was 160. The Administrator was notified on 7/18/24, of the Immediate Jeopardy (IJ) past non-compliance which began on 7/12/24. The facility educated all nursing staff on visual checks during rounds, educated all staff on the facility's elopement policy and procedures, completed an audit of all residents at risk for elopement and updated care plans accordingly, performed an elopement drill, and audited all windows and alarmed doors. The deficiency was corrected on 7/15/24. Review of the facility's Essential Functions of Certified Nurse Aide (CNA), revised 1/2024, included: -Notes observations of resident behavior, complaints, or symptoms and communicates immediately to nursing supervisors any known or suspected changes in residents' condition; -Follows all company policies and procedures; -Other duties as assigned. Review of the facility's Missing Resident/Elopement policy, last revised on 4/26/24, showed: -Policy: The Charge Nurse is responsible for knowing the location of their assigned residents. Residents who are participating in various programs such as Physical Therapy, Recreational Activities, Dining, etc., the employees in these programs will be responsible for the location of their participants; -Responsibility: All employees, interdisciplinary team (IDT) Members, Nursing Administration, Director of Nursing (DON) and Licensed Nursing Home Administrator; -Procedure: -It is the responsibility of all employees to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse immediately; -At any time in which a resident is determined missing, the following procedure will be followed: -The Supervisor/Charge Nurse will alert all personnel by all-paging Code Gray and location (including Unit and Room Number); -A search of the immediate area will be initiated under the direction of the Nursing Supervisor/Charge Nurse; -A search will be conducted of all rooms including locked rooms; -The Nursing Supervisor/Charge Nurse will designate employees to search the surrounding building as appropriate (patio, parking lot, etc.); -If the search of the immediate area (building) is unsuccessful, the Nursing Supervisor/Charge Nurse will immediately contact the Administrator and DON, local police department, family/responsible party, Regional Nurse and Director of Operations, attending physician and Department of Health and Senior Services (DHSS). Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/18/24, showed: -Moderate cognitive impairment; -Wandering behaviors not exhibited; -Frequently incontinent of bowel and bladder; -Once standing, ability to walk 150 feet in a corridor or similar space: Supervised or touching assistance. Helper provides verbal cues or touch/steadying assistance; -Diagnoses included: Alzheimer's disease, schizophrenia, high blood pressure, and diabetes. Review of the resident's undated care plan, in use during the investigation, showed: -Focus: Resident has impaired cognitive function/dementia. Resident carries a baby doll around; -Goal: Will maintain current level of cognitive function; -Interventions: Administer meds as ordered. Identify self at each interaction. Face resident when speaking; -Focus: At risk for elopement as evidenced by: History or wandering; -Goal: Will not leave the facility unattended; -Interventions: Identify pattern of elopement. If resident exits the building, do not leave unattended, walk with resident and/or keep within eye sight. Monitor location closely. Review of the resident's April, May, and June 2024 Elopement Risk Evaluations, showed: -At risk; -Does the resident have a history of elopement or an attempted elopement while at home? Yes; -Does the resident have a history of attempting to leave the facility without informing staff? Yes; -Does the resident wander? Yes; -Is the wandering behavior a pattern, goal directed (i.e. specific destination in mind, going home, etc.)? Yes. Review of the resident's progress notes, showed: -Nursing note on 4/17/24 at 7:19 P.M., Resident actively exit seeking and pushing on doors. Resident becoming increasingly agitated. Resident redirected to his/her room. Medical doctor notified; -Nursing note on 7/12/24 at 5:41 P.M., Resident refused medications this evening x 3, family member informed; -Administration note on 7/12/24 at 11:27 P.M., Received a call that resident was not in his/her room upon rounds at approximately 10:45 P.M. Facility conducted facility wide and surrounding area checks with no results. Resident noted to refuse medication today. Resident belongings noted on his/her bed and covered with blanket and remain in his/her room at this time. Resident's Power of Attorney (POA, a legal document that allows someone to act on the behalf of someone else), medical doctor, and local police notified and search continued; -Nursing note on 7/13/24 at 6:15 A.M., Resident returned to facility accompanied by local police officer. Resident currently sitting in TV area waiting for family to arrive, family stated they're going to take him/her to the hospital for observation. Police officer is still waiting with resident until family arrives. Management made aware of resident return. Review of the facility's completed investigation, dated 7/13/24, included: -On 7/12/24 at approximately 10:15 P.M., staff reported they entered the resident's room, called out to him/her with no reply they then approached the bed and pulled back the covers and noticed the resident was not in his/her bed. Staff searched his/her room as well as the unit and immediately initiated a Code Gray. The Administrator, DON and Assistant Director of Nursing (ADON) were notified. Staff then initiated a facility wide search including the grounds and surrounding community. The doctor, POA and police were made aware of the situation; -Weather report checked (which was 73 degrees); -Upon completion of the investigation, the window in the dining room appeared tampered with (retaining screws removed and screen torn) therefore, it was determined the resident exited the facility through the dining room window of the unit. During an interview Licensed Practical Nurse (LPN) C reported he/she observed the resident in the dining room with another resident at approximately 6:00 P.M. LPN C indicated he/she did not observe the resident exit seeking during the shift. LPN C recalled the resident ambulating between his/her room and the dining room, cleaning tables. During an interview with CNA D, he/she explained he/she last saw the resident in his/her room between 5:45 P.M. and 5:55 P.M. According to CNA D, the resident did not exhibit exit seeking behaviors during his/her shift; -During staff interview with CNAs B and A, they said at approximately 8:30 P.M., they were making their rounds and noticed what appeared to be the resident lying in bed with his/her blanket covering him/her. According to the CNAs, the resident is continent of bowel and bladder and appeared to be comfortable; without disturbing the resident they went to assist the other residents on the unit. During staff interviews with CNAs B and A, they explained they work together on their assignments and during their first rounds they noticed what they thought was the resident lying in his/her bed and it was not until their second round at approximately 10:15 P.M., they realized what they thought was the resident was actually his/her pillow and his/her multiple baby dolls covered with the resident's blanket. Upon searching, the resident was not in his/her room or on the unit, therefore a Code Gray was initiated; -On 7/13/24 the resident was located safely and escorted back to the facility at 6:15 A.M. Attempted to interview the resident regarding leaving the facility, however the resident was unable to provide any information. Observation of the facility's surveillance video on 7/17/24 at 10:52 A.M., showed: -The surveillance camera faced the back of the facility; -At approximately 6:11 P.M. on 7/12/24, the resident could be seen walking into the line of sight of the camera; -The resident quickly walked past the back of the building and continued up the driveway towards the front of the building, outside of the camera's line of sight; -The resident wore jeans, a t-shirt, a hoodie, and shoes. Review of www.timeanddate.com for temperatures in Florissant, MO on 7/12/24 and 7/13/24, showed: -At 6:51 P.M. on 7/12/24, the temperature was 86 degrees Fahrenheit (F); -At 5:51 A.M. on 7/13/24, the temperature was 76 degrees F. Review of the resident's progress notes, showed: -Nursing note on 7/13/24 at 6:54 A.M., No injuries noted, no signs/symptoms of acute distress. Resident was in good spirits, upbeat, smiling and seemed happy to be back; -Social Services (SS) note on 7/13/24 at 11:23 A.M., SS met with resident to see how he/she was doing and to discuss recent behaviors. Due to illness resident gets confused at times. Resident was able to state he/she was well and appeared in a positive mood. Resident was unable to discuss recent behaviors. Resident did not appear to be displaying any exit seeking behaviors at this time. Resident is currently on 1:1 with staff. SS will continue 1:1 three times a week for four weeks. There were no further concerns with resident at this time per nurse. Resident will be monitored accordingly. Observation and interview of the resident, showed: -On 7/17/24 at 9:25 A.M., the resident sat in a wheelchair in the doorway of his/her room. The resident had two baby dolls on his/her lap. He/She appeared calm and engaged with the baby dolls; -On 7/28/24 at 9:18 A.M., the resident sat in a chair by the nurse's station. He/She was rocking a baby doll back and forth. The resident introduced his/her baby to the surveyor. The resident said he/she had lived at the facility here and there two times. The resident said he/she had siblings. The resident's brother took the resident out and was coming later that day. The resident said it wasn't easy being at the facility. He/She denied ever leaving the facility alone. The resident said he/she would tell them, and pointed to the nurse's station, if he/she was going to leave. During an interview on 7/17/24 at 11:53 A.M., LPN C said he/she worked the 7:00 A.M. to 7:00 P.M. shift on 7/12/24. The last time LPN C saw the resident, was at approximately 5:50 P.M. The resident was in the dining room with his/her hands on the table and holding his/her baby dolls. LPN C was surprised when he/she heard the resident eloped. The resident had not displayed exit seeking behavior in the last 30 days. LPN C did not know the window could be lifted all the way up. There was an elopement book at the nurse's station that lists residents at risk for elopement. If a resident could not be found, they were to call a Code Gray. LPN C said staff were expected to complete rounds every two hours and lay eyes on the residents assigned to staff. The resident is now on 1:1 with staff and staff are also completing 15 minute checks. During an interview on 7/17/24 at 12:19 P.M., CNA D said he/she was familiar with the resident. The resident was always quiet and to himself/herself. The resident liked to stay in his/her room, at a chair by the nurse's station or in the dining room. CNA D had observed the resident fiddle with the blinds in his/her room and look outside, but had never observed the resident mess with the window. CNA D worked the 7:00 A.M. to 7:00 P.M. shift on 7/12/24. CNA D was aware the resident was exit seeking. He/She last saw the resident on 7/12/24 between 5:50 P.M. and 5:55 P.M. The resident was in his/her room with his/her baby dolls. When staff completed rounds, they should lay eyes on every resident on their assignment. If a resident wasn't in their room, CNA D would go look for them. During an interview on 7/18/24, CNA B said he/she had worked the 7:00 P.M. to 7:00 A.M. shift and the resident was usually on his/her assignment. The resident usually stayed in his/her room, sat by the nurse's station or sat in the dining room. CNA B had never known the resident to try to get out. He/She had never seen the resident fiddle with the windows at all. CNA B was shocked when he/she found out the resident left through a window. The CNAs who work the day shift are always gone when the night shift CNAs begin work. The nurse provided information about the residents during report at shift change. CNA B did not see the resident at the start of his/her shift on 7/12/24. All of the residents were up at the beginning of the shift. The first time he/she checked on the resident, CNA B peeked his/her head into the resident's room. The resident appeared to be asleep. The second time CNA B checked on the resident, he/she thought maybe the resident needed a drink, so CNA B pulled back the cover and saw the resident wasn't there. The first time CNA B checked on the resident, he/she did not go in the room. Once the resident was discovered to be missing, a Code Gray was called. They checked all resident rooms, bathrooms, shower rooms and opened all doors. He/She checked the windows in resident rooms, but did not check the windows in the dining room. The ADON then called the police. CNA B did not know what the resident was wearing because he/she had not seen the resident at all during his/her shift. During an interview on 7/18/24 at 6:33 A.M., CNA A said he/she was familiar with the resident and said the resident was pretty independent. When he/she started his/her shift, the CNAs from the earlier shift had already left. CNA A would get report from the nurse or the Certified Medication Technician (CMT). That night, the CMT came to the hall at 10:30 P.M., but should have been there at 7:00 P.M. CNA A and CNA B usually completed rounds together. The resident's routine varied in the evening. He/She usually sat by the nurse's station. The night of 7/12/24, the resident appeared to be asleep, so he/she did not wake the resident. The second time they completed rounds, they were going to offer the resident water and snacks. They pulled back the covers and the resident was not there. After checking resident rooms, bathrooms and the dining room, a Code Gray was called. CNA A had not seen the resident all shift and did not know what the resident wore. CNA A asked a CMT what the resident had on and was told blue jeans and a black shirt. CNA A was aware he/she should do visual checks on residents when completing rounds. During an interview on 7/18/24 at 9:12 A.M., the Maintenance Director said the maintenance team checks the windows throughout the facility on a monthly basis. He said sometimes when lifting up and down, the screws in place to prevent the window from opening more than four inches are worn down. He may have missed this window during the monthly checks. The resident had torn the blinds down in his/her room in the past, but had not ever messed with the window or the screen. During an interview on 7/17/24 at 10:52 A.M., the Administrator said the resident was admitted to the facility after he/she tried to elope from home while living with a family member. She was not aware of the resident exhibiting any exit seeking behaviors at the facility. Staff knew the resident was an elopement risk, and his/her room was nearest to the nurse's station as an added prevention. They assumed the resident left the building through a window in the dining room on the secured unit. This was based on what the camera showed, and an opened window with torn screen in the dining room. Staff did not realize the resident was out of the building until 10:15 P.M. The resident was found by police near a hospital, approximately two miles away. The resident returned to the facility at 6:15 A.M. on 7/13/24. The Administrator said she never told staff specifically to visually verify a resident when making rounds, but that was the expectation. During an interview on 7/17/24 at 2:43 P.M., the Medical Director said he was made aware of the resident's elopement immediately. This incident was very out of the ordinary. He expected staff to visually check on residents when doing rounds. During an interview on 7/23/24 at 12:47 P.M., the resident's POA said prior to coming to the facility, the resident lived alone. After the resident had moved into the facility, the POA took the resident out on a visit and the resident walked away. He/She had been made aware of the resident's elopement by the facility on 7/12/24 between 10:30 P.M. and 11:00 P.M. The POA thought the resident was at the facility in a locked unit for his/her safety. The POA and another family member came to the facility the night of 7/12/24 and helped search for the resident. Law enforcement informed him/her the resident had been found between 5:30 A.M. and 6:00 A.M. on 7/13/24. MO00238922 MO00238924 -

Based on observation, interview and record review, the facility failed to provide protective oversight to one of three sampled residents identified by the facility as at risk for elopement. Resident #8, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia (a serious mental health condition that affects how people think, feel and behave) and was assessed to have moderate cognitive impairment. The resident had a known history of elopement and was admitted to the facility due to elopements while at home. During routine rounds, staff who were assigned to the resident failed to visibly check for confirmation of the resident's whereabouts. The resident left the building without staff knowledge and remained out of the building for approximately four hours before staff realized the resident was missing. The resident was found 12 hours later, approximately two miles away from the facility and had to cross a busy intersection to arrive at the location he/she was found. The census was 160. The Administrator was notified on 7/18/24, of the Immediate Jeopardy (IJ) past non-compliance which began on 7/12/24. The facility educated all nursing staff on visual checks during rounds, educated all staff on the facility's elopement policy and procedures, completed an audit of all residents at risk for elopement and updated care plans accordingly, performed an elopement drill, and audited all windows and alarmed doors. The deficiency was corrected on 7/15/24. Review of the facility's Essential Functions of Certified Nurse Aide (CNA), revised 1/2024, included: -Notes observations of resident behavior, complaints, or symptoms and communicates immediately to nursing supervisors any known or suspected changes in residents' condition; -Follows all company policies and procedures; -Other duties as assigned. Review of the facility's Missing Resident/Elopement policy, last revised on 4/26/24, showed: -Policy: The Charge Nurse is responsible for knowing the location of their assigned residents. Residents who are participating in various programs such as Physical Therapy, Recreational Activities, Dining, etc., the employees in these programs will be responsible for the location of their participants; -Responsibility: All employees, interdisciplinary team (IDT) Members, Nursing Administration, Director of Nursing (DON) and Licensed Nursing Home Administrator; -Procedure: -It is the responsibility of all employees to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse immediately; -At any time in which a resident is determined missing, the following procedure will be followed: -The Supervisor/Charge Nurse will alert all personnel by all-paging Code Gray and location (including Unit and Room Number); -A search of the immediate area will be initiated under the direction of the Nursing Supervisor/Charge Nurse; -A search will be conducted of all rooms including locked rooms; -The Nursing Supervisor/Charge Nurse will designate employees to search the surrounding building as appropriate (patio, parking lot, etc.); -If the search of the immediate area (building) is unsuccessful, the Nursing Supervisor/Charge Nurse will immediately contact the Administrator and DON, local police department, family/responsible party, Regional Nurse and Director of Operations, attending physician and Department of Health and Senior Services (DHSS). Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/18/24, showed: -Moderate cognitive impairment; -Wandering behaviors not exhibited; -Frequently incontinent of bowel and bladder; -Once standing, ability to walk 150 feet in a corridor or similar space: Supervised or touching assistance. Helper provides verbal cues or touch/steadying assistance; -Diagnoses included: Alzheimer's disease, schizophrenia, high blood pressure, and diabetes. Review of the resident's undated care plan, in use during the investigation, showed: -Focus: Resident has impaired cognitive function/dementia. Resident carries a baby doll around; -Goal: Will maintain current level of cognitive function; -Interventions: Administer meds as ordered. Identify self at each interaction. Face resident when speaking; -Focus: At risk for elopement as evidenced by: History or wandering; -Goal: Will not leave the facility unattended; -Interventions: Identify pattern of elopement. If resident exits the building, do not leave unattended, walk with resident and/or keep within eye sight. Monitor location closely. Review of the resident's April, May, and June 2024 Elopement Risk Evaluations, showed: -At risk; -Does the resident have a history of elopement or an attempted elopement while at home? Yes; -Does the resident have a history of attempting to leave the facility without informing staff? Yes; -Does the resident wander? Yes; -Is the wandering behavior a pattern, goal directed (i.e. specific destination in mind, going home, etc.)? Yes. Review of the resident's progress notes, showed: -Nursing note on 4/17/24 at 7:19 P.M., Resident actively exit seeking and pushing on doors. Resident becoming increasingly agitated. Resident redirected to his/her room. Medical doctor notified; -Nursing note on 7/12/24 at 5:41 P.M., Resident refused medications this evening x 3, family member informed; -Administration note on 7/12/24 at 11:27 P.M., Received a call that resident was not in his/her room upon rounds at approximately 10:45 P.M. Facility conducted facility wide and surrounding area checks with no results. Resident noted to refuse medication today. Resident belongings noted on his/her bed and covered with blanket and remain in his/her room at this time. Resident's Power of Attorney (POA, a legal document that allows someone to act on the behalf of someone else), medical doctor, and local police notified and search continued; -Nursing note on 7/13/24 at 6:15 A.M., Resident returned to facility accompanied by local police officer. Resident currently sitting in TV area waiting for family to arrive, family stated they're going to take him/her to the hospital for observation. Police officer is still waiting with resident until family arrives. Management made aware of resident return. Review of the facility's completed investigation, dated 7/13/24, included: -On 7/12/24 at approximately 10:15 P.M., staff reported they entered the resident's room, called out to him/her with no reply they then approached the bed and pulled back the covers and noticed the resident was not in his/her bed. Staff searched his/her room as well as the unit and immediately initiated a Code Gray. The Administrator, DON and Assistant Director of Nursing (ADON) were notified. Staff then initiated a facility wide search including the grounds and surrounding community. The doctor, POA and police were made aware of the situation; -Weather report checked (which was 73 degrees); -Upon completion of the investigation, the window in the dining room appeared tampered with (retaining screws removed and screen torn) therefore, it was determined the resident exited the facility through the dining room window of the unit. During an interview Licensed Practical Nurse (LPN) C reported he/she observed the resident in the dining room with another resident at approximately 6:00 P.M. LPN C indicated he/she did not observe the resident exit seeking during the shift. LPN C recalled the resident ambulating between his/her room and the dining room, cleaning tables. During an interview with CNA D, he/she explained he/she last saw the resident in his/her room between 5:45 P.M. and 5:55 P.M. According to CNA D, the resident did not exhibit exit seeking behaviors during his/her shift; -During staff interview with CNAs B and A, they said at approximately 8:30 P.M., they were making their rounds and noticed what appeared to be the resident lying in bed with his/her blanket covering him/her. According to the CNAs, the resident is continent of bowel and bladder and appeared to be comfortable; without disturbing the resident they went to assist the other residents on the unit. During staff interviews with CNAs B and A, they explained they work together on their assignments and during their first rounds they noticed what they thought was the resident lying in his/her bed and it was not until their second round at approximately 10:15 P.M., they realized what they thought was the resident was actually his/her pillow and his/her multiple baby dolls covered with the resident's blanket. Upon searching, the resident was not in his/her room or on the unit, therefore a Code Gray was initiated; -On 7/13/24 the resident was located safely and escorted back to the facility at 6:15 A.M. Attempted to interview the resident regarding leaving the facility, however the resident was unable to provide any information. Observation of the facility's surveillance video on 7/17/24 at 10:52 A.M., showed: -The surveillance camera faced the back of the facility; -At approximately 6:11 P.M. on 7/12/24, the resident could be seen walking into the line of sight of the camera; -The resident quickly walked past the back of the building and continued up the driveway towards the front of the building, outside of the camera's line of sight; -The resident wore jeans, a t-shirt, a hoodie, and shoes. Review of www.timeanddate.com for temperatures in Florissant, MO on 7/12/24 and 7/13/24, showed: -At 6:51 P.M. on 7/12/24, the temperature was 86 degrees Fahrenheit (F); -At 5:51 A.M. on 7/13/24, the temperature was 76 degrees F. Review of the resident's progress notes, showed: -Nursing note on 7/13/24 at 6:54 A.M., No injuries noted, no signs/symptoms of acute distress. Resident was in good spirits, upbeat, smiling and seemed happy to be back; -Social Services (SS) note on 7/13/24 at 11:23 A.M., SS met with resident to see how he/she was doing and to discuss recent behaviors. Due to illness resident gets confused at times. Resident was able to state he/she was well and appeared in a positive mood. Resident was unable to discuss recent behaviors. Resident did not appear to be displaying any exit seeking behaviors at this time. Resident is currently on 1:1 with staff. SS will continue 1:1 three times a week for four weeks. There were no further concerns with resident at this time per nurse. Resident will be monitored accordingly. Observation and interview of the resident, showed: -On 7/17/24 at 9:25 A.M., the resident sat in a wheelchair in the doorway of his/her room. The resident had two baby dolls on his/her lap. He/She appeared calm and engaged with the baby dolls; -On 7/28/24 at 9:18 A.M., the resident sat in a chair by the nurse's station. He/She was rocking a baby doll back and forth. The resident introduced his/her baby to the surveyor. The resident said he/she had lived at the facility here and there two times. The resident said he/she had siblings. The resident's brother took the resident out and was coming later that day. The resident said it wasn't easy being at the facility. He/She denied ever leaving the facility alone. The resident said he/she would tell them, and pointed to the nurse's station, if he/she was going to leave. During an interview on 7/17/24 at 11:53 A.M., LPN C said he/she worked the 7:00 A.M. to 7:00 P.M. shift on 7/12/24. The last time LPN C saw the resident, was at approximately 5:50 P.M. The resident was in the dining room with his/her hands on the table and holding his/her baby dolls. LPN C was surprised when he/she heard the resident eloped. The resident had not displayed exit seeking behavior in the last 30 days. LPN C did not know the window could be lifted all the way up. There was an elopement book at the nurse's station that lists residents at risk for elopement. If a resident could not be found, they were to call a Code Gray. LPN C said staff were expected to complete rounds every two hours and lay eyes on the residents assigned to staff. The resident is now on 1:1 with staff and staff are also completing 15 minute checks. During an interview on 7/17/24 at 12:19 P.M., CNA D said he/she was familiar with the resident. The resident was always quiet and to himself/herself. The resident liked to stay in his/her room, at a chair by the nurse's station or in the dining room. CNA D had observed the resident fiddle with the blinds in his/her room and look outside, but had never observed the resident mess with the window. CNA D worked the 7:00 A.M. to 7:00 P.M. shift on 7/12/24. CNA D was aware the resident was exit seeking. He/She last saw the resident on 7/12/24 between 5:50 P.M. and 5:55 P.M. The resident was in his/her room with his/her baby dolls. When staff completed rounds, they should lay eyes on every resident on their assignment. If a resident wasn't in their room, CNA D would go look for them. During an interview on 7/18/24, CNA B said he/she had worked the 7:00 P.M. to 7:00 A.M. shift and the resident was usually on his/her assignment. The resident usually stayed in his/her room, sat by the nurse's station or sat in the dining room. CNA B had never known the resident to try to get out. He/She had never seen the resident fiddle with the windows at all. CNA B was shocked when he/she found out the resident left through a window. The CNAs who work the day shift are always gone when the night shift CNAs begin work. The nurse provided information about the residents during report at shift change. CNA B did not see the resident at the start of his/her shift on 7/12/24. All of the residents were up at the beginning of the shift. The first time he/she checked on the resident, CNA B peeked his/her head into the resident's room. The resident appeared to be asleep. The second time CNA B checked on the resident, he/she thought maybe the resident needed a drink, so CNA B pulled back the cover and saw the resident wasn't there. The first time CNA B checked on the resident, he/she did not go in the room. Once the resident was discovered to be missing, a Code Gray was called. They checked all resident rooms, bathrooms, shower rooms and opened all doors. He/She checked the windows in resident rooms, but did not check the windows in the dining room. The ADON then called the police. CNA B did not know what the resident was wearing because he/she had not seen the resident at all during his/her shift. During an interview on 7/18/24 at 6:33 A.M., CNA A said he/she was familiar with the resident and said the resident was pretty independent. When he/she started his/her shift, the CNAs from the earlier shift had already left. CNA A would get report from the nurse or the Certified Medication Technician (CMT). That night, the CMT came to the hall at 10:30 P.M., but should have been there at 7:00 P.M. CNA A and CNA B usually completed rounds together. The resident's routine varied in the evening. He/She usually sat by the nurse's station. The night of 7/12/24, the resident appeared to be asleep, so he/she did not wake the resident. The second time they completed rounds, they were going to offer the resident water and snacks. They pulled back the covers and the resident was not there. After checking resident rooms, bathrooms and the dining room, a Code Gray was called. CNA A had not seen the resident all shift and did not know what the resident wore. CNA A asked a CMT what the resident had on and was told blue jeans and a black shirt. CNA A was aware he/she should do visual checks on residents when completing rounds. During an interview on 7/18/24 at 9:12 A.M., the Maintenance Director said the maintenance team checks the windows throughout the facility on a monthly basis. He said sometimes when lifting up and down, the screws in place to prevent the window from opening more than four inches are worn down. He may have missed this window during the monthly checks. The resident had torn the blinds down in his/her room in the past, but had not ever messed with the window or the screen. During an interview on 7/17/24 at 10:52 A.M., the Administrator said the resident was admitted to the facility after he/she tried to elope from home while living with a family member. She was not aware of the resident exhibiting any exit seeking behaviors at the facility. Staff knew the resident was an elopement risk, and his/her room was nearest to the nurse's station as an added prevention. They assumed the resident left the building through a window in the dining room on the secured unit. This was based on what the camera showed, and an opened window with torn screen in the dining room. Staff did not realize the resident was out of the building until 10:15 P.M. The resident was found by police near a hospital, approximately two miles away. The resident returned to the facility at 6:15 A.M. on 7/13/24. The Administrator said she never told staff specifically to visually verify a resident when making rounds, but that was the expectation. During an interview on 7/17/24 at 2:43 P.M., the Medical Director said he was made aware of the resident's elopement immediately. This incident was very out of the ordinary. He expected staff to visually check on residents when doing rounds. During an interview on 7/23/24 at 12:47 P.M., the resident's POA said prior to coming to the facility, the resident lived alone. After the resident had moved into the facility, the POA took the resident out on a visit and the resident walked away. He/She had been made aware of the resident's elopement by the facility on 7/12/24 between 10:30 P.M. and 11:00 P.M. The POA thought the resident was at the facility in a locked unit for his/her safety. The POA and another family member came to the facility the night of 7/12/24 and helped search for the resident. Law enforcement informed him/her the resident had been found between 5:30 A.M. and 6:00 A.M. on 7/13/24. MO00238922 MO00238924 -

Based on observation, interview and record review, the facility failed to ensure staff who transport residents in the facility van were certified in Cardiopulmonary Resuscitation (CPR) for healthcare providers, when residents potentially requiring CPR were being transported. This affected one resident (Resident #10) who was a full code (CPR to be provided in the event the heart stops beating) observed to be transported in the facility van with staff who was not CPR certified. The census was 169. The Administrator was notified on [DATE] at 1:04 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's cardiopulmonary resuscitation policy, last reviewed 9/2023, showed: -Policy: the facility will provide basic life support, prior to the arrival of Emergency Medical Services (EMS) including initiation of CPR to a resident who experiences cardiac arrest (heart stops beating) in accordance with the resident's advanced directives; -Procedure: -Upon resident assessment with absent vital signs; -Resident who is a full code will have CPR initiated immediately; -CPR will continue until EMS arrives to take over CPR. Review of Resident #10's medical record, showed: -Diagnoses included: irregular heartbeat, high blood pressure and end stage kidney disease. -The re-admission physician order sheet, showed an order dated [DATE], for full code. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: request full code; -Goal: code status will be maintained; -Interventions: call for an ambulance, in the event of cardiac arrest staff should begin CPR measures, transfer to hospital of choice, notify physician and responsible party of transfer and provide emergency measures. During an interview on [DATE] at 8:17 A.M., Transportation Aide E said he/she worked as both the transportation aide and a certified nurse aide (CNA). He/She is not CPR certified. He/She may transport a resident alone, other times additional staff may be in the van to assist with resident care. During an interview on [DATE] at 12:47 P.M., the Social Service Director said he/she assists with driving the facility transportation van when needed and said he/she was accompanied by CPR certified staff. He/She is not CPR certified. He/She will be the backup driver if Transportation Aide E is unavailable. Additional staff may not attend all transports, dependent on the resident care needs. During an observation on [DATE] at 9:49 A.M., Transportation Aide E placed Resident #10 into the facility transportation van and secured the wheelchair in place. Transportation Aide E got into the driver's seat and left the facility. No other facility staff were inside the van. During an interview on [DATE] at 11:02 A.M., the Director of Nurses (DON) said Transportation Aide E was alone in the van with the resident. During an interview on [DATE] at 1:30 P.M., Transportation Aide E said he/she and Resident #10 were the only persons in the facility van when he/she took the resident to his/her appointment. Transportation Aide E did not know if Resident #10 wanted CPR. If a resident stopped breathing, he/she would pull over and hold the resident's hand and call EMS. He/She could not provide CPR, since he/she is no longer CPR certified. The facility used to provide CPR classes to staff, and no longer do. During an interview on [DATE] at 2:32 P.M., the DON and the Administrator said Transportation Aide E worked part time as the transportation aide at the facility, he/she also worked as a CNA. There may not be a second staff member in the facility van when transporting a resident. The Administrator and DON were unaware at least one staff member had to have CPR certification in the van while transporting residents who were full code status. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to ensure one resident's safety during transportation in the facility's van. The facility failed to properly secure one resident's safety belt prior to transporting (Resident #1). Resident #1 required full assistance due to a diagnosis of quadriplegia (paralysis that affects all four extremities) and had been assessed with unsteady balance. On 6/13/23, Driver/Social Worker A and Driver H were returning the resident to the facility from a medical appointment. When another car swerved in front of the facility van, Driver/Social Worker A pressed the brake quickly. The resident fell out of the wheelchair, and sustained a head injury when he/she hit his/her head on a fire extinguisher. Driver/Social Worker A and Driver H, who were not nurses, picked up the resident and placed him/her back in the wheelchair and returned to the facility. At the facility, 911 was called and the resident was transferred to the hospital. He/She sustained a head laceration and spraining of cervical (neck area of the spine) and thoracic (T) ligaments of T1-T2 and T2-T3. Neurosurgery spinal fusion was performed from T1-T4 on 6/16/23. The census is 169. The administrator was informed on 9/29/23 at 3:23 P.M., of an Immediate Jeopardy (IJ) past noncompliance which began on 6/13/23. The facility conducted an investigation and immediately in-serviced all facility van drivers of transportation safety including seatbelt use on the resident and transportation equipment, staff response in an accident or a resident slides/falls from a wheelchair and staff should not move residents that are involved in an accident or fall from a chair. Facility drivers had to preform testing and return demonstration of proper technique. The IJ was corrected on 6/13/23. Review of the facility's fall management policy, last reviewed 2/28/23, showed: -Policy: to provide an environment that remains as free of accident hazards as possible; -Prevention/treatment: -Prior to moving the resident, the nurse will evaluate for injury; -Complete a neurological evaluation post fall on residents with a potential head injury; -If injury is known or suspected: -provide emergency first aid as applicable; -notify the physician and resident representative; -notify nursing management; -investigate the circumstances and surrounding where the fall occurred; -document in the medical record. Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 9/26/23, showed: -Moderate cognitive impairment; -Total dependence on staff for bed mobility, transfers, dressing and toileting; -Diagnoses included: quadriplegia, spinal cord injury, irregular heartbeat and depression. Review of the resident's progress notes dated 6/13/23 at 12:45 P.M., showed the resident was out to a physician appointment. During an interview on 9/28/23 at 9:58 A.M., the resident said the afternoon of 6/13/23, he/she was picked up in the facility van by the Social Worker (SW) and Driver H following a medical appointment. The resident used his/her personal electric wheelchair to get into the van. The SW was the driver and Driver H secured the wheelchair into the van. Driver H did not apply the seatbelt to him/her in the van. The SW suddenly slammed on the breaks, and he/she went flying out of his/her wheelchair. His/Her head struck the fire extinguisher on the floor of the van between the front seats. The SW pulled the van over, the SW and Driver H both picked up the resident and placed him/her back into the wheelchair. He/She was bleeding from his/her forehead and asked the SW to call 911. The SW said the van was very close to the facility and Driver H called the facility and told the staff the resident fell out of the wheelchair. The SW proceeded to drive the resident back to the facility. When he/she arrived at the facility, several nurses provided care and called 911. The resident left the facility in the ambulance. He/She received staples, stitches and a spinal fusion because of the accident. During an interview on 9/28/23 at 12:47 P.M., Driver/Social Worker A said he/she was the backup driver and drove the facility transportation van on the afternoon of 6/13/23. He/She and Driver H were the staff members in the van with the resident. He/She and Driver H picked the resident up after an appointment. Driver H was responsible to secure the resident into the van. Driver H told him/her they were good to go after the resident entered into the van. Driver/Social Worker A did not verify with Driver H the resident was appropriately secured. Shortly after the driver turned left onto the main road, a car pulled out in front of him/her. He/She had to slow down to avoid a collision. He/She heard the resident grunt. When he/she looked down, the resident was lying on the van floor and appeared to be bleeding. The resident did not say much and appeared confused. Driver H called the facility and notified the Director of Nursing (DON) the resident had fallen out of the wheelchair. Driver/Social Worker A drove the short distance to the facility where nursing staff attended to the resident. He/She and Driver H left the resident to lie on the floor of the van and did not move the resident. Review of the statement written by Driver H, dated 6/13/23 at 4:40 P.M., showed while on the way back from a doctor's appointment, Driver/Social Worker A was cut off by a car and had to brake. When Driver/Social Worker A hit the brakes, Resident #1 fell out of his/her power chair. The power chair was secured to the van and the resident fell out of the seatbelt. The driver pulled over, and both Driver H and Driver/Social Worker A placed the resident back into his/her wheelchair. The driver called the facility and notified them of the incident. Multiple nursing staff were available when the van arrived at the facility. Review of the resident's progress notes, showed on 6/13/23 at 5:01 P.M., a social service note: the writer assisted with resident transport after a physician appointment. During the return trip back, the resident fell forward out of the power chair. The resident appeared to be bleeding. The writer called the facility to notify nursing staff. The incident occurred a few minutes away from the facility. Upon arrival at the facility, nursing staff waited outside and assessed the resident and provided care. Review of the resident's progress notes, showed on 6/13/23 at 5:01 P.M., a social service note: the writer assisted with resident transport after a physician appointment. During the return trip back, the resident fell forward out of the power chair. The resident appeared to be bleeding. The writer called the facility to notify nursing staff. The incident occurred a few minutes away from the facility. Upon arrival at the facility, nursing staff waited outside and assessed the resident and provided care. Review of the resident's progress notes documented by the nurse on 6/13/23 at 5:47 P.M., showed the resident returned to the facility by transportation vehicle with staff. The resident had fallen out of the wheelchair during the van ride back to the facility. The writer responded to the front of the building to assess the resident for injuries. The physician was notified and new order received to send to the hospital for injuries. Review of the resident's hospital emergency room record, dated 6/13/23 at 5:27 P.M., showed: -Chief complaint: patient reports the driver slammed on the breaks and the patient flew forward in the van, hitting his/her head. The patient is quadriplegic and he/she was not strapped onto the wheelchair. The patient has a laceration to the forehead and states he/she thinks he/she had a loss of consciousness lasting a few seconds; -Review of symptoms: -General: in acute pain; -Head, ear, nose and throat: an 8 centimeter (cm) forehead laceration. Laceration closed with 8 staples and 3 stitches; -Cat Scan (CT) thoracic spine trauma: trace fluid and fat stranding surrounding the upper esophagus. At the same level there appeared to be a slight widening of the T2-T3 disc space. Considerations include ligamentous or distraction injury at the T2-T3. No acute fracture noted. Review of the resident's neurosurgical consult note, dated 6/13/23, showed: -Chief complaint: motor vehicle accident, spinal ligamentous injury; -Patient reported he/she was being transported in a van by the skilled nursing facility when the vehicle stopped abruptly and caused him/her to launch forward out of the wheelchair, and hit his/her head. The patient reported new bilateral (both sides) of the lower extremity (LE) weakness, and usually able to kick legs out but he/she is not able to since the accident. An magnetic resonance imaging (MRI) of the thoracic spine revealed acute discoligamentous (severe spinal injuries in which the intervertebral disc and the intervertebral ligamentous structures are involved) injury at T2-T3 with mild distraction, disruption of the anterior longitudinal ligament (ALL)/bridging syndesmophyte (damage bridges across the spine) and sprain of the interspinous (between the vertebrae) ligaments both T1-T2 and T2-T3. The patient would benefit from surgical intervention; -Tentative plan: posterior spinal fusion with extension of the previous cervical fusion down to the T4 level. Review of the resident's progress notes, showed the following: -On 6/14/23 at 12:54 P.M., received a call from the hospital. The resident is admitted with a spinal injury; -On 6/19/23 at 12:15 P.M., the resident remains in the hospital for a fusion and drain to the back; -On 6/27/23 at 4:28 P.M., the resident readmitted to the facility. Alert and orientated to person, place and time. Treatments applied as ordered. During an interview on 9/28/23 at 1:54 P.M., the Assistant Director of Nursing (ADON) said on 6/13/23, Driver/Social Worker A called the facility and said the resident fell from his/her wheelchair in the van and was bleeding from his/her head. Multiple nurses responded to the front entrance and assisted with providing first aid to the resident. The resident was in his/her electric wheelchair when the van arrived and he/she had a laceration to the top of the forehead. Emergency services was notified and the resident went to the hospital for care. During an interview on 9/28/23 at 1:11 P.M., the DON said she was contacted by Driver H that the resident had fallen out of the wheelchair in the transport van on 6/13/23. Driver/Social Worker A was the driver at the time and said he/she had to stop suddenly to avoid an accident, he/she was located very close to the facility and was on the way back to the facility. The van arrived and several nurses were at the front entrance. The resident was in his/her electric wheelchair and the seat belt was in place. The resident was bleeding from a laceration to the top of his/her forehead. The resident said Driver/Social Worker A was driving and suddenly hit the brakes, and he/she flew out of the wheelchair and hit his/her head. Driver/Social Worker A said he/she was driving and had to stop suddenly. The resident fell out of the wheelchair and hit his/her head on something between the front seats. First aid was provided and emergency services was called when the resident arrived at the facility. During an interview on 9/29/23 at 10:48 A.M., the DON and Administrator said residents who fall should not be moved until assessed by the nurse or emergency personnel. Residents should be appropriately secured in the facility van. If a resident has an incident in the facility van, staff should not move the resident and wait for emergency services to provide aid.

See 6M3212 Based on observation, interview and record review, the facility failed to implement an effective system to ensure appropriate supervision and assistance needs were identified and provided for one resident (Resident #3), who was assessed by the facility as having disorganized thinking and delusions, and assessed by his/her psychiatrist as having exacerbation of delusions- in order to keep the resident safe. On-duty facility staff took the resident out with him/her to smoke and then left the resident outside alone, although his/her care plan directed staff to provide supervised smoking. The charge nurse on the resident's hall was unaware the resident left and another facility staff person found the resident unattended and outside the facility in the parking lot. Additionally, the facility failed to develop and implement interventions to ensure the safety of Resident #22, who had diagnoses including cognitive communication deficit and anoxic brain injury and a history of elopement. Resident #22 left the facility unattended and was found along a two-lane road by the police. Three residents were sampled. The census was 144. The administrator was notified on 8/26/22 of the immediate jeopardy (IJ) which occurred on 7/24/22 and on 8/19/22. The IJ was removed on 8/26/22 as confirmed by onsite verification. Review of the facility's notification of a change in a resident's condition policy, dated 11/1/18, showed the following: -Policy: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations; -Procedure: Guideline for Notification of Physician/Resident Representative (not all inclusive): Any Accident or Incident (per Federal and State regulations); Unusual Behavior; Missing Resident; -Document in the Interdisciplinary Team (IDT) Notes: The resident change in condition; Notification of the physician; Notification of the resident representative. Review of the facility's missing resident/elopement policy, dated 4/28/21, showed the following: -Policy: The unit charge nurse is responsible for knowing the location of their residents; -Responsibility: The charge nurse and all other staff; -It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical; -Should an employee observe a resident leaving the premises, he/she should: Attempt to prevent the departure; Obtain assistance from other staff in the immediate vicinity, if necessary; Instruct another staff member to inform the charge nurse or Director of Nursing that a resident has left the premises; Be courteous in preventing the departure and in returning the resident to the facility; -Upon Return of the resident to the facility, the Director of Nursing or charge nurse should: Examine the resident for injuries; Contact the attending physician and report the incident; Contact the resident's legal representative and inform him/her of the incident; Complete and file an incident report; Make appropriate notations in the resident's medical record; -The charge nurse will document the incident in the resident's medical record including times (time discovered, time of contact); -The charge nurse will complete a resident Accident/incident report, implement interventions, update care plan and kardex (a quick fact sheet showing plan of care); -The Administrator/Director of Nursing will notify the Department of Health per State Regulations. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/16/22, showed the following: -Moderately impaired vision; -Cognitively intact; -Disorganized thinking; -Delusions; -Wandering not present; -Independent locomotion on and off the unit; -Diagnoses included diabetes mellitus, seizures, bipolar disease (psychiatric illness characterized by both manic and depressive episodes), depression, schizophrenia (a serious mental disorder in which people interpret reality abnormally), post-traumatic stress disorder and asthma. Review of the resident's medical record, showed an undated care plan, with the following: -the resident has a visual deficit secondary to blindness in the right eye; -the resident has manipulative behaviors related to schizophrenia and ineffective coping skills with periods of delusional behaviors with rapid pressured speech. Interventions included update physician regarding changes in cognitive status, behavior problems; -the resident smokes tobacco-cigarette products and participates in supervised smoking breaks daily. Interventions included monitor and supervise the resident's smoking activity in designated smoking areas, reinforce the smoking policy for safety and hazards only to smoke in designated areas. Review of the resident's medical record, showed the following: -A psychiatric note, dated 6/30/22 at 6:58 A.M., showed the Assessment and Plan included the resident was noted to have some exacerbation of delusion, has received intramuscular Risperdal (antipsychotic used to treat schizophrenia) twice this month. Will continue old Risperdal, will reassess patient in two to four weeks, and will consider increasing intramuscular Risperdal if noted to have ongoing delusions and paranoia; -A note, dated 7/1/22 at 3:55 P.M., showed the psychiatrist gave new orders, if the Medical Director (MD) agrees, to have a urine analysis completed related to increased delusion and dysarthria (slurred) speech; -A psychiatrist note, dated 7/19/22 at 6:16 P.M., showed the resident was seen to assess recent exacerbations of target/new symptoms as reported by staff/family and assess response to ongoing psychiatric treatment and monitor psychotropic (drugs used to treat mental illnesses) medications. Assessment included the resident saying I'm being held back for what I want to accomplish, people are taking away from my business. Endorses having auditory hallucinations stating, I hear gluttony going on. Yells, I'm the Attorney General and you think I'm crazy. Assessment and Plan included: Noted to have some exacerbation of delusions, has received intramuscular Risperdal this month, is scheduled to receive the next dose today. Patient noted to have ongoing exacerbation of hallucinations and delusions for a few months now, will increase the intramuscular Risperdal to 37.5 mg every two weeks. Will continue the Risperdal 4 mg at night; Diagnoses included paranoid schizophrenia and vascular dementia with behavioral disturbance (a form of dementia that causes cognitive difficulty with reasoning and judgement, affects memory). Review of the resident's medical record on 7/28/22, showed no documentation the resident left the building on 7/25/22. Observation on 7/28/22 at 12:43 P.M., showed the resident in his/her room, fully dressed, lying in his/her bed. During an interview on 7/28/22 at 12:45 P.M., the resident said the following: -He/she was outside of the building a few days ago, looking for his/her parent's house; -He/she walked out of the building through the front door and went across the street onto a nearby cross street; -Someone, staff from the facility, stopped their car while he/she was walking down the road and told him/her to get into the car; -The staff member drove him/her back to the facility and brought him/her back inside; -The charge nurse on his/her floor did not know he/she left the building; -He/she left early in the morning, around daybreak, and he/she could not see well outside because it was a little dark; -It was the first time in five years or so that he/she left the building. During an interview on 8/2/22 at 3:00 P.M., the Assistant Director of Nursing (ADON) said the following: -On Monday morning, 7/25/22 around 5:30 A.M., he/she was driving to work when he/she saw the resident on the parking lot of the facility smoking a cigarette. The resident was alone; -He/she asked the resident why he/she was outside and the resident answered because he/she was smoking a cigarette and he/she fucking could be outside; -The ADON invited the resident into his/her car, and then drove the resident to the back parking lot, a few feet away; -The ADON took the resident into the facility and back to his/her room; -The ADON called the administrator and the DON and told them what happened around 8:00 A.M.; -He/she did not write an incident report because he/she did not consider it an elopement. The resident was responsible for self, had a high Brief Interview for Mental Status (BIMS, a brief screener of cognition) score and signed him/herself out; -He/she did not interview staff or perform a skin assessment on the resident because it was not an elopement; -The resident was allowed to go out of the building unattended even though he/she was confused, because he/she was responsible for self; -The facility was responsible for the resident's safety; -The ADON was not sure if the resident was on the facility parking lot the entire time he/she was outside, did not know how long the resident was outside alone, and how he/she left the building; -If the resident wanted to go outside, the ADON would let him/her out but then sit with the resident to ensure safety as the resident was not alert and oriented to self, place, time and situation (A&O X 4) at all times. During an interview on 8/2/22 at 8:06 P.M., Nurse O said the following: -He/she was working as the charge nurse on the shift in which the resident left the building; -He/she last saw the resident between 3:00 A.M. and 4:00 A.M.; -He/she was new to the unit and did not receive orientation to the unit before his/her shift. The 24 hour report sheet did not give information on the residents such as diagnoses, transfer status, code status or behaviors; -He/she was not told the resident was experiencing delusions during on-coming report; -He/she was responsible for two halls during that shift; -He/she did not know the resident left the building until the ADON brought the resident back into the unit. He/she could not recall the time the resident was brought back; -He/she did not know how the resident left the building; -He/she was upset to hear the resident was outside by him/herself, and he/she feared for the resident's safety; -He/she took the resident back to his/her room and obtained vital signs on the resident, which were normal; -He/she tried to do a skin assessment on the resident but the resident refused; -The ADON told him/her the DON gave instructions to not write a progress note describing the event and also to not write an incident report; -He/she was told the event was not an incident because the resident was A&O X 4, responsible for self and had signed him/herself out of the building; -He/she was prepared to document the resident left the building without supervision but did not, to follow instructions; -He/she told the nurse's aides (NAs) and the certified nurse's aides (CNAs) working during that shift to keep a close eye on the resident to ensure safety after he/she returned. During an interview on 8/2/22 at 9:17 A.M., CNA M said the following: -He/she was on staff the night the resident left the building; -The last time he/she saw the resident was around 3:30 A.M. that early morning; -He/she did not know the resident had left the building until anther staff member, the ADON brought the resident back to the hall around 5:30 A.M. or 6:00 A.M.; -He/she was told by the ADON that the resident was found walking down the main road in front of the facility. The ADON asked the resident to get into his/her car and then drove the resident back to the facility; -The resident was very confused when he/she came back into the building because he/she had not left the facility before then; -He/she went with the nurse on duty that night to check on the resident. The resident would not allow the nurse to perform a skin assessment; -He/she was told to keep a close eye on the resident to ensure safety; -The ADON told the nurse to call the resident's psychiatrist; -He/she did not know how the resident left the building. During an interview on 8/2/22 at 4:28 P.M., the administrator, DON and the regional nurse consultant said the following: -The cameras at the front entrance were new. They were installed on 7/25/22; -The doors were alarmed and had a keypad with a code for resident and staff safety; -The resident signed him/herself out in the resident sign out log, showing he/she left the building on 7/25/22 at 5:55 A.M.; -The ADON called the DON sometime that morning to talk about what was going on in the building, as that was commonly done when the DON was not at the building yet. During the call, the ADON reported the resident was found outside smoking a cigarette on the facility parking lot; -The DON did not ask the ADON if the resident was supervised while outside, as the resident was A&O X 4 every time she spoke to the resident. She did not know if the resident had periods of confusion, or was ever less that A & O X 4. The resident was always cognizant during their conversations; -She did know how long the resident was outside of the facility; -The resident had a BIMS score of 13 or 14 and was responsible for self, therefore he/she was safe to go out by him/herself; -Social services never told them the resident was anything but cognitively intact; -The ADON called and notified the administrator sometime around 8:00 A.M.; -The resident signed him/herself out; -They did not know how the resident left the building; he/she might have memorized the code from someone telling him/her or might have followed someone out of the building; -They did not think to interview the resident after the fact, nor did anyone think to ask him/her how he/she was able to light his/her cigarette, how he/she left the building or how long he/she was outside; -They did not investigate the matter because the resident was safe to go out by him/herself as evidenced by the high BIMS score, the sign out sheet and because the resident was responsible for self; -They expected staff to know when residents left the building as it related to resident safety; -The ADON made the charge nurse complete a head count because he/she was angry at the charge nurse, not because there was an elopement. During an interview on 8/2/22 at 5:10 P.M., Nurse A said the following: -The resident was not safe to leave the facility unattended due to his/her confusion and delusions; -The resident often states he/she owns another planet, sometimes has hallucinations thinking he/she is someone else, somewhere else; -The resident wasn't safe out of the premises unattended because he/she was not always in his/her right mind, and could go on a journey based on his/her delusions at the time and get hurt; -The resident would not have the ability to sign him/herself out as he/she lacked the cognitive ability and had difficulty seeing anything small; -Nurse A would consider it an elopement if the resident left the building unattended because he/she was not safe and could not make good decisions; -Nurse A worked with the resident for the past three years. During an interview on 8/2/22 at 6:06 P.M., MDS Coordinator M and MDS Coordinator N said the following: -When assessing the residents to complete the MDS forms, they used the information found in the medical records, physicians' notes, hospital discharge paperwork, assessments and interviews with family members, staff and residents; -They assessed the resident in order to complete the MDS form and found the resident as A&O X 4 with confusion; -They saw in the psychiatrist's notes that the resident had delusions and hallucinations; -Based on their conversations with the resident and on the psychiatrist's notes, they did not feel the resident was safe to go outside by him/herself into the community; -They would not expect the resident to know the name of any of the side streets that surround the facility as the resident did not have a history of leaving the facility; -They do not believe the resident could have signed him/herself out unless he/she was prompted to do so based on their assessment of the resident and because it would have been new to the resident as he/she did not leave the facility. During an interview on 8/2/22 at 5:39 P.M., the administrator, DON and the regional nurse consultant said the following: -The DON, MDS coordinators and the ADONs were responsible for reviewing the Medical Director and psychiatrist notes and evaluations as they are sent to the facility; -The DON reviewed the psychiatrist note, dated 7/19/22 at 6:16 P.M., which was in the resident's medical records under progress notes; -The DON did not recall the resident was diagnosed with vascular dementia or was experiencing delusional thoughts at the time of the psychiatrist's assessment; -After the surveyor brought their attention to the psychiatric notes in the medical file, the DON said given the 7/19/22 assessment, the resident was not safe outside unattended; -They expected staff to report and document the resident was having delusional thoughts, as that would be considered a change in condition. During an interview on 8/12/222 at 12:53 P.M., the psychiatrist said the following: -She was not alerted to the resident leaving the building unattended until after the surveyor's visit to the facility; -The resident has chronic schizophrenia and increased delusional thoughts. He/she often says he/she owns multiple businesses, talks with the President and the FBI, and thinks a motorcycle gang is after him/her; -The resident was not safe outside of the facility unattended because there was no telling what his/her mind was telling him/her at any given time. The resident could think the motorcycle gang was coming after him/her and act upon it; -A BIMS score is not the only parameter in which to gauge whether or not a resident was capable of making safe decisions for themselves, especially given the history and diagnoses of the resident; -She increased the resident's Risperdal due to his/her increased delusions; -She expected staff to document any odd behavior the resident exhibited as it helped her when assessing the resident and also gave a clearer picture of the resident's mental health for all staff; -She would speak to the nursing staff while she was there assessing the resident and learned of his/her behaviors; -It was not her opinion that the resident was responsible for self because the resident did not understand he/she had a mental illness; -The resident was living with his/her mother until she passed away a few years ago and then went in and out of the hospital because he/she was noncompliant with medications and would deteriorate; -The resident does have a diagnosis of vascular dementia, it was not a new diagnosis; -She expected the facility to include vascular dementia in the resident's diagnoses; -She expected the facility to have awareness of the resident's increased delusions; -The resident was not living at a lower level of care because he/she was not safe to do so; -She does not think the resident was safe outside of the building unattended due to his/her history of delusions and hallucinations; -She expected the facility to notify her immediately when the resident left the building unattended as it was out of character for him/her to leave the facility. It was a change of condition. During an interview on 8/12/22 at 1:53 P.M., the DON said the following: -She expected nursing staff to follow physician orders; -The administrator opened an investigation on the resident leaving the building unattended after the surveyor brought the matter to their attention; -She called and notified both the psychiatrist and the Medical Director of the resident leaving the building after the surveyor left the facility; -The Medical Director said the resident was not safe outside by him/herself. The Medical Director did not elaborate and the DON did not think to ask why not; -The psychiatrist also said the resident was not safe outside of the building by him/herself due to delusional thoughts; -Based on her interviews with the psychiatrist and Medical Director, the resident was not safe outside of the building unattended. During an interview on 8/15/22 at 3:25 P.M., the administrator said the following; -Knowing what he knows now, the resident is not safe outside of the building unattended; -He conducted an investigation after the surveyor alerted him to the situation and found that a new CNA took the resident out with him/her to smoke and then left the resident outside alone; -The charge nurse on the resident's hall was also new to the unit/facility and did not know the resident very well; -The CNA should have verified with the nurse to see if the resident was safe outside unsupervised; -The diagnosis of vascular dementia should have been listed in the resident's medical file as an active diagnosis; -Nursing staff were expected to read progress notes, the resident's BIMS score and diagnoses in order to get a complete picture of the resident; -He expected staff to notify him if they had a concern about the resident's safety immediately and he would have conducted an investigation; -He expected staff to follow facility policies and procedures. During an interview on 8/23/22 at 2:29 P. M., CNA P said the following: -He/she did get orientated to the smoking policy. It said if it is outside of the designated time to smoke, employee can choose to take resident out to smoke in designated area; -Staff are required to stay with residents if they take them out on a smoking break. He/she knew that at the time that the policy was to stay outside with the resident; -He/she was walking towards the front entrance when the resident approached him/her and asked if he/she could go outside with the CNA to smoke; -He/she said yes and took the resident out through the front alarmed door to smoke with him/her; -He/she did not know if the front of the building is a designated area for resident to smoke; -He/she left the resident outside because a white four door car pulled up and parked in the front row, a female was inside the car rummaging around gathering bags as if to take them into work; -He/she told the resident to go back inside with the female in the white car; -He/she went back into the building through the front door, leaving the resident outside alone; -He/she did not wait until the female exited the car; he/she did not know who the female was or if the female was coming into the building; he/she did not tell the female to bring the resident back into the building; -The resident had his/her own cigarettes. The CNA lit the first cigarette for him/her. He/she did not know how the resident lit the second cigarette; -He/she did not know how the resident came back into the building; -He/she did not know if the resident wandered off of the property; -He/she did not tell anyone he/she took the resident outside. He/she doesn't know why he/she didn't notify anyone; -He/she told a NA in casual conversation that he/she left the resident outside. He/she does not know who that NA was or if the NA told anyone else; -He/she doesn't know why she didn't tell the resident's nurse the resident was outside by him/herself; -He/she was not working on the resident's unit. He/she was leaving the building when the resident approached him/her and asked if he/she could come out with him/her to smoke; -He/she thinks the resident signed him/herself out. He/she did not witness it. The resident was walking behind him/her and stopped at the desk. He/she assumed the resident signed him/herself out; -He/she was unaware the resident was a risk to go outside by him/herself because he/she was very independent with ADLs; -If he/she had to do it all over again, CNA P would not have taken the resident outside; -He/she was in a rush to get back into the building so he/she could wake up the residents; -He/she worked the night shift 7:00 P.M. through 7:00 A.M.; -He/she had been a CNA for [AGE] years; -He/she worked for the facility as an agency CNA since March, and was hired full time in June. During an interview on 8/25/22 at 2:06 P.M., the administrator said the following: -The resident's smoking assessment clarified if a resident should be supervised while smoking; -The smoking policy said all residents are supervised when smoking; -He expected staff to follow policies and procedures; -Smoking assessments were performed on admission, quarterly and as needed; -Elopement risk assessments were performed on admission, quarterly and as needed; -Care plans were updated quarterly and as needed after investigations were compete; -Staff were informed care plans were updated by the ADON and DON; -Residents' kardex was also updated showing care plan changes; -Nurses were also expected to inform oncoming staff in report of any changes in plan of care and also notate changes on the 24 hour report sheet; -The facility did not complete elopement risk assessments on all residents. 2. Review of Resident #22's admission MDS, dated [DATE], showed the following: -admitted on [DATE]; -Moderate cognitive impairment; -No behaviors present; -Independent locomotion on and off the unit; -Wheelchair for mobility; -Diagnoses included cognitive communication deficit (impairment in organization/thought, sequencing, attention, memory, planning, problem-solving, and safety awareness), stroke, anoxic brain damage (diminished oxygen supply to the brain causing serious impairment in cognitive skills), end stage renal disease (kidney failure), dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood), encephalopathy (any brain disease that alters brain function or structure) and seizures. Review of the resident's medical record, showed the following: -An elopement risk assessment, dated 2/22/22, showed low risk for elopement; -An order, dated 7/7/22, for dialysis services at an outside dialysis center on Mondays, Wednesdays and Fridays; -An elopement risk assessment, dated 8/19/22, showed at high risk for elopement; -A care plan, undated, showed the resident was at risk for elopement related to leaving the facility without notifying staff on 8/19/22. Interventions included: Monitor for location every 15 minutes for 72 hours; the resident was sent to the emergency room for evaluation and treatment. There were no interventions on the care related to preventing elopement in the future. Review of the resident's progress notes, dated 1/7/22 through 8/25/22, showed the following: -No documentation regarding the resident being found at a hospital downtown by the facility's driver; -No documentation regarding the resident eloping from the outside dialysis center; -No documentation regarding a chaperone accompanying the resident to the outside dialysis center; -No documentation regarding the resident's discharge from the outside dialysis center due to high elopement risk. During an interview on 8/25/22 at 11:52 A.M., Nurse A said the following: -The resident had eloped from the facility the previous week and a neighbor called the facility to alert them of a possible resident in a wheelchair seen on the two-lane street located in front of their building; -Nurse A knew the incident had occurred because he/she learned about it in report; -The resident had been acting differently before the elopement, wandering more around the building; -He/she did not document the change of behavior in the resident's medical record; -A few weeks ago, the resident had left from his/her dialysis center located in midtown and walked to a hospital that was located 2.4 miles away, a 50 minute walk; -The facility's transportation driver found the resident; -Changes were not made to the resident's plan of care, including any new interventions; -He/she did not know why the facility did not change the plan of care for safety. During an interview on 8/25/22 at 12:23 P.M., the administrator said the following: -Through their investigation, they found while watching security footage from the front door entrance, a CNA entered the building through the electronic, automatic doors and walked to the left, rounded the corner and was out of sight; -The resident was sitting in his/her wheelchair near the door and was seen wheeling him/herself out of the building through the front doors, before the doors completely shut from the CNA's entrance; -The facility had since changed the delay time before the door closes; -The elopement occurred on a Thursday night. The nurse called the administrator to inform him a neighbor called the facility, at approximately 11:45 P.M., to alert them a resident was seen on the main road located in front of the facility; -The facility called a code gray (the elopement code), a head count of all residents was made and the resident was found missing; -The resident had called 911 while he/she was out of the facility, asking to go to the hospital; -At approximately 12:00 A.M., the police came to the facility after locating the resident on the two lane road, informing them they called the emergency medical service and the resident was sent to the hospital; -The resident returned from the hospital at approximately 4:00 A.M. that same morning; -The resident was not identified as an elopement risk before the incident; -The resident previously attended an outside dialysis center located in midtown; -He was not aware of any reports of the resident leaving the outside dialysis center; -He expected the outside dialysis center to report if the resident had eloped from their center so the facility could have identified the resident as an elopement risk, and include it in the resident's care plan; -He expected any reports of the resident eloping from the outside dialysis center documented in the resident's medical record; -He expected nurses to document any new behaviors in the resident's medical record so nursing management was aware and could possibly change plan of care. During an interview on 8/25/22 at 1:24 P.M., the clinical manager from the outside dialysis center, said the following: -The resident was discharged from their dialysis center on 8/16/22; -The discharge reason was due to high elopement risk, as the resident had left from the dialysis center many times; -The facility was aware the resident had a history of elopement. -The staff at the dialysis center told the facility the resident would frequently leave the center and then was found two or three blocks away; -The facility admission staff came to the dialysis center to pick up lab work and staff at the dialysis center had a conversation regarding the resident leaving the dialysis center. During an interview on 8/25/22 at 1:50 P.M., the social worker (SW) from the outside dialysis center, said the following: -Staff had reported the resident had left the center and was found down the street; -He/she did tell the facility's Social Service Director (SSD) about the resident's habit of eloping from the center before they discharged the resident back to the facility. The SSD was informed they were concerned of the resident's safety due to elopements; -The SSD said he/she was not aware of the resident eloping from the dialysis center prior to their conversation about the discharge; -The SSD said he/she would inform the administrative team at the facility; -The SW never heard back from the facility's SSD. During an interview on 8/25/22 at 2:06 P.M., the administrator said the following: -Elopement risk assessments were performed on admission, quarterly and as needed; -Care pl

Based on observation, interview and record review, the facility failed to implement an effective system to ensure appropriate supervision and assistance needs were identified and provided for one resident (Resident #3), who was assessed by the facility as having disorganized thinking and delusions, and assessed by his/her psychiatrist as having exacerbation of delusions- in order to keep the resident safe. On-duty facility staff took the resident out with him/her to smoke and then left the resident outside alone, although his/her care plan directed staff to provide supervised smoking. The charge nurse on the resident's hall was unaware the resident left and another facility staff person found the resident unattended and outside the facility in the parking lot. Additionally, the facility failed to develop and implement interventions to ensure the safety of Resident #22, who had diagnoses including cognitive communication deficit and anoxic brain injury and a history of elopement. Resident #22 left the facility unattended and was found along a two-lane road by the police. Three residents were sampled. The census was 144. The administrator was notified on 8/26/22 of the immediate jeopardy (IJ) which occurred on 7/24/22 and on 8/19/22. The IJ was removed on 8/26/22 as confirmed by onsite verification. Review of the facility's notification of a change in a resident's condition policy, dated 11/1/18, showed the following: -Policy: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations; -Procedure: Guideline for Notification of Physician/Resident Representative (not all inclusive): Any Accident or Incident (per Federal and State regulations); Unusual Behavior; Missing Resident; -Document in the Interdisciplinary Team (IDT) Notes: The resident change in condition; Notification of the physician; Notification of the resident representative. Review of the facility's missing resident/elopement policy, dated 4/28/21, showed the following: -Policy: The unit charge nurse is responsible for knowing the location of their residents; -Responsibility: The charge nurse and all other staff; -It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical; -Should an employee observe a resident leaving the premises, he/she should: Attempt to prevent the departure; Obtain assistance from other staff in the immediate vicinity, if necessary; Instruct another staff member to inform the charge nurse or Director of Nursing that a resident has left the premises; Be courteous in preventing the departure and in returning the resident to the facility; -Upon Return of the resident to the facility, the Director of Nursing or charge nurse should: Examine the resident for injuries; Contact the attending physician and report the incident; Contact the resident's legal representative and inform him/her of the incident; Complete and file an incident report; Make appropriate notations in the resident's medical record; -The charge nurse will document the incident in the resident's medical record including times (time discovered, time of contact); -The charge nurse will complete a resident Accident/incident report, implement interventions, update care plan and kardex (a quick fact sheet showing plan of care); -The Administrator/Director of Nursing will notify the Department of Health per State Regulations. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/16/22, showed the following: -Moderately impaired vision; -Cognitively intact; -Disorganized thinking; -Delusions; -Wandering not present; -Independent locomotion on and off the unit; -Diagnoses included diabetes mellitus, seizures, bipolar disease (psychiatric illness characterized by both manic and depressive episodes), depression, schizophrenia (a serious mental disorder in which people interpret reality abnormally), post-traumatic stress disorder and asthma. Review of the resident's medical record, showed an undated care plan, with the following: -the resident has a visual deficit secondary to blindness in the right eye; -the resident has manipulative behaviors related to schizophrenia and ineffective coping skills with periods of delusional behaviors with rapid pressured speech. Interventions included update physician regarding changes in cognitive status, behavior problems; -the resident smokes tobacco-cigarette products and participates in supervised smoking breaks daily. Interventions included monitor and supervise the resident's smoking activity in designated smoking areas, reinforce the smoking policy for safety and hazards only to smoke in designated areas. Review of the resident's medical record, showed the following: -A psychiatric note, dated 6/30/22 at 6:58 A.M., showed the Assessment and Plan included the resident was noted to have some exacerbation of delusion, has received intramuscular Risperdal (antipsychotic used to treat schizophrenia) twice this month. Will continue old Risperdal, will reassess patient in two to four weeks, and will consider increasing intramuscular Risperdal if noted to have ongoing delusions and paranoia; -A note, dated 7/1/22 at 3:55 P.M., showed the psychiatrist gave new orders, if the Medical Director (MD) agrees, to have a urine analysis completed related to increased delusion and dysarthria (slurred) speech; -A psychiatrist note, dated 7/19/22 at 6:16 P.M., showed the resident was seen to assess recent exacerbations of target/new symptoms as reported by staff/family and assess response to ongoing psychiatric treatment and monitor psychotropic (drugs used to treat mental illnesses) medications. Assessment included the resident saying I'm being held back for what I want to accomplish, people are taking away from my business. Endorses having auditory hallucinations stating, I hear gluttony going on. Yells, I'm the Attorney General and you think I'm crazy. Assessment and Plan included: Noted to have some exacerbation of delusions, has received intramuscular Risperdal this month, is scheduled to receive the next dose today. Patient noted to have ongoing exacerbation of hallucinations and delusions for a few months now, will increase the intramuscular Risperdal to 37.5 mg every two weeks. Will continue the Risperdal 4 mg at night; Diagnoses included paranoid schizophrenia and vascular dementia with behavioral disturbance (a form of dementia that causes cognitive difficulty with reasoning and judgement, affects memory). Review of the resident's medical record on 7/28/22, showed no documentation the resident left the building on 7/25/22. Observation on 7/28/22 at 12:43 P.M., showed the resident in his/her room, fully dressed, lying in his/her bed. During an interview on 7/28/22 at 12:45 P.M., the resident said the following: -He/she was outside of the building a few days ago, looking for his/her parent's house; -He/she walked out of the building through the front door and went across the street onto a nearby cross street; -Someone, staff from the facility, stopped their car while he/she was walking down the road and told him/her to get into the car; -The staff member drove him/her back to the facility and brought him/her back inside; -The charge nurse on his/her floor did not know he/she left the building; -He/she left early in the morning, around daybreak, and he/she could not see well outside because it was a little dark; -It was the first time in five years or so that he/she left the building. During an interview on 8/2/22 at 3:00 P.M., the Assistant Director of Nursing (ADON) said the following: -On Monday morning, 7/25/22 around 5:30 A.M., he/she was driving to work when he/she saw the resident on the parking lot of the facility smoking a cigarette. The resident was alone; -He/she asked the resident why he/she was outside and the resident answered because he/she was smoking a cigarette and he/she fucking could be outside; -The ADON invited the resident into his/her car, and then drove the resident to the back parking lot, a few feet away; -The ADON took the resident into the facility and back to his/her room; -The ADON called the administrator and the DON and told them what happened around 8:00 A.M.; -He/she did not write an incident report because he/she did not consider it an elopement. The resident was responsible for self, had a high Brief Interview for Mental Status (BIMS, a brief screener of cognition) score and signed him/herself out; -He/she did not interview staff or perform a skin assessment on the resident because it was not an elopement; -The resident was allowed to go out of the building unattended even though he/she was confused, because he/she was responsible for self; -The facility was responsible for the resident's safety; -The ADON was not sure if the resident was on the facility parking lot the entire time he/she was outside, did not know how long the resident was outside alone, and how he/she left the building; -If the resident wanted to go outside, the ADON would let him/her out but then sit with the resident to ensure safety as the resident was not alert and oriented to self, place, time and situation (A&O X 4) at all times. During an interview on 8/2/22 at 8:06 P.M., Nurse O said the following: -He/she was working as the charge nurse on the shift in which the resident left the building; -He/she last saw the resident between 3:00 A.M. and 4:00 A.M.; -He/she was new to the unit and did not receive orientation to the unit before his/her shift. The 24 hour report sheet did not give information on the residents such as diagnoses, transfer status, code status or behaviors; -He/she was not told the resident was experiencing delusions during on-coming report; -He/she was responsible for two halls during that shift; -He/she did not know the resident left the building until the ADON brought the resident back into the unit. He/she could not recall the time the resident was brought back; -He/she did not know how the resident left the building; -He/she was upset to hear the resident was outside by him/herself, and he/she feared for the resident's safety; -He/she took the resident back to his/her room and obtained vital signs on the resident, which were normal; -He/she tried to do a skin assessment on the resident but the resident refused; -The ADON told him/her the DON gave instructions to not write a progress note describing the event and also to not write an incident report; -He/she was told the event was not an incident because the resident was A&O X 4, responsible for self and had signed him/herself out of the building; -He/she was prepared to document the resident left the building without supervision but did not, to follow instructions; -He/she told the nurse's aides (NAs) and the certified nurse's aides (CNAs) working during that shift to keep a close eye on the resident to ensure safety after he/she returned. During an interview on 8/2/22 at 9:17 A.M., CNA M said the following: -He/she was on staff the night the resident left the building; -The last time he/she saw the resident was around 3:30 A.M. that early morning; -He/she did not know the resident had left the building until anther staff member, the ADON brought the resident back to the hall around 5:30 A.M. or 6:00 A.M.; -He/she was told by the ADON that the resident was found walking down the main road in front of the facility. The ADON asked the resident to get into his/her car and then drove the resident back to the facility; -The resident was very confused when he/she came back into the building because he/she had not left the facility before then; -He/she went with the nurse on duty that night to check on the resident. The resident would not allow the nurse to perform a skin assessment; -He/she was told to keep a close eye on the resident to ensure safety; -The ADON told the nurse to call the resident's psychiatrist; -He/she did not know how the resident left the building. During an interview on 8/2/22 at 4:28 P.M., the administrator, DON and the regional nurse consultant said the following: -The cameras at the front entrance were new. They were installed on 7/25/22; -The doors were alarmed and had a keypad with a code for resident and staff safety; -The resident signed him/herself out in the resident sign out log, showing he/she left the building on 7/25/22 at 5:55 A.M.; -The ADON called the DON sometime that morning to talk about what was going on in the building, as that was commonly done when the DON was not at the building yet. During the call, the ADON reported the resident was found outside smoking a cigarette on the facility parking lot; -The DON did not ask the ADON if the resident was supervised while outside, as the resident was A&O X 4 every time she spoke to the resident. She did not know if the resident had periods of confusion, or was ever less that A & O X 4. The resident was always cognizant during their conversations; -She did know how long the resident was outside of the facility; -The resident had a BIMS score of 13 or 14 and was responsible for self, therefore he/she was safe to go out by him/herself; -Social services never told them the resident was anything but cognitively intact; -The ADON called and notified the administrator sometime around 8:00 A.M.; -The resident signed him/herself out; -They did not know how the resident left the building; he/she might have memorized the code from someone telling him/her or might have followed someone out of the building; -They did not think to interview the resident after the fact, nor did anyone think to ask him/her how he/she was able to light his/her cigarette, how he/she left the building or how long he/she was outside; -They did not investigate the matter because the resident was safe to go out by him/herself as evidenced by the high BIMS score, the sign out sheet and because the resident was responsible for self; -They expected staff to know when residents left the building as it related to resident safety; -The ADON made the charge nurse complete a head count because he/she was angry at the charge nurse, not because there was an elopement. During an interview on 8/2/22 at 5:10 P.M., Nurse A said the following: -The resident was not safe to leave the facility unattended due to his/her confusion and delusions; -The resident often states he/she owns another planet, sometimes has hallucinations thinking he/she is someone else, somewhere else; -The resident wasn't safe out of the premises unattended because he/she was not always in his/her right mind, and could go on a journey based on his/her delusions at the time and get hurt; -The resident would not have the ability to sign him/herself out as he/she lacked the cognitive ability and had difficulty seeing anything small; -Nurse A would consider it an elopement if the resident left the building unattended because he/she was not safe and could not make good decisions; -Nurse A worked with the resident for the past three years. During an interview on 8/2/22 at 6:06 P.M., MDS Coordinator M and MDS Coordinator N said the following: -When assessing the residents to complete the MDS forms, they used the information found in the medical records, physicians' notes, hospital discharge paperwork, assessments and interviews with family members, staff and residents; -They assessed the resident in order to complete the MDS form and found the resident as A&O X 4 with confusion; -They saw in the psychiatrist's notes that the resident had delusions and hallucinations; -Based on their conversations with the resident and on the psychiatrist's notes, they did not feel the resident was safe to go outside by him/herself into the community; -They would not expect the resident to know the name of any of the side streets that surround the facility as the resident did not have a history of leaving the facility; -They do not believe the resident could have signed him/herself out unless he/she was prompted to do so based on their assessment of the resident and because it would have been new to the resident as he/she did not leave the facility. During an interview on 8/2/22 at 5:39 P.M., the administrator, DON and the regional nurse consultant said the following: -The DON, MDS coordinators and the ADONs were responsible for reviewing the Medical Director and psychiatrist notes and evaluations as they are sent to the facility; -The DON reviewed the psychiatrist note, dated 7/19/22 at 6:16 P.M., which was in the resident's medical records under progress notes; -The DON did not recall the resident was diagnosed with vascular dementia or was experiencing delusional thoughts at the time of the psychiatrist's assessment; -After the surveyor brought their attention to the psychiatric notes in the medical file, the DON said given the 7/19/22 assessment, the resident was not safe outside unattended; -They expected staff to report and document the resident was having delusional thoughts, as that would be considered a change in condition. During an interview on 8/12/222 at 12:53 P.M., the psychiatrist said the following: -She was not alerted to the resident leaving the building unattended until after the surveyor's visit to the facility; -The resident has chronic schizophrenia and increased delusional thoughts. He/she often says he/she owns multiple businesses, talks with the President and the FBI, and thinks a motorcycle gang is after him/her; -The resident was not safe outside of the facility unattended because there was no telling what his/her mind was telling him/her at any given time. The resident could think the motorcycle gang was coming after him/her and act upon it; -A BIMS score is not the only parameter in which to gauge whether or not a resident was capable of making safe decisions for themselves, especially given the history and diagnoses of the resident; -She increased the resident's Risperdal due to his/her increased delusions; -She expected staff to document any odd behavior the resident exhibited as it helped her when assessing the resident and also gave a clearer picture of the resident's mental health for all staff; -She would speak to the nursing staff while she was there assessing the resident and learned of his/her behaviors; -It was not her opinion that the resident was responsible for self because the resident did not understand he/she had a mental illness; -The resident was living with his/her mother until she passed away a few years ago and then went in and out of the hospital because he/she was noncompliant with medications and would deteriorate; -The resident does have a diagnosis of vascular dementia, it was not a new diagnosis; -She expected the facility to include vascular dementia in the resident's diagnoses; -She expected the facility to have awareness of the resident's increased delusions; -The resident was not living at a lower level of care because he/she was not safe to do so; -She does not think the resident was safe outside of the building unattended due to his/her history of delusions and hallucinations; -She expected the facility to notify her immediately when the resident left the building unattended as it was out of character for him/her to leave the facility. It was a change of condition. During an interview on 8/12/22 at 1:53 P.M., the DON said the following: -She expected nursing staff to follow physician orders; -The administrator opened an investigation on the resident leaving the building unattended after the surveyor brought the matter to their attention; -She called and notified both the psychiatrist and the Medical Director of the resident leaving the building after the surveyor left the facility; -The Medical Director said the resident was not safe outside by him/herself. The Medical Director did not elaborate and the DON did not think to ask why not; -The psychiatrist also said the resident was not safe outside of the building by him/herself due to delusional thoughts; -Based on her interviews with the psychiatrist and Medical Director, the resident was not safe outside of the building unattended. During an interview on 8/15/22 at 3:25 P.M., the administrator said the following; -Knowing what he knows now, the resident is not safe outside of the building unattended; -He conducted an investigation after the surveyor alerted him to the situation and found that a new CNA took the resident out with him/her to smoke and then left the resident outside alone; -The charge nurse on the resident's hall was also new to the unit/facility and did not know the resident very well; -The CNA should have verified with the nurse to see if the resident was safe outside unsupervised; -The diagnosis of vascular dementia should have been listed in the resident's medical file as an active diagnosis; -Nursing staff were expected to read progress notes, the resident's BIMS score and diagnoses in order to get a complete picture of the resident; -He expected staff to notify him if they had a concern about the resident's safety immediately and he would have conducted an investigation; -He expected staff to follow facility policies and procedures. During an interview on 8/23/22 at 2:29 P. M., CNA P said the following: -He/she did get orientated to the smoking policy. It said if it is outside of the designated time to smoke, employee can choose to take resident out to smoke in designated area; -Staff are required to stay with residents if they take them out on a smoking break. He/she knew that at the time that the policy was to stay outside with the resident; -He/she was walking towards the front entrance when the resident approached him/her and asked if he/she could go outside with the CNA to smoke; -He/she said yes and took the resident out through the front alarmed door to smoke with him/her; -He/she did not know if the front of the building is a designated area for resident to smoke; -He/she left the resident outside because a white four door car pulled up and parked in the front row, a female was inside the car rummaging around gathering bags as if to take them into work; -He/she told the resident to go back inside with the female in the white car; -He/she went back into the building through the front door, leaving the resident outside alone; -He/she did not wait until the female exited the car; he/she did not know who the female was or if the female was coming into the building; he/she did not tell the female to bring the resident back into the building; -The resident had his/her own cigarettes. The CNA lit the first cigarette for him/her. He/she did not know how the resident lit the second cigarette; -He/she did not know how the resident came back into the building; -He/she did not know if the resident wandered off of the property; -He/she did not tell anyone he/she took the resident outside. He/she doesn't know why he/she didn't notify anyone; -He/she told a NA in casual conversation that he/she left the resident outside. He/she does not know who that NA was or if the NA told anyone else; -He/she doesn't know why she didn't tell the resident's nurse the resident was outside by him/herself; -He/she was not working on the resident's unit. He/she was leaving the building when the resident approached him/her and asked if he/she could come out with him/her to smoke; -He/she thinks the resident signed him/herself out. He/she did not witness it. The resident was walking behind him/her and stopped at the desk. He/she assumed the resident signed him/herself out; -He/she was unaware the resident was a risk to go outside by him/herself because he/she was very independent with ADLs; -If he/she had to do it all over again, CNA P would not have taken the resident outside; -He/she was in a rush to get back into the building so he/she could wake up the residents; -He/she worked the night shift 7:00 P.M. through 7:00 A.M.; -He/she had been a CNA for [AGE] years; -He/she worked for the facility as an agency CNA since March, and was hired full time in June. During an interview on 8/25/22 at 2:06 P.M., the administrator said the following: -The resident's smoking assessment clarified if a resident should be supervised while smoking; -The smoking policy said all residents are supervised when smoking; -He expected staff to follow policies and procedures; -Smoking assessments were performed on admission, quarterly and as needed; -Elopement risk assessments were performed on admission, quarterly and as needed; -Care plans were updated quarterly and as needed after investigations were compete; -Staff were informed care plans were updated by the ADON and DON; -Residents' kardex was also updated showing care plan changes; -Nurses were also expected to inform oncoming staff in report of any changes in plan of care and also notate changes on the 24 hour report sheet; -The facility did not complete elopement risk assessments on all residents. 2. Review of Resident #22's admission MDS, dated [DATE], showed the following: -admitted on [DATE]; -Moderate cognitive impairment; -No behaviors present; -Independent locomotion on and off the unit; -Wheelchair for mobility; -Diagnoses included cognitive communication deficit (impairment in organization/thought, sequencing, attention, memory, planning, problem-solving, and safety awareness), stroke, anoxic brain damage (diminished oxygen supply to the brain causing serious impairment in cognitive skills), end stage renal disease (kidney failure), dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood), encephalopathy (any brain disease that alters brain function or structure) and seizures. Review of the resident's medical record, showed the following: -An elopement risk assessment, dated 2/22/22, showed low risk for elopement; -An order, dated 7/7/22, for dialysis services at an outside dialysis center on Mondays, Wednesdays and Fridays; -An elopement risk assessment, dated 8/19/22, showed at high risk for elopement; -A care plan, undated, showed the resident was at risk for elopement related to leaving the facility without notifying staff on 8/19/22. Interventions included: Monitor for location every 15 minutes for 72 hours; the resident was sent to the emergency room for evaluation and treatment. There were no interventions on the care related to preventing elopement in the future. Review of the resident's progress notes, dated 1/7/22 through 8/25/22, showed the following: -No documentation regarding the resident being found at a hospital downtown by the facility's driver; -No documentation regarding the resident eloping from the outside dialysis center; -No documentation regarding a chaperone accompanying the resident to the outside dialysis center; -No documentation regarding the resident's discharge from the outside dialysis center due to high elopement risk. During an interview on 8/25/22 at 11:52 A.M., Nurse A said the following: -The resident had eloped from the facility the previous week and a neighbor called the facility to alert them of a possible resident in a wheelchair seen on the two-lane street located in front of their building; -Nurse A knew the incident had occurred because he/she learned about it in report; -The resident had been acting differently before the elopement, wandering more around the building; -He/she did not document the change of behavior in the resident's medical record; -A few weeks ago, the resident had left from his/her dialysis center located in midtown and walked to a hospital that was located 2.4 miles away, a 50 minute walk; -The facility's transportation driver found the resident; -Changes were not made to the resident's plan of care, including any new interventions; -He/she did not know why the facility did not change the plan of care for safety. During an interview on 8/25/22 at 12:23 P.M., the administrator said the following: -Through their investigation, they found while watching security footage from the front door entrance, a CNA entered the building through the electronic, automatic doors and walked to the left, rounded the corner and was out of sight; -The resident was sitting in his/her wheelchair near the door and was seen wheeling him/herself out of the building through the front doors, before the doors completely shut from the CNA's entrance; -The facility had since changed the delay time before the door closes; -The elopement occurred on a Thursday night. The nurse called the administrator to inform him a neighbor called the facility, at approximately 11:45 P.M., to alert them a resident was seen on the main road located in front of the facility; -The facility called a code gray (the elopement code), a head count of all residents was made and the resident was found missing; -The resident had called 911 while he/she was out of the facility, asking to go to the hospital; -At approximately 12:00 A.M., the police came to the facility after locating the resident on the two lane road, informing them they called the emergency medical service and the resident was sent to the hospital; -The resident returned from the hospital at approximately 4:00 A.M. that same morning; -The resident was not identified as an elopement risk before the incident; -The resident previously attended an outside dialysis center located in midtown; -He was not aware of any reports of the resident leaving the outside dialysis center; -He expected the outside dialysis center to report if the resident had eloped from their center so the facility could have identified the resident as an elopement risk, and include it in the resident's care plan; -He expected any reports of the resident eloping from the outside dialysis center documented in the resident's medical record; -He expected nurses to document any new behaviors in the resident's medical record so nursing management was aware and could possibly change plan of care. During an interview on 8/25/22 at 1:24 P.M., the clinical manager from the outside dialysis center, said the following: -The resident was discharged from their dialysis center on 8/16/22; -The discharge reason was due to high elopement risk, as the resident had left from the dialysis center many times; -The facility was aware the resident had a history of elopement. -The staff at the dialysis center told the facility the resident would frequently leave the center and then was found two or three blocks away; -The facility admission staff came to the dialysis center to pick up lab work and staff at the dialysis center had a conversation regarding the resident leaving the dialysis center. During an interview on 8/25/22 at 1:50 P.M., the social worker (SW) from the outside dialysis center, said the following: -Staff had reported the resident had left the center and was found down the street; -He/she did tell the facility's Social Service Director (SSD) about the resident's habit of eloping from the center before they discharged the resident back to the facility. The SSD was informed they were concerned of the resident's safety due to elopements; -The SSD said he/she was not aware of the resident eloping from the dialysis center prior to their conversation about the discharge; -The SSD said he/she would inform the administrative team at the facility; -The SW never heard back from the facility's SSD. During an interview on 8/25/22 at 2:06 P.M., the administrator said the following: -Elopement risk assessments were performed on admission, quarterly and as needed; -Care plans were update

Based on interview and record review, the facility failed to protect one resident from harm during care. The resident required the assist of two during care, and fell from bed while care was being provided by only one staff member. The resident complained of severe pain, but staff transferred the resident from the floor and back into bed using a mechanical lift (a mechanical device used to transfer someone who is unable to stand on their own or whose weight or other circumstance makes it unsafe to move or lift them manually, from one place to another), at which time the resident's left foot got caught in the mechanical lift handle causing a skin tear to the left heel and left shin that bleed profusely. The resident was sent to the hospital and diagnosed with [REDACTED].#21 and #12). The sample was 26. The census was 131. Review of the facility's Accident and Incident Documentation and Investigation Policy, dated 8/30/18, showed: -Policy: Accidents and/or incidents involving resident care or visitors will be investigated and documented on the Incident entry in Point Click Care, electronic medical record system. An Incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enhance preventive measures to reduce occurrences of incidents; -Responsibility: Administrator, Director of Nursing, Licensed Nurse and Department Heads as applicable; -Procedure: -General Information: -The licensed nurse assigned at the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the supervisor, Director of Nursing and/or the administrator, as appropriate; -The licensed nurse at the time of the incident is responsible for initiating/completing the incident report, ensuring that all items have been completed as applicable to the accident/incident; -The licensed nurse at the time of the incident is responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth on the incident report; -Notification and Documentation in the Resident's Medical Record: -The licensed nurse shall document the incident and notify the supervisor and Director of Nursing for follow through as needed; -The licensed nurse may complete a nurse's note and update the care plan, as needed; -The nurse's notes could contain the following documentation: -Clear objective facts of what occurred; -An evaluation of the resident's condition at the time of the accident/incident may include a description of the resident, vital signs and any other physical characteristics apparent as a result of the incident/accident; -Any treatment provided; -Any contacts made or attempted with the resident's physician, family, legal representative, or any other health care professional or person involved in the resident's care; -The resident's outcome and any information concerning the incident; -The nurse's signature, date and time of charting; During an interview on 2/24/21 at 12:35 P.M., the Director of Nursing (DON) said the information provided in the policy was the facility's fall protocol. 1. Review of Resident #21's Fall Scale Assessments, dated 10/29/20 and 12/24/20, showed: -admitted on [DATE]; -No history of falls; -Bedrest/wheelchair/nurse assist; -Exhibited impaired gait; -Resident knows own limits; -Moderate risk for falls. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/20, showed: -admitted on [DATE] from acute hospital; -Cognitively impaired; -Exhibited no behaviors; -Required extensive assistance of two plus staff for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed); -Required total dependence on two plus staff for transfers; -Required extensive assistance of two plus staff for personal hygiene; -Not steady, only able to stabilize with human assistance for surface to surface transfers. Review of the resident's physician's orders [REDACTED]. Review of the resident's five day MDS, dated [DATE], showed: -Reentry from acute hospital on [DATE]; -Cognitively Intact; -Exhibited no behaviors; -Height 5'8, weight 210 pounds; -Required extensive assistance of two plus staff for bed mobility; -Required extensive assistance of two plus staff for personal hygiene. Review of the resident's nurse's notes, showed: -On 1/9/21 at 8:56 A.M., at 8:45 A.M., the nurse was notified by a certified nursing assistant (CNA) that during perineal care (cleaning the private areas), the resident was instructed to turn over in bed and as doing so, the resident fell out of bed and onto the floor. The resident fell on his/her left side and is now complaining of severe back pain and right hip pain rating 10 on a numerical pain scale (scale is 1 to 10, with 10 being the highest level of pain). As the resident was being transferred back to bed with a mechanical lift, the resident's left foot got caught in the handle of the lift, which caused a skin tear on his/her left heel and left shin that was bleeding profusely. The nurse wrapped both areas with gauze and elevated the extremity on a pillow. The ambulance was notified and they will be transporting him/her to the hospital for further evaluation. During an interview on 2/22/21 at 10:11 A.M., the hospital nurse said the resident had not been discharged from the hospital as of 2/22/21. The resident was admitted on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. The plan of care was for the resident to undergo surgery for [REDACTED]. Now, they were trying to stabilize the resident and return him/her back to his/her baseline before he/she was released. Review of the resident's undated care plan, with 1/9/21 updates, showed: ADL (activities of daily living) Function: Focus: Requires staff intervention to complete ADLs and/or is at risk for decline in ADL self-performance and associated complications R/T limitation in function ROM (range of motion), impaired balance; -Goal: -Will have ADL needs met with staff assistance and be clean, neat, odor-free, and appropriately dressed for the season. Target date 3/9/21. -Will participate with mobility needs to the limit of his/her ability. Target date 3/9/21. -Interventions: -Allow time for resident to complete tasks, do not rush. Allow for rest breaks, if he/she tires. Monitor for frustration/inability to complete tasks and intervene to assist as indicated to complete care, and to meet mobility needs. -Self-performance may vary. Provide more assistance in the evening, at night when tired, or when in pain. -Keep call light within reach. -Anticipate and meet needs for resident for routine/AM/HS care on routine rounds and PRN. -Monitor resident for and report to nurse/physician decline or improvement in resident's self-care performance, mobility status. -Include resident and/or responsible party in treatment plan. Update as indicated by change in condition/treatment plan. Resident is high, risk for falls related to gait/balance problems. Actual fall from bed during assisted bed mobility with injury to left foot/shin 1/9/21. -Goal: Resident will be free of falls through the review date. Target date 3/9/21. -Interventions: -Be sure resident's call light is within reach and encourage him/her to use it for assistance as needed. -Follow facility fall protocol. -Intervention to fall with injury on 1/9/21: Post fall assessment. -Post pain secondary to fall assessment -Resident discharged to hospital for further evaluation. -RP/MD notification. -Inserviced staff of 2 person assistance with bed mobility. -Bed changed out to LAL (low air loss) Bari (bariatric, larger) mattress. -Therapy to evaluate for bed mobility upon return. -Therapy to evaluate resident for side rails upon return. -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. Review of the resident's Fall Scale Assessment, dated 1/9/21, showed: -No history of falls; -Bedrest/wheelchair/nurse assist; -Exhibited impaired gait; -Resident knows own limits; -Moderate risk for falls. Further review of the resident's nurse's notes, showed on 1/10/21 at 11:14 P.M., Nurse D held an in-service meeting and provided education to CNA staff on how to use the mechanical lift by making sure that the resident's body is always turned away from the lift during transfers to prevent any injuries from occurring. New interventions that will be implemented for the resident includes placing new side rails on the bed to prevent him/her from sliding off during perineal care and providing a larger mattress for his/her bed. During an interview on 2/10/21 at 2:25 P.M., CNA F said he/she worked at the facility for seven years and was familiar with the resident. The resident required the assistance of at least two staff persons when providing care or transferring. Since the resident was admitted to the facility, he/she was always a two person assist. It was possible staff sometimes worked alone with residents because they were short staffed. He/she was not working the day the resident fell and obtained the skin tear. During an interview on 2/10/21 at 2:30 P.M., CNA H said he/she was familiar with the resident. He/she did not work the day of the incident but knew the resident required two staff to assist with personal care. During an interview on 2/11/21 at 12:21 P.M., CNA E said he/she was working with another resident when a staff person asked for assistance in getting the resident off the floor. When he/she arrived to the resident's room, the resident's body was positioned on the floor next to the bed in an angle, up against the wheelchair. In order to move the resident, they had to re-position him/her. The resident was not angled properly because of the way his/her body lay on the floor. As they placed the pad of the mechanical lift under the resident, he/she screamed and said he/she was in pain, but they could not leave the resident on the floor. They could not just leave the resident laying in an awkward position on the floor. As they lifted the resident with the mechanical lift, his/her body shifted and his/her leg got caught onto the corner handle of the lift, causing a skin tear and bleeding. The mechanical lift functioned properly but the resident was uncomfortable. They placed the resident onto the bed. The nurse assessed the resident. The nurse was present when CNA E and the other staff lifted the resident, but did not assist with the transfer. During an interview on 2/11/21 at 10:15 A.M., CNA G said he/she worked at the facility for five months and was familiar with the resident. The resident required the assistance of two staff. On the day of the incident, he/she cleaned the resident alone because they were short staffed. As he/she cleaned the resident, the resident's body shifted and he/she fell on to the floor. CNA G ran to get the nurse immediately. The nurse assessed the resident. As the nurse assessed the resident, CNA G requested help from staff. CNA E came to assist. The resident said he/she did not want to get on the mechanical lift because of pain, but they had to get him/her up. CNA E kept repeating, they could not just leave him/her on the floor. They also had to use a green pad instead of the blue pad they usually use when transferring the resident. The green pad had to go between the resident's legs and could be uncomfortable and cut the area between the legs. The green pad was placed underneath the resident. The resident said he/she did not want to be lifted but they had to get him/her off the floor. As the resident was being lifted with the mechanical lift, his/her body started shifting, and the foot hit the edge of the handle of the lift, causing a skin tear and the resident to start bleeding. The resident screamed as he/she was transferred back into the bed. CNA G felt the green pad was not placed on properly, because prior to being lifted, the resident said he/she was uncomfortable and did not want to be lifted. The nurse was present during the transfer to the bed from the floor, but did not assist with the transfer. During an interview on 2/11/21 at 10:55 A.M., Nurse D said CNA G was working with the resident alone and provided two different stories. One story was he/she turned his/her back from the resident, and the resident fell . CNA G later said the resident slipped from his/her grasp. He/she entered the room to assess the resident. The resident was laying on his/her back and said he/she was in a lot of pain. The nurse assessed the resident and left him/her on the floor to contact the physician because he/she did not want to move the resident after the resident complained of back pain. When the nurse returned to the room, the resident was back in bed. He/she denied being in the room when the resident was moved. He/she did not instruct staff to move the resident. Nurse D denied telling staff to move the resident back into bed. The resident was screaming in pain and CNA G showed the nurse the skin tear. The laceration was deep and the resident was bleeding profusely. The resident required the assistance of two staff to care for him/her and CNA G was aware of this. All staff have access to resident records, showing each resident's care needs. During an interview on 2/18/21 at 8:43 A.M. and 2/24/21 at 12:35 P.M., the DON said the resident required the assistance of one staff prior to the incident. After the fall, she was changed to a two person assist for bed mobility. She in-serviced the staff on the use of mechanical lifts as a refresher after the incident. They are always in-servicing staff after a fall. The in-service was not directly related to the incident with Resident #21. The staff did not do anything wrong when one person provided care to the resident, causing the resident to fall. The staff who lifted the resident with the mechanical lift also used the lift correctly. After the nurse assessed the resident, it was determined the resident could be moved from the floor, onto the bed. When asked why the resident was transferred back into bed before EMS arrived, she said, Did the resident say to leave him/her on the floor? When told the nurse documented the resident screamed in pain and the pain level was at a 10, the DON said it was a generalized complaint of pain and just because someone says their pain level is at a 10, it would not determine whether a person should be moved or not. Also, if the staff did not document the resident saying to leave him/her on the floor, the resident did not say it. When told during interviews, staff said the resident said not to move him/her, the DON said it was not in the notes. The pain assessment would not determine if a resident should be left on the floor. After the nurse assessed the resident, she told the staff it was okay to move her. The resident was alert and oriented to person, place, time and situation and could make his/her needs known. During interviews on 2/11/21 at 9:41 A.M. and 2/25/21 at 9:00 A.M., the resident's family member said the resident told him/her CNA G was providing care for the resident alone. Another staff came into the doorway of the resident's room, and the CNA became distracted. CNA G turned away from the resident. The resident then fell and broke his/her hip. The facility staff then placed a pad under the resident and lifted him/her. As they lifted the resident, the blade cut his/her leg. While the family member was at the hospital, he/she spoke with the facility staff, including CNA G. CNA G admitted to becoming distracted and turning away from the resident, causing the resident to fall. CNA G was distraught and apologetic about the situation. The resident passed away on 2/22/21 at the hospital. During an interview on 2/19/21 at 11:21 A.M., the resident's physician said the facility staff should have followed what staff determined the resident's care needs were. If documentation said the resident required the assistance of two people, staff should have followed the nursing recommendations. During an interview on 2/19/21 at 11:33 A.M., the physician said he contacted the DON, and she told him the resident required the assistance of one staff for care, prior to the incident. After the resident fell , he/she was changed to a two person assist. 2. Review of Resident #12's quarterly MDS, dated [DATE], showed: -Cognitively Intact; -Required extensive assistance of two plus staff for transfer; -Required a wheelchair for ambulation; -[DIAGNOSES REDACTED]. Review of the resident's undated care plan, in use at the time of the survey, showed: -Focus: Resident is at risk for falls related to gait/balance problems, incontinence, unaware of safety needs; -Goal: Resident will be free of falls through the review date; -Interventions: Anticipate and meet the residents' needs. The resident uses Hoyer (full body mechanical lift) times 2 staff for positioning into wheelchair from the bed. Uses stand up lift for toileting. Be sure the resident's call light is within reach and encourage him/her to use it for assistance when needed. Review of the resident's POS, showed no order for transfer status. Observation on 2/11/21 at 3:48 P.M., showed CNA I used a stand up lift to transfer the resident from his/her wheelchair to his/her bed by him/herself without assistance. During an interview on 2/18/21 at 11:46 A.M., the DON said all staff is trained to use the mechanical lifts. Everyone knows the facility policy is to use two staff with any lifts. It does not matter what type of lift it is. On 1/16/21, the facility had just provided a transfer in-service with the entire building. She would expect for all staff to follow their policy when transferring a resident with the lifts. Review of the facility's sit to stand lift instruction guide, showed: -The sit-to-stand lift is especially designed for people who have difficulty in standing up on their own from a seated position; -Safety Instructions: The product is intended for use in healthcare environments. Lifting and transferring a resident shall always be performed with the assistance of at least one caregiver. -The guide did not indicate the facility required two staff when transferring a resident using the sit to stand lift. During an interview on 2/25/21 at 1:00 P.M., the administrator said it is the facility's policy for staff to follow the manufacture guidelines during transfers. The administrator clarified that the facility does not have a transfer or mechanical lift policy. He would expect staff to follow the instruction guide to the lift. MO 908

Based on interview and record review, the facility failed to implement adequate interventions for one resident with cognitive impairment who pulled out their femoral [MEDICAL TREATMENT] catheter (a catheter used for exchanging blood to and from a [MEDICAL TREATMENT] machine), and suffered a massive hemorrhage. This affected one of three sampled residents (Resident #1). The census was 240. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/5/17, showed the following: -Brief interview for Mental Status (BIMS, a brief screener of cognition), score of 12 (moderately impaired cognition); -Understood/understands; -Adequate vision, speech and hearing; -No behaviors, no rejection of care; -Required extensive assistance of staff for bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene; -Functional limitation of range of motion (ROM), upper and lower extremities on one side; -Required wheelchair for mobility; -[DIAGNOSES REDACTED]. -Anticoagulant medication, received six days out of seven. Review of the resident's care plan, dated 7/5/17, showed the following: -Focus: Need for [MEDICAL TREATMENT] due to [MEDICAL CONDITION], at risk for complications and dehydration; -Goal: No signs/symptoms of complications from [MEDICAL TREATMENT] through the review date; -Interventions: Check and change dressing as needed at access site. Monitor/document, report to physician signs or symptoms of depression. Obtain order for mental health consult if needed. Monitor/document/report to physician, as needed, any signs or symptoms of infection to access site: Redness, swelling, warmth or drainage. Review of the resident's nurse's notes, showed the following: -On 9/7/17 at 4:09 P.M., the resident arrived by stretcher accompanied by two attendants and transferred to bed. Alert to self and place. Denied pain or discomfort. A single lumen peripherally inserted central catheter (PICC line, a form of intravenous access) to right upper arm. [MEDICAL TREATMENT] catheter in right upper frontal thigh area. Scar tissue to right and left buttock and sacral area, no opened areas. Gastrostomy tube ([DEVICE], a tube inserted through the abdomen that delivers nutrition directly to the stomach), in place to mid abdomen; -On 9/8/17 at 1:00 P.M., this nurse made multiple visits to the resident's room due to him/her playing with the [DEVICE] valve. Resident had been clamping feeding off and turning valve off. Feeding infuser had been alarming off and on multiple times due to this situation. Abdominal binder placed with resident, no longer playing with the valve. Resident escorted to front of lobby to await transportation for [MEDICAL TREATMENT]; -On 9/8/17 at 6:40 P.M., spoke with the physician and notified of need for [DEVICE] flush order and if to resume blood sugar and insulin orders with new orders received and noted. Review of the resident's physician's orders [REDACTED].M., showed the following: -Give all meds by mouth or by [DEVICE]; -Trazadone (an antidepressant) 50 milligrams at bedtime (HS) for [MEDICAL CONDITION], take as needed; -Accu-checks three times a day (TID) at 6:00 a.m., 11:00 a.m., and 4:00 p.m. Further review of the resident's nurse's notes, showed the following: -On 9/9/17 at 1:57 A.M., the resident had remained awake all P.M., pulling at [DEVICE] and PICC line tubing, though promptings were given constantly. Requires constant watching. Has no short term memory. Is not aware of usage of call light. Forgets instruction immediately. Side rails up. Monitored as often as possible; -On 9/9/17 at 2:54 A.M., PICC dressing replaced, resident was in the process of removing old dressing. PICC dressing change required two staff to replace dressing per resident holding PICC tubing and would not remove hands after multiple requests. This shift resident has disconnected [DEVICE] twice, remains awake the entire shift pulled at both [DEVICE] and PICC tubing. Staff unable to get resident to stop these behaviors; -On 9/9/17 at 4:18 A.M., PICC dressing removed a second time this shift, replaced with new dressing. Contacted pharmacy to send in multiple central line dressings per repeated replacement necessary. Continues to pull at [DEVICE] and PICC tubing after multiple requests to stop. Staff have attempted to replace tubing in his/her hands with different items, but resident continues to put those down and continue to pull at the tubing. Resident remains awake for entire shift thus far; -Late entry, (per facility electronic medical record, EMR, created on 9/11/17 at 12:10:44 P.M.) on 9/9/17 at 5:42 A.M., resident still awake, continued behaviors after trazadone administered at 3:24 A.M. Review of the resident's Medication Administration Record [REDACTED]. Further review of the resident's nurse's notes, showed the following: -Late entry, (per facility EMR, created on 9/11/17 at 3:48:08 A.M.), on 9/9/17 at 6:38 A.M., entered resident's room to do finger stick and to administer insulin. Compliant. Does not appear to be uncomfortable. Resident is awake and alert. Voiced no complaints. [DEVICE] intact. [MEDICAL TREATMENT] catheter intact. PICC line remained intact; -On 9/9/17 at 6:50 A.M., resident removed dressing to right groin again this shift and was able to pull out stitches and catheter. This nurse was called to the room to find a significant amount of blood on the floor and bed. Immediately applied pressure to site and yelled for the CNA to call the supervisor, stat and 911. Oxygen applied at 4 liters, increased gradually with increased loss of consciousness. Supervisor assisted with pressure to right groin; -On 9/9/17 at 6:55 A.M., call was placed to 911, informed 911 the resident pulled his/her [MEDICAL TREATMENT] port from their right groin. The resident is conscious at this time, able to move eyes when name is called. Resident no longer able to respond; -On 9/9/17 (effective date entered, 9/11/17 at 12:05 P.M.), clarification from notes dated 9/9/17 at 2:54 A.M. and 4:18 A.M., the dressing changes were to the [MEDICAL TREATMENT] fistula to the right groin, not to the PICC to the right arm. During an interview on 9/27/17 at 8:40 A.M., (certified nurse aide) CNA C said he/she arrived for work around 8:30 P.M. on 9/8/17. He/she did not know the resident. The resident pulled at his/her PICC line and when CNA C told the nurse, the nurse replied, that's what he/she does. During the night, the resident pulled his/her [DEVICE] out, enough for it to leak all over. The resident had a binder on, but was able to get up underneath it. Later, when he/she walked into the resident's room, the resident had the [MEDICAL TREATMENT] catheter in his/her hand, trying to pull it out. CNA C told Nurse A and Nurse B the resident was pulling at the [MEDICAL TREATMENT] catheter. He/she told them all night, about a thousand times, what the resident was doing. Neither nurse told him/her to get the resident up or told him/her to sit in the resident's room and watch him/her. CNA C started rounds in the morning. He/she was busy getting people up and when he/she walked past the resident's room, CNA C looked in and saw all the blood. During an interview on 9/14/17 at 9:00 A.M., Nurse A said when the resident returned from the hospital, he/she was significantly more confused than before his/her hospital stay. The resident was touching everything and Nurse A was told in report he/she would be in the room all night because of the behaviors. Nurse A said during the night, CNA C called him/her to the resident's room because the resident disconnected his/her [DEVICE]. The resident also pulled off his/her [MEDICAL TREATMENT] dressing and by the time they changed his/her gown, the resident pulled the dressing to his/her PICC line down to his/her wrist. The resident pulled at his/her [MEDICAL TREATMENT] fistula and feeding tube. He/she cleaned the resident up twice because the resident pulled at his/her feeding tube and was covered in tube feeding. Nurse A called the pharmacy for additional dressings. Around 3:23 A.M., he/she talked to the night supervisor about giving trazadone. Nurse A borrowed the trazadone from another resident because the resident's trazadone had not arrived yet. At 5:42 A.M., the resident was still having behaviors. The night supervisor told him/her to call the physician in the morning. Nurse A said CNA C yelled the resident was bleeding and when he/she arrived to the resident's room, the resident had pulled out the [MEDICAL TREATMENT] catheter and was holding the catheter in his/her right hand. Nurse A grabbed a blanket off the linen cart and applied pressure to the resident's groin. Nurse A did not think the resident would be able to pull the catheter out. If he/she would have thought about it, Nurse A would have put the resident at the nurse's station. Nurse A really didn't know what to do to get the resident to stop fidgeting. During an interview on 9/14/17 at 8:32 A.M., Nurse B said he/she worked on 9/9/17 on the 10:00 P.M., to 7:00 A.M. shift. The first time he/she saw the resident, the resident was smiling and appeared to not be in any distress, although the resident was grasping at his/her [DEVICE]. Nurse B thought the resident would understand direction, but after talking to him/her for a little while, he/she did not. Nurse B told the resident not to pull on the [DEVICE] and he/she would pull on the [DEVICE]. The resident was awake most of the night. The resident kept taking his/her dressings off, three or four times through the course of the night. During an interview on 9/28/17 at 8:02 A.M., the night supervisor said on 9/9/17 around 1:00 A.M., Nurse A called and said the resident removed his/her dressing. The night supervisor was not IV certified and did not touch the dressings. He/she retrieved a couple IV kits with dressings from another wing of the facility for Nurse A. The nurse could have called the physician for an [MEDICATION NAME] (a sedative), but the resident did get a trazadone around 3:30 A.M. The night supervisor wished he/she had thought about wrapping the [MEDICAL TREATMENT] catheter with an ace wrap. With a person who at risk to fall, he/she would get them up and sit them at the nurse's station. The night nurse had done that many times. It's safest to put the resident at the nurse's station if someone was there to watch them. The nurses just thought the resident was pulling at the dressings. They goofed up by not calling the physician. During an interview on 9/27/17 at 3:10 P.M., Emergency Medical Technician (EMT) D said when he/she arrived on the scene, the resident's catheter was completely out of his/her leg. Staff had placed a blanket onto the site and applied pressure. There was a large amount of blood underneath the bed and on the bed. Some of the blood was liquid and some had coagulated. The resident was not conscious. Staff were unable to say when the incident happened or when he/she was last seen. Their stories conflicted. During an interview on 9/28/17 at 2:50 P.M., the Director of Nursing (DON) said the facility utilized one on one nursing care if a resident was a threat to themselves or others and the resident could have placed him/herself at risk by pulling at his/her dressings/catheter. During an interview on 9/28/17 at 3:07 P.M., the administrator said she expected staff to have called either herself or the DON regarding the resident's behaviors. She did not believe staff exhausted all efforts at possible interventions. When in doubt, staff should let them know in a timely manner. Staff should have called the physician about the change in condition and she expected staff to follow the facility policy. Review of the facility change in condition policy, dated 1/1/2014 and revised on 3/2017, showed the following: -The facility will make every effort to inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there is the following; -An accident involving the resident which results in injury and has the potential for requiring physician intervention; -A significant change in the physical, mental or psychosocial status, that is a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications; -A need to alter treatment significantly, that is a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment; -A decision to transfer or discharge the resident from the facility; -Procedure: -If the physician cannot be reached, the medical director will be notified; -During medical emergencies, notifications will be made as soon as possible. MO 748

Based on observation, interview and record review, the facility failed to provide protective oversight for one of five sampled residents with cognitive and physical impairments by leaving him/her unsupervised in the shower room whirlpool tub for eight hours. Staff found the resident expired in the whirlpool tub. Certified Nurse Aide (CNA) A was assigned to provide the resident's care. He/she had a history of [REDACTED]. (Resident #1) The census was 165. Review of CNA A's employee file, showed an administrative counseling form, dated [DATE], for uncaring disrespectful language. CNA A told a resident who fell on to the floor, I don't feel sorry for you. I told you to stay seated. Received a one day suspension. During an interview on [DATE] at 9:33 A.M., CNA A said the resident who fell was always trying to get up out of his/her chair and basically did what he/she wanted to do despite redirection. All evening, CNA A had told him/her to stay seated. When the resident fell , CNA A told the resident, I'm not gonna to talk to you. I've been telling you to sit down all evening. I'm not gonna feel sorry for you. The fall did not injure the resident. Review of CNA A's employee file, showed an administrative counseling form, dated [DATE], for negligence in performance of assigned duties. CNA A left a resident unattended in the shower room in a shower chair. Received a one day suspension. During an interview on [DATE] at 3:15 P.M., CNA A said he/she knew not to leave a resident alone in the shower room. However, CNA A had used all of the towels he/she brought into the shower room and the resident's legs were bleeding or something. CNA A stepped out of the shower room in order to get more towels from a cart in the hallway and heard the resident fall. During an interview on [DATE] at 11:30 A.M., the Director of Nursing (DON) said the identity of the resident left alone in the shower room, in ,[DATE], was unknown because it was not documented on the counseling form. Administrative counseling consisted of talking to the employee about what they did wrong. The employee did not receive any additional training. Twice a year, all direct care staff attended classes on abuse and neglect. Resident rights were part of those training sessions. During an interview on [DATE] at 12:45 P.M., the administrator said the facility no longer had access to records pertaining to the unknown resident, left alone in the shower last year by CNA A, because those records were in the possession of the company recently bought out by the current owners of the facility. Review of the information provided by the facility, for the Honeysuckle Hill unit for [DATE], 7:00 P.M. to 7:00 A.M. shift, showed the following: -The midnight census report showed a census of 34 for this unit; -A copy of a handwritten page, showed staff for this unit included one nurse, two CNAs and a Certified Medication Technician (CMT B). CMT B listed for the 7:00 P.M. to 7:00 A.M. shift was also listed for the previous 7:00 A.M. to 7:00 P.M. shift. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] and a quarterly dated [DATE], showed the following: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. ([DATE] annual) and depression; -Responsible staff or provider informed of potential for self-harm ([DATE] annual); -Transfer assistance of one with bathing, limited assistance of one with toilet use; -Antianxiety medication used daily; -Antidepressant medication used daily. Review of the resident's care plan, dated [DATE], showed the following: -Cognitive loss and altered mood status related to depression and decreased social interaction; -Potential for falling due to antidepressant usage and activities of daily living (ADLs) status; -Occasional episodes of incontinence; -Monitor restlessness as a sign of the need for toileting; -Limited assist with toileting due to transfer, maneuvering clothing, hygiene and incontinence; -Provide shower/bath two times a week, check finger and toenails (limited assist). No individualized information addressed; -Impaired independent mobility due to weakness; -Administer medications as ordered and monitor behavior for changes/side effects. No individualized information addressed. Each section of the care plan showed it had been reviewed on [DATE] and there were no significant changes and to continue current approaches. Review of the resident's nurse's note, dated [DATE] at 6:00 P.M., showed the resident ambulated to the nurse's station and asked about going to work. Staff redirected him/her and the resident remembered he/she did not work and laughed. Review of the resident's physician's orders [REDACTED]. Review of the resident's physician's progress note, dated [DATE], showed he/she was experiencing decreased ADL performance, weakness, gait instability, memory loss, forgetfulness, acute edema of the bilateral lower extremities and progressive dementia. Review of the resident's fall risk assessment, dated [DATE], showed a total score of 10. The [DATE] assessment showed a total score of 5. The form instructions showed a score of 10 or greater indicated a high risk for potential falls. Review of the facility's investigative report, dated [DATE], showed at 8:30 P.M. on [DATE], CNA A put the resident into the whirlpool tub in the shower room, washed the resident and turned on the whirlpool jets. The resident asked for privacy, so CNA A told the resident to activate the call light when he/she was ready for assistance out of the whirlpool tub and stepped out of the shower room. The resident never activated the call light. During an interview on [DATE] at 1:56 P.M., CMT B said the resident preferred to take his/her medications prior to showering. Consequently on [DATE], CMT B administered the resident's 9:00 P.M. and bedtime medications at ten minutes to 8:00 P.M. CMT B worked from 3:00 P.M. until 11:00 P.M., but did not see the resident again after administering the medications. Review of the resident's medication administration record, dated [DATE] through [DATE], showed the resident received the following medications on the night of [DATE]: -Atorvastatin (lowers cholesterol) 10 milligrams (mg), one tablet every evening at 9:00 P.M.; -Donepezil hydrochloride (treats dementia) 75 mg, one tablet at bedtime; -Ibuprofen 400 mg, one tablet three times daily at 9:00 A.M., 4:00 P.M. and 9:00 P.M. During an interview on [DATE] at 11:30 A.M., the DON said the earliest that medications should be administered was one hour before the prescribed time. If the resident expressed a preference for receiving the medications any earlier, staff should obtain a physician's orders [REDACTED]. During interviews on [DATE] at 3:15 P.M. and [DATE] at 9:20 A.M., CNA A said he/she assisted the resident into the whirlpool tub in the men's shower room around 8:30 P.M. on [DATE], turned on the water and adjusted the temperature by holding one hand under the tub spout and turning the water temperature control valve towards hot or cold. There was no way to set the temperature. He/she turned off the water, assisted the resident with bathing and then left the shower room when the resident requested privacy. Normally, CNA A only left the resident alone in the whirlpool tub for five to seven minutes. During that time, he/she would periodically check on the resident and ask if he/she was ready to get out of the whirlpool tub. That did not occur on the night of [DATE]. Leaving the shower room to give the resident privacy, CNA A emerged and immediately began assisting a resident across the hall who had fallen onto the floor. Afterwards, he/she attended to residents who activated their call lights. He/she was very busy and forgot to check on the resident in the whirlpool tub. The Honeysuckle Hill unit had changed drastically during the past couple of weeks. It became a Medicare (Med) A unit. When one of the CNAs quit, CNA A rotated from elsewhere in the unit into that person's assignment. Prior to [DATE], he/she had only worked the assignment for a few days. There were two CNAs attending to 35 residents. He/she felt overwhelmed after the change because there was too much to do. The Med A residents who moved into the unit required more help than the previous residents and were demanding. Staff responding to their call lights might have to be in those rooms for 30 minutes or go back and forth, in and out of their rooms, in order to resolve the issues. Transferring those residents required two or three staff. CNAs from Honeysuckle Hill and other units told the DON about the work overload caused by short-staffing and she said the facility was attempting to get help, but no one had applied for the open CNA positions. When staffing was short, the facility did not call in extra help. CNAs had access to the care plans, information about residents was passed on during the change of shift report and they had a know-it-all book where information was charted about residents. During an interview on [DATE] at 11:30 A.M., the DON said the facility had recently transitioned the Honeysuckle Hill unit into a Medicare unit. Consequently, 20 or more residents moved to another unit. Some residents, like Resident #1 and his/her roommate were waiting for rooms to open up in other units. Staff assigned to the Honeysuckle Hill unit complained about short-staffing because they were accustomed to the unit being staffed with three CNAs, not because a third CNA was required. No one had complained to her about an inability to complete tasks due to the change in staffing. The residents on the Honeysuckle Hill Med A unit were more demanding, but there was not a higher percentage among them who were dependent for assistance with ADLs. Part of the certification training for CNAs was the directive to conduct, what the DON called, breathing rounds every two hours. Nurses were expected to conduct rounds at the beginning of each shift. At some point, during the middle of the shift, they were to check in with the CNAs and see if any residents needed a nurse to assess or otherwise assist them. During an interview on [DATE] at 9:20 A.M., CNA A said CNAs were expected to conduct rounds on all of their assigned residents every two hours. However, the resident and his/her roommate always kept the door to their room closed. The resident activated his/her call light whenever he/she needed assistance. The resident wore an adult brief and required minimal assistance with ADLs, but toileted him/herself without assistance. That was why the CNA did not open the resident's door during rounds on [DATE] and the morning of [DATE]. Consequently, CNA A did not realize the resident never returned to his/her room after CNA A assisted him/her into the whirlpool tub. During an interview on [DATE] at 7:05 A.M., Nurse C said he/she might have seen CNA A take the resident into the shower room at 8:30 P.M., but it was so busy he/she could not be sure the recollection was not from a previous night. The resident always took his/her shower at around 8:30 P.M. That would have been the only time Nurse C saw the resident alive on [DATE]. It was hard for him/her to manage the increased work load with two CNAs. Even before the third CNA quit and Honeysuckle Hill became a Med A unit, the facility tended to pull that CNA to other units. When Nurse C reported for duty on [DATE], the day shift nurse was overwhelmed, so he/she began assisting that nurse get physician's orders [REDACTED]. When he/she returned to the Honeysuckle Hill unit, a resident began to complain of back pain and before he/she could contact the physician to request an order for [REDACTED]. Next, Nurse C found a high fall risk resident in the shower room, assisted him/her back to his/her room and had to assist the resident to get dressed. It was extremely busy that night. Nurses usually conducted rounds every two to three hours and the CNAs did their rounds every two hours on certain residents, in order to change their adult briefs. Normally, the first rounds were conducted 30 minutes after the oncoming staff received the change of shift report from the outgoing staff, at the start of the 7:00 P.M. to 7:00 A.M. shift. On [DATE], Nurse C did not conduct his/her first rounds until 9:30 P.M. or 10:00 P.M. He/she also did not finish taking vital signs on 17 residents until midnight, because so much was going on in the unit. Nurse C entered the resident's room between 10:30 P.M. and 11:30 P.M., to take his/her roommate's temperature. Resident #1 was not in his/her bed and Nurse C assumed he/she was in the bathroom and did not attempt to locate him/her. During an interview on [DATE] at 11:30 A.M., the DON said Nurse C should have followed-up when he/she saw the resident was not in bed, in order to locate the resident and make sure the resident was safe. During an interview on [DATE] at 9:20 A.M., CNA A said on the morning of [DATE], he/she began collecting residents' water pitchers. He/she always collected them between 4:00 A.M. and 4:30 A.M. The resident was not in his/her bed. The CNA asked Nurse C where the resident was and the nurse suggested checking the resident's bathroom. CNA A checked, returned to the hallway and was walking in the direction of the residents' shower rooms when he/she recalled leaving the resident in the whirlpool tub during the previous night. During an interview on [DATE] at 7:05 A.M., Nurse C said at 4:30 A.M. on the morning of [DATE], CNA A asked Nurse C where the resident was and followed Nurse C's suggestion to check the resident's bathroom. CNA A said, Oh, my God! upon realizing he/she had left the resident in the shower room whirlpool tub during the previous night. CNA A ran up the hall and opened the shower room door. When Nurse C entered the shower room shortly after him/her, the privacy curtain obscured the whirlpool tub. Nurse C walked around the curtain and CNA A was standing next to the whirlpool tub screaming about having forgotten the resident was in the shower room. The resident was seated in the whirlpool tub clearly dead, with blue lips and his/her head tilted against the back of the tub. The water was up by his/her navel and Nurse C could hear the running whirlpool jets. Without releasing the water in the tub or touching the resident, Nurse C left the room, seeking assistance from Nurse E on another unit. CNA D entered the shower room and began screaming. During interviews on [DATE] at 3:20 P.M. and [DATE] at 5:40 A.M., CNA D said he/she entered the shower room after hearing CNA A screaming, crying and calling CNA D's name. Nurse C had entered and left the room. The resident was seated in the whirlpool tub with water up to his/her thighs, arms to the sides, head tilted backwards and his/her body leaned over sideways a tad. The resident's head was not touching the water. CNA D did not see the call light pull cord at the time. The entire shift had been very busy. A resident fell and call lights kept going off. The Honeysuckle Hill unit was normally staffed with three CNAs. With only two CNAs, the unit was understaffed and it was extremely hard to attend to all of the residents. The Med A residents were supposed to be self-care because they were at the facility for physical rehabilitation. However, during some shifts, CNA D found him/herself asking for assistance from CNAs on other units in order to meet the residents' demands. During an interview on [DATE] at 3:20 P.M., Nurse E said that at about 4:45 A.M. on [DATE], Nurse C asked for assistance with a death. Nurse E went and saw the resident's body in the whirlpool tub at 4:47 A.M. At that point, the water had already been drained from the tub. Blood was trickling from the left corner of the resident's blue lips and all of his/her blood had pooled in the lower half of his/her arms, legs and buttocks. The resident's skin looked waxy. He/she was wet from the back of the shoulders down, but not on the front of his/her body from the waist up. The hair on the front and top of the resident's head was dry but the shoulder length curls were damp. His/her body was limp and felt room temperature. CNA A, Nurse C and Nurse E used a lift to remove the resident's body from the whirlpool tub. His/her skin peeled around the torso when they lifted him/her out. Nurse E could not recall whether or not the pull cord for the call light was attached to the whirlpool tub. During an interview on [DATE] at 7:05 A.M., Nurse C said upon returning to the shower room with Nurse E, Nurse C touched the resident's chest, which was dry. The water was still in the whirlpool tub. His/her body temperature was still kind of warm. From the neck down, the resident was limp. The only exception was his/her slightly stiff right arm. Blood trickled out of his/her mouth. He/she was perplexed by the bleeding and could not determine whether or not the resident had hit his/her mouth. Nurse C could not recall if the call light pull cord was attached to the whirlpool tub. During an interview on [DATE] at 1:01 P.M., CNA D said he/she assisted staff to get the resident into bed. The skin on his/her legs and a portion of his/her lower back was peeling a lot. During an interview on [DATE] at 9:20 A.M., CNA A said he/she did not touch the resident until he/she assisted staff to remove the resident from the whirlpool tub. They put a gown on the resident and placed him/her into bed. During an interview on [DATE] at 10:05 A.M., the administrator said the facility employed best practices in making the determination as to whether or not a resident could safely be left alone in the shower room. Nurses and CNAs collaborated in taking into consideration whether or not a resident was alert and oriented, able to make his/her needs known and capable of pulling the call light for assistance. If a resident asked for privacy, then staff would leave him/her alone in the shower room. However, staff was expected to check back every two to five minutes, ensure that they received a verbal cue from the resident to open the door and a verbal response to their question(s). Staff attempted not to exceed five minutes of alone time for residents in the shower room. Staff did not leave anyone alone in the shower room that could not make his/her needs known. Observation in the Honeysuckle Hill unit men's shower room, on [DATE] at 5:37 A.M., showed the call light pull cord for the whirlpool area was tied to the end of the metal chain attached to the whirlpool drain plug and slung over the inside hand rail next to the whirlpool tub seat. The call light pull cord had to be removed from the hand rail in order to insert the drain plug into the drain without pulling on the call light. Standing next to the outside of the whirlpool tub, by the seat with arms fully extended, the call light pull cord was beyond arm's reach as it hung against the wall to which it was attached via a pull cord station. During an interview on [DATE] at 6:15 A.M., the physical plant manager said the pull cord station was 36 inches away from the edge of the whirlpool tub at the opposite end from the seat inside the tub. Normally, the pull cord was tied to the whirlpool tub hand rail and the chain for the drain plug was attached to a metal disk mounted on the inside of the tub. No one had informed him that the chain had become detached from the side of the tub or that the call light pull cord was tied to the end of it. The water temperature control valve was set to prevent the water from exceeding a maximum temperature of 130 degrees Fahrenheit (F). Review of the owner's operator and maintenance manual for the whirlpool tub, copyrighted 2009, showed the water temperature control valve, sets and maintains the temperature for all incoming water. Hyperthermia occurred when the body's internal temperature reached several degrees above 98.6 degrees F. Symptoms of hyperthermia included dizziness, lethargy, drowsiness and fainting. The effects included failure to perceive heat, physical inability to exit the tub and unconsciousness resulting in danger of drowning. The use of medication could greatly increase the risk of fatal hyperthermia. To reduce the risk of injury, infirm persons were not to be allowed to use the unit unless supervised at all times. The recommended length of a bath was five to ten minutes. If nausea, dizziness or headache developed, then the individual was to get out at once and cool down. Persistent symptoms warranted medical attention. During an interview on [DATE] at 9:33 A.M., CNA A said during his/her shift, the shower rooms on the Honeysuckle Hill unit were always really, really warm because the shower rooms were heated and staff gave all the residents' their showers at the beginning of their shift. The whirlpool tub room got humid due to the heat of the water, which stayed warm after residents bathed. During an interview on [DATE] at 11:30 A.M., the DON said the resident was alert and appropriate to be left alone in the shower room. However, she expected staff to open the shower room door every five minutes, ask if the resident was okay and make sure that they received a verbal response. During an interview on [DATE] at 11:28 A.M., the resident's psychiatrist said she had last seen the resident on [DATE]. The resident was alert: aware of his/her surroundings, knew where he/she was, could give appropriate answers to questions, ambulate to the dining room and recognize his/her family and roommate. However, the resident was not very well oriented at times. Having to be redirected on the night of [DATE], because he/she believed he/she had to go to work indicated confusion. Any confusion or forgetfulness the resident experienced stemmed from his/her dementia. The resident's psychiatrist would not have left the resident alone in the whirlpool tub for any longer than five to ten minutes. The level of alertness in a resident with dementia changed based upon their physical condition. They could be alert and fully functioning one minute and then suddenly become drowsy or unable to walk due to an infection. The change in their level of alertness could develop during the course of a day or within hours. The appropriateness of leaving the resident alone in the whirlpool tub depended upon the status of his/her health. If the resident was ill, then he/she should not have been left alone in the whirlpool tub for one minute. During an interview on [DATE] at 2:19 P.M., the resident's physician said given the resident's cognitive and physical impairments, as well as his/her declining health condition, it was not safe for him/her to be left alone in a whirlpool tub for eight hours. The maximum amount of time the resident could safely be left alone in the tub was 30 minutes with staff checking on him/her at least every ten minutes. The resident's overall health condition was one of progressive decline due in large part to dementia and depression. He/she also suffered from a lot of upper respiratory infections, going into winter and spring, which were chronic and required monitoring via frequent lab tests. Fluctuations in any of the aforementioned health conditions could result in an increase of confusion and decrease in level of alertness. Due to the fact that the resident suffered from high blood pressure, coronary artery disease and was experiencing weakness, the risk of hyperthermia was very high. The peeling of the skin on the resident's lower extremities was likely due to a combination of the resident having sat in water for an extended period of time and the temperature of the water. Without examining the resident, it was difficult to determine the cause of the bleeding from the mouth. It was most likely due to a seizure (which was not among his/her diagnoses) or physical trauma. Staff had not reported any recent significant changes in the resident's condition to his/her physician. Review of the facility's policy titled, Abuse and Neglect Prevention, dated [DATE], defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurred on an individual basis when a resident did receive a lack of care in one or more areas (e.g., failure to provide assistance with feeding for a resident known to require assistance with meal service). The facility was to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. Staff was to be deployed on each shift, in sufficient numbers, to meet the needs of the residents. The assigned staff was expected to have knowledge of the individual resident's care needs. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction which included in-servicing nurses and CNAs on not leaving any residents alone in the shower room, team huddle discussions about the status of each resident, the continued responsibility of CNAs for conducting walking rounds at the beginning of each shift and every two hours, charge nurses' responsibility for doing walking rounds at the start of every shift and every four hours. CMTs will remain compliant with medication administration time frames, in addition to visualizing and observing all residents on the unit during their last round. The DON or a designee will review, follow-up and implement resolutions to all team huddle issues and concerns. This process will be reviewed for compliance at the next two quality assurance and performance improvement meetings. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 041 MO 049

Based on observation, interview and record review, the facility failed to provide adequate interventions for one of four sampled residents (Resident #1), who was at risk for elopement. The resident removed his/her electronic monitoring device (EMD) on [DATE] and [DATE]. The resident removed his/her EMD again on [DATE] and left the facility at 3:39 A.M. without staff's knowledge. A passerby found the resident over a mile away from the facility and contacted the police. Facility staff were unaware the resident was not in the building until approximately 6:00 A.M. The police returned the resident to the facility at 6:20 A.M. The census was 160. Review of Resident #1's admission face sheet, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the elopement risk assessment form, dated [DATE], showed the resident was at risk for elopement. As interventions, staff placed an EMD on the resident's right wrist and planned to monitor the resident every two hours. The resident had the following risk factors: -[DIAGNOSES REDACTED]. -Independent ambulation, with or without the use of an assistive device; -Recent admission and not accepting of the situation; -Family/responsible party voiced concerns the resident may wander or try to leave; -Resident verbally expressed the desire to go home, packed belongings, talked about going on a trip, or stayed near the exit door. Review of the fall risk assessment form, dated [DATE], showed the resident was not at risk for falls. Review of the physician's orders [REDACTED]. -Up ad lib; -Namenda (Alzheimer's medication) 10 milligrams (mg) twice daily; -Aspirin (blood thinning medication) 81 mg daily; -Buspar (anti-anxiety medication) 5 mg twice daily; -Lexapro (anti-anxiety/anti-depressant medication) 10 mg daily; -Lorazepam (Ativan, anti-anxiety medication) 0.5 mg every four hours as needed (PRN). Review of the admission history and physical, dated [DATE], showed the resident transferred to the facility after a psychiatric hospital admission where he/she received a medication adjustment. The resident had dementia and generalized weakness and was alert and oriented times three (person, place and time). Review of the physician's orders [REDACTED]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Moderately impaired cognition; -No behaviors and no wandering; -Limited one-person assistance with ambulation. Review of the resident's care plan, dated [DATE], showed the following: -The resident required supervision to limited assistance with activities of daily living (ADLs) after a hospitalization that caused weakness. The approaches included the following: -Ambulation required supervision and contact guard assistance (hands-on contact with the resident but no physical assistance if not needed) when gait unsteady (non-compliant with assist at times therefore orientation on physical status is required); -Gait at times unsteady therefore frequent reminders are required for the need for assistance from staff. -The resident was at risk for falling related to the current ADL status and use of psychoactive medications. The approaches included the following: -Observe for unsteady gait, decrease or loss of functional status; -Teach the resident safety measures and provide reminders that resident needs supervision and contact guard assistance until he becomes stronger and steady; -EMD placed after first attempt to elope. The device will be checked weekly for proper functioning. Staff will respond promptly to door alarms when sounded. The resident may attempt to remove the EMD, therefore staff will monitor and provide education to the resident regarding the importance of the EMD. -The resident had periods of anxiety as evidenced through attempted elopement outside of the facility and verbal distress when the resident exceeded the amount of calls the family would like him/her to make each day. The approaches included the following: -Emergency psychiatric referral in addition to regularly scheduled psychiatric services if needed; -Staff to offer redirection activities/opportunities to prevent elopement attempts (interview resident in order to determine areas of interest); -Staff will complete 15-minute checks of the resident from [DATE] through [DATE]. At that time, the approach will be reviewed for its continued need; -The resident will have an EMD in place, and staff will check it according to facility policy; -When the resident inquires about calling his/her family, remind him/her of the three calls per day his/her family would like him/her to make, as well as when he/she placed the last call. Also remind the resident his/her spouse will call each morning and evening in an effort to reduce anxiety. Review of the nurses' notes, showed the following: -On [DATE] at 10:50 P.M., the resident was alert and oriented times three and ambulated with a steady gait; -On [DATE] at 8:30 A.M., the resident was confused this shift and alert and oriented times one to two. The resident asked if he/she was a patient; -On [DATE] at 11:30 A.M., the resident's spouse gave approval for a psychiatric consultation for the resident; -On [DATE] at 10:00 P.M., the resident was agitated and spent the first part of the shift yelling at staff to use the phone to call his/her spouse. The resident placed two calls to his/her spouse with no response. The resident was alert and oriented times two with confusion; -On [DATE] at 10:30 P.M., the resident was alert and oriented times one with confusion and forgetfulness. The resident repeatedly asked to use the phone and call his/her family. The resident asked why he/she was at the facility and if he/she was a patient or a visitor; -On [DATE] at 2:00 A.M., the resident came to the nurses' station wanting to call his/her spouse. Staff informed the resident he/she could call in the morning because his/her spouse was sleeping; -On [DATE] at 3:50 A.M., the resident came to the nurses' station wanting to call his/her spouse about a missing contact lens. Staff informed the resident he/she could call his/her spouse at 7:00 A.M. The resident was agitated and erratic; -On [DATE] at 4:15 P.M., the resident came to the nurses' station several times asking to use the phone. The resident had increased agitation, and staff administered Ativan; -On [DATE] at 6:30 P.M., the resident attempted to leave the building. The resident yelled and swung at staff. Staff contacted the family and physician; -On [DATE] at 7:10 P.M., the resident removed his/her EMD and had it in his/her pocket. The nurse and supervisor placed the EMD back on the resident's ankle. The resident continued on 15 minute checks. During an interview on [DATE] at 1:50 P.M., Nurse C said the exit doors at the end of the halls on the wings had alarms which sounded whenever anyone attempted to open the door. The main front door and the main back door only alarmed when a resident with an EMD attempted to open the door. Nurse C said one day ([DATE]) as he/she walked into the building, he/she saw the resident attempting to leave the building. The resident was aggressive and feisty and tried to hit staff. Review of the social service notes, dated [DATE], showed after an attempted elopement, staff began 15 minute checks of the resident as a safety measure and would be reviewed on [DATE]. Review of the psychiatric consultation, dated [DATE], showed the following: -Reason for the consultation was due to the resident's increase in physical aggression and threatening behavior. The resident had a previous hospitalization on [DATE] after threatening to kill his/her dogs and spouse. In the emergency room , the resident was uncooperative, yelled and attempted to hit the security guards. While at the facility, the resident called home frequently, attempted to leave, and when redirected, threatened staff and became agitated. -The resident told the psychiatrist, I'm not sure why I'm here. I came with someone to return and the next thing I know I'm here. No one wants to help you. How do I get out of here? Do I stay calm and quiet? Would you help get me out? -Mini Mental State Examination (MMSE, short questionnaire to measure cognitive impairment) score of 23 out of 30 (mild cognitive impairment). -The psychiatrist ordered: -Continue the Lexapro and Namenda; -Buspar 5 mg every morning for one week and then discontinue; -Lorazepam 0.25 mg daily at 1 P.M.; -Risperdal (anti-psychotic medication) 0.25 mg every evening. Review of the assignment sheet, dated [DATE] (7 P.M.-7 A.M. shift), showed no special instructions for staff to conduct 15 minute checks on the resident. Further review of the nurses' notes, showed the following: -On [DATE] at 9:30 P.M., the resident asked to use the phone three times. The resident called his/her spouse, daughter and son. While on the phone with the son, the resident became agitated; -On [DATE] at 10:45 P.M., the back door alarm sounded. The resident ran out into the back parking lot and staff followed him/her. The resident swung at the staff and yelled I'm going home. You try to stop me and I'll break your nose. Don't you get close to me. I'll break your nose. After ten minutes of talking with the resident, the resident went back indoors. The resident remained agitated and said he/she wanted to call his/her father who is a cop. The resident wanted to call his/her spouse and son. The resident called his/her family multiple times this evening and now the spouse and son did not answer the phone. Staff initiated one-on-one with the resident since he/she tore off his/her EMD again. -On [DATE] at 11:05 P.M., staff contacted the primary physician; -On [DATE] at 11:07 P.M., the primary physician said to contact the psychiatrist; -On [DATE] at 11:35 P.M., the psychiatrist ordered Ativan 0.5 mg now; -On [DATE] at 11:45 P.M. the resident refused the Ativan due to agitation; -On [DATE] at 12:10 A.M., the resident demanded to use the phone and stated You can't hold me here against my will. By God, I will kill myself. I hope you are proud of yourself, driving an old (person) crazy. Staff were unable to redirect the resident, and the resident still refused the medication. A certified nurses' assistant (CNA) sat at the resident's door; -On [DATE] at 12:30 A.M., the resident demanded to use the telephone and yelled down the hall, Let me go. I wanna go home. What have I done that I am locked up here? The resident slammed his/her door. A CNA remained at the resident's door; -On [DATE] at 12:44 A.M., the resident yelled out into the hall, Damn you. Let me go home. I'll kill myself. I mean it. The resident slammed his/her door. A CNA sat by the resident's door; -On [DATE] at 1:02 A.M., the resident screamed, I'll get my dad down here. He's a cop. Let me go home. The resident slammed the door, and a CNA remained by the door; -On [DATE] at 1:10 A.M., the resident was out in the hall yelling, Who has to die before I get out of here? I'm leaving tonight or someone dies. Take your pick you sons of [***] es. The resident slammed the door, and a CNA remained by the door; -On [DATE] at 1:24 A.M., the resident yelled, I'm not a resident here. You can't make me one. What's wrong with you? Are you stupid? You just look at me like I'm not talking to you. Are you the guard? Well guard me, I oughtta break your nose. What do you think about that? I have rights. I get a phone call. Staff explained the residents do not use the phone between 10 P.M. and 7 A.M. since that is the time most people sleep. The resident screamed, I don't give a damn about anyone's sleep. I wanna go home now! Damn you. I'll get you and I'll get your kids too. They aren't grown up. The resident slammed the door, and a CNA remained by the door. During an interview on [DATE] at 1:10 P.M., Nursing Supervisor (NS) F (night shift), said he/she did not recall if staff called the physician back about the resident's medication refusal during this particular incident. NS F did not remember this particular incident. However, the normal practice if a resident refused this medication would be to see if a different staff member could help the resident take the medication. If the resident still refused, then staff would routinely call the physician back for a different medication route (injectable). Generally with this resident, from 7 P.M.-11 P.M., they assigned a specific staff member to be with the resident one-on-one since that was the time frame the resident had the most agitation. After 11 P.M., the resident usually slept, then the assigned CNA sat in the hall to monitor the resident's room, but the CNA from 11 P.M.-7 P.M. would also have other residents on the assignment. The resident verbally made threats, but according to the family, the resident was a lot of talk. If NS F thought the resident was in danger, he/she would have sent him/her out. Review of the resident's record, showed the resident signed a note, dated [DATE], that he/she would only make three phone calls per day. Review of the social service notes, showed the following: -On [DATE], the social worker observed the resident in a heightened verbal state asking the Director of Nurses (DON) if he/she could use the phone. When reminded he/she just called his/her family, and he/she could only call three times per day, the resident was upset, threw his/her hands in the air and did not want to talk. -On [DATE], the social worker heard the resident yell. When the social worker arrived at the resident's room, he/she said, Call my (spouse), call my (spouse), get him/her on the phone right now, call him/her or I might threaten to hurt myself. That would get you to get him/her on the phone, wouldn't it? Call my (spouse!) The social worker asked the other staff to leave the area so the resident did not feel surrounded and told the resident he/she could call his/her spouse. The resident did not have a plan to hurt him/herself at the time, and the social worker contacted the administrator-in-training. The social worker left a message for the spouse about the resident wanting to speak with him/her and asked about returning the phone to the resident's room. The social worker returned the phone to the resident for the evening. The social worker verified with nursing staff the 15 minute checks continued and to monitor for any additional behaviors related to suicidal ideations. Review of the assignment sheet, dated [DATE] (7 P.M.-7 A.M. shift), showed no special instructions for staff to conduct 15 minute checks on the resident. Further review of the nurses' notes, showed the following: -On [DATE] at 10:30 P.M., the resident was alert and oriented times one with forgetfulness and confusion. The resident was very agitated at staff and demanding to call his/her family. The resident threatened to harm him/herself. The resident continued to ask why he/she was here and if he/she was a patient. The resident called the family several times with no answer. A one-on-one sitter remained until 11 P.M. and 15 minute checks were completed by the nurse; -On [DATE] at 12:45 A.M., the nurse entered the resident's room for a 15 minute safety check and to check for EMD placement. The EMD was not on. The resident told the nurse he/she took the EMD off and showed it was in his/her candy stash. The resident screamed at the nurse to get out. When the nurse returned with a new EMD, the resident said he/she chewed off the last one. The resident screamed he/she was going home, and they held him/her there against his/her will. The resident grabbed the nurse's arm and tried to push the nurse out of the way. The resident told another nurse he/she would break the nurse's nose. Staff allowed the resident to use the phone. Staff contacted the primary physician who ordered the resident to the hospital. Further review of the social service notes, dated [DATE], showed the social worker spoke with the resident's family regarding the resident's behaviors. They returned the phone to the resident's room. The resident's spouse said he/she would call every morning and every evening to check on him/her, but the family would allow the call to go to voice mail in between those times since they received 150 calls in one night. The spouse said he/she would also post information about the season, etc., as well as the family visiting schedule to help calm the resident. Further review of the nurses' notes, showed the following: -On [DATE] at 10:50 A.M., the resident returned to the facility. The family requested a phone back in the resident's room; -On [DATE] at 10:20 P.M., the resident yelled at staff about his/her kidney stones. Review of the assignment sheet, dated [DATE] (night shift), showed Nurse B noted staff should complete 15 minute checks on the resident through the entire shift. Further review of the nurses' notes, showed on [DATE] at 10:55 P.M., the resident continued on one-on-one observation and 15 minute checks. During an interview on [DATE] at 2:30 P.M., social worker (SW) G said the resident came from a stable home environment. The resident could remember his/her family lived close but could not remember why he/she was at the facility. The resident liked to call his/her family often and one time called them over a 100 times in one night. The resident's family requested staff remove the phone from the resident's room. Even after they returned the resident's phone to his/her room, due to increased agitation, the resident's behaviors did not fully de-escalate. Review of the resident's Medication Administration Record (MAR), dated [DATE], showed staff documented the placement of the resident's EMD every shift, (7 A.M.-7 P.M. and 7 P.M.-7 A.M.). During an interview on [DATE] at 9:15 A.M., the assistant administrator said there were no two hour check sheets for the EMD during the first two weeks of the resident's stay at the facility. Review of the assignment sheet, dated [DATE] (night shift), showed Nurse B noted staff should complete 15 minute checks on the resident through the entire shift. Review of the 24 hour observation sheet, dated [DATE], showed Nurse A initialed as completed 15 minute checks from 3:00 A.M. through 5:15 A.M. on [DATE]. Observation of the facility's security camera recordings showed on [DATE] at 3:32 A.M., a security guard walked down the back hall and looked out of the back door window. At 3:39 A.M., the resident walked out of the back door wearing shoes, pants and a flannel coat. Review of the nurses' notes, dated [DATE] at 6:40 A.M., showed the nurse entered the resident's room to administer morning medications and observed an empty room. When the nurse could not locate the resident, he/she informed the night supervisor. The nurse received a phone call from the resident's spouse who stated the resident was at his/her home with a police officer and would return to the facility. At 6:30 A.M., the resident returned to the facility with no injury and no EMD on. The resident's vital signs were temperature 97.6 degrees Fahrenheit (F) (normal 97XXX,[DATE].1), pulse 84 (normal ,[DATE]), respirations 18 (normal ,[DATE]) and blood pressure ,[DATE] (normal ,[DATE]-,[DATE]). Staff contacted the physician. During an interview on [DATE] at 12:25 P.M., CNA D said he/she saw the resident up in his/her chair between 2:,[DATE]:00 A.M. on [DATE]. Between rounds, CNA D sat on the 300 hall to monitor the residents. At approximately 4:00 A.M., the CNA went to another resident's room to provide care. At 6:00 A.M., when the CNA went to Resident #1's room, the resident was not in the room. The CNA said no one told him/her during the night shift of ,[DATE] through [DATE] he/she should check the resident every 15 minutes. During previous shifts, the CNA remembered the nurse told him/her about not leaving the resident unattended, but the CNA said he/she did not know he/she should have checked the resident every 15 minutes or told a co-worker when he/she needed to make rounds or take a break on this particular night (,[DATE] through [DATE]). During an interview on [DATE] at 11:40 A.M., Nurse A said when the resident first came to the facility, he/she had no behavior issues. The resident became agitated and would call his/her family hundreds of times and come to the nurses' station every five to ten minutes. The resident became upset when the family wanted the phone removed from his/her room. The nurse said the resident left the building on one previous occasion. The resident had also previously removed his/her EMD. During the night shift of ,[DATE] through [DATE], the resident was no more agitated than usual. The nurse thought he/she saw the resident around midnight. Between 3:00 A.M. and 4:00 A.M., the nurse provided treatments to other residents. The nurse said CNA D sat in another resident's doorway on the same hall. The nurse did not know why the CNA sat in that part of the hallway because the CNA sat inside the doorway and could not see Resident #1's doorway from where the CNA sat. No other resident on the hall was on one-on-one observation or 15 minute checks. The nurse said he/she documented the 15 minute checks were done, even though he/she was not the one who completed them. Because the form was at the nurses' station, the nurse assumed he/she should complete the paperwork. The nurse could see the CNA sat on the hall. The nurse heard no alarms sound during the shift. The nurse said he/she worked at the facility for approximately two months, and no one reviewed with him/her how to properly document the 15 minute checks. During an interview on [DATE] at 1:30 P.M., Nurse B said the resident was pleasant at first after his/her admission to the facility. The nurse said he/she worked with the resident during two prior nights when the resident was agitated and wanting to call his/her family or leave the facility. The nurse said he/she told CNA D about the resident's 15 minute checks on ,[DATE] through [DATE], and the nurse wrote the information on the assignment sheets, which all the CNAs received. On [DATE], the nurse last saw the resident at approximately 3:30 A.M. telling the nurse supervisor he/she wanted to go home. The nurse saw the CNA check on the resident at approximately 1:00 A.M. and 2:00 A.M. Nurse A documented the 15 minute checks because the form was up at the nurses' station, and the nurses could see the CNA checked on the resident. At approximately 6:10 A.M., Nurse B entered a resident's room across the hall, and CNA D asked the nurse if the resident went to first breakfast. They started looking for the resident, and when they could not locate the resident, the nurse informed the night supervisor. During an interview on [DATE] at 2:15 P.M., NS F said the resident's behaviors were difficult because he/she could not understand why he/she was at the facility. The resident's home was not far from the facility. On [DATE] at approximately 3:30 A.M., NS F saw the resident in his/her room. The resident said he/she was not a patient and wanted to call his/her spouse. NS F told the resident he/she could call his/her spouse after breakfast in the morning, and the resident got back in bed. CNA D sat in the hallway and monitored the resident. The resident's room was visible from where the CNA sat. NS F and Nurse B both told CNA D he/she needed to monitor the resident and to get another staff member if he/she needed to take a break or get up from his/her monitoring spot. Staff wrote this information on the assignment sheets. CNA D was responsible for documenting the 15 minute checks. NS F heard no door alarms sound during the shift. At approximately 6:00 A.M., staff realized the resident was not in his/her room and notified NS F. They searched the building and began searching the grounds when the local police department arrived with the resident. The resident had no injuries and his/her vital signs were stable. NS F put another EMD on the resident. During an interview on [DATE] at 11:30 A.M., the assistant administrator said on [DATE], the resident took off his/her EMD and left out of the back door. During an interview on [DATE] at 10:10 A.M., security guard E said he/she only worked at the facility a few days when the resident left the building. The security guard remembered seeing the resident, but did not see the resident leave the building on [DATE]. Prior to [DATE], the facility did not show the security guard pictures of residents to watch for or special instructions regarding what to do if there were a problem with a resident. During an interview on [DATE] at 9:15 A.M., the police dispatcher said they received a call on [DATE] at 6:05 A.M. to check on the status of a confused, older person. During an interview on [DATE] at 10:40 P.M., police officer (PO) H said when he/she arrived, the resident was in a parking lot. The female driver told PO H, she almost hit the resident when she turned at the intersection. The driver did not feel comfortable leaving the resident and that was why she stayed until PO H arrived. The resident seemed tired, and PO H steadied the resident a little to make sure he/she would not fall. The resident repeated several times I don't know this area. I'm not recognizing this area. It was still dark outside. The resident gave the PO H his/her home address. When PO H returned the resident to his/her home address, the resident's spouse said the resident lived at the facility. PO H returned the resident to the facility. Observation on [DATE] at 11:25 A.M., showed the facility on the south side of a two-lane residential street. One side of the street had a sidewalk, and the other side of the street had intermittent areas of sidewalk. The speed limit was 30 miles per hour (MPH). Where the residential street intersected a busy, major road, the residential two lane road divided into three turn lanes in one direction and two turn lanes in the other direction. 1.4 miles north of this stop-light intersection, along the major road, was the location of the business where the police officer saw the resident. The major road had two lanes in each direction, with an additional turn lane, which divided the two directions. There was a sidewalk along the major road, and the speed limit was 40 MPH. Review of faxed correspondence from the administrator, dated [DATE], showed the staff began 15 minute checks on the resident on [DATE] per nursing judgment due to the resident's elopement attempt. The one-on-one observation began when the resident got out of the building on [DATE]. The facility did not have a written policy regarding 15 minute checks or one-on-one monitoring. The 15 minute checks and the one-on-one monitoring continued until the day of the resident's discharge from the facility. During an interview on [DATE] at 1:20 P.M. and 1:30 P.M., the administrator said facility staff were responsible for the one-on-one monitoring of the resident. During day shift, staff conducted 15 minute checks and during the night shift, staff conducted 15 minute checks and one on-one monitoring. During the one-on-one monitoring of the resident on night shift, the administrator expected between rounds, the assigned CNA should have sat outside of the resident's door, since the resident liked his/her door closed. When the CNA needed to do rounds, the nurse should have taken over the monitoring. This information would have been communicated verbally during report. Staff should have updated the resident's care plan about the one-on-one monitoring. Staff should have contacted the physician when the resident refused the Ativan during the night shift of ,[DATE] through [DATE]. During an interview on [DATE] at 4:00 P.M., the psychiatrist said the resident's dementia and MMSE score were not bad, but he/she had no safety awareness. The resident would not be safe out on his/her own. The resident had no clue what was going on or why he/she needed to be in a facility. The resident had no recollection of being in the hospital or why the family wanted the phone taken away. The resident removed his/her wanderguard, but it was impossible to reason with the resident why he/she needed it. Trying to reason with the resident just made him/her angry. The resident had no insight that he/she had memory impairment, which led to impaired judgment. Review of the facility's Wanderguard (EMD) Protocol, review date [DATE], showed the following: -Any time staff issued a wanderguard to a resident, the charge nurses and CNAs would check the placement of the wanderguard every two hours for two weeks. If the resident complied with wearing the wanderguard during the two weeks, the certified medication technician (CMT) would check the wanderguard three times per day for 30 days and document the checks on the MAR. -If staff found the resident non-compliant, the cycle would start over until compliance was achieved. -If the resident was compliant, the CMT would check wanderguard placement every shift with documentation on the MARs, and the restorative CNA would check the wanderguard weekly for placement and function. Review of the facility's Protocol for Wanderers, review date [DATE], showed the following: -All pre-admits will be screened for wandering habits and patterns; -All ambulatory residents should be assessed for wandering behaviors with information from the family and staff on the first day of admission; -If a resident exhibited ambulatory restlessness or had a prior history of wandering, staff should immediately place a wanderguard bracelet and begin the wanderguard protocol; -Staff should interview the family regarding past, successful interventions; -Staff should introduce the wandering residents to staff on other wings for identification purposes; -Staff should identify all ADL needs (toileting needs, hunger, sleep, etc); -Staff should ensure continuity of care as much as possible by having the same staff care for the resident. One-on-one care would be provided as needed during the initial adjustment period; -Staff should immediately notify the physician of the resident's wandering and appropriate measures to keep the resident safe should be discussed; -If a resident exited the facility, staff should approach the resident calmly and not grab the resident; -If the resident could not be found in the building or on the grounds, staff should contact the local police department. MO 098 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction that included the following: in-services to direct care staff regarding communication, 15 minute checks, one-on-one monitoring and elopement check sheet forms. The facility reviewed and updated their policy regarding 15 minute checks. The facility provided education to the security guard personnel regarding residents at risk for elopement. The facility planned to re-assess all residents at risk for elopement and newly admitted residents for elopement risk and appropriate interventions. The resident no longer lived in the facility. At the time of the exit, the facility still needed to complete in-services to a small amount of staff and determine how they will imp

Based on observation, interview and record review, the facility failed to routinely assess the skin underneath a removable knee splint for one resident. Of the six residents sampled with orders for ace wraps to the legs, one had a knee splint attached by the ace wrap, and the resident developed two Stage IV and one unstageable pressure ulcers underneath the knee splint. (Resident #6) The census was 176. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, from the resident's previous nursing facility, dated 5/31/11, showed [DIAGNOSES REDACTED]. Review of a local hospital report, dated 6/8/11, showed the resident was admitted to the hospital, from a local nursing facility, with a non-displaced fracture (the bone cracks either part or all of the way through but maintains it's proper alignment) of the right knee. Hospital staff applied a coaptation splint (a short splint to keep the broke bones in place) on the resident's right knee and sent him/her back to the same nursing facility he/she transferred from. Review of the resident's admission nurse's note, dated 6/28/11 at 5:10 P.M., showed an admission to this facility from another nursing facility, alert and oriented times one (either person, place or time), a non-displaced [MEDICAL CONDITION] knee and required a total lift for transfers. Review of the resident's "Admission Nursing History and Assessment", completed on 6/28/11, showed the following: -Scar tissue to coccyx area and scar tissue and discoloration to buttocks; -A 1.6 centimeter (cm) by 1.6 cm open area on groin; -Right closed (non-displaced) [MEDICAL CONDITION] knee; -Inaccessible areas to the bilateral inner thighs with bloody drainage; -Severe contracture of the left hand and leg; -Severe right foot drop (dropping of the forefoot); -Superficial area to the right upper thigh and left contracted shin; -The assessment contained no documentation about a right knee splint or pressure ulcers on the right knee or shin. Review of the resident's "Skin Attention Form", completed on 6/28/11, showed no documentation about a right knee splint or pressure ulcers on the right knee or shin. Review of the resident's "Braden Scale" (assessment for predicting pressure sore risk), dated 6/28/11, showed the following: -Score "12", high risk; -Sensory perception: Responded to verbal commands, but could not always communicate discomfort or need to be turned, or had some sensory impairment which limits ability to feel pain or discomfort in one or two extremities. Review of the resident's admission physician's orders [REDACTED]. Review of the resident's nurse's note, dated 6/29/11 at 2:20 A.M., showed the following: -Splint with ace wrap on right knee; -[DIAGNOSES REDACTED]. -Mostly non-verbal, followed with eyes when name called; -Left upper and lower extremities severely contracted across body; -No signs or symptoms of pain, moans during care; -The nurse failed to document if he/she removed the right knee splint to assess the skin underneath. Review of the nurse's notes, dated 6/30/11, showed no documentation about the resident's right knee splint or the condition of the skin underneath. Review of the resident's POS, dated 7/1/11 through 7/31/11, showed the following: -Hospice care started on 7/6/11; -No order for a right knee splint. Review of the resident's treatment administration record (TAR), dated 7/1/11 through 7/31/11, showed no order for a right knee splint. Review of the nurse's notes, dated 7/1/11, showed no documentation about the resident's right knee splint or the condition of the skin underneath. Review of a nurse's note, dated 7/2/11 at 11:10 A.M., showed: -Splint to right leg intact; -The nurse failed to document if he/she removed the right knee splint to assess the skin underneath. Review of the resident's "Weekly Body Assessment", dated 7/3/11 through 7/9/11, showed the resident had a treatment to the left leg and perineal area. The assessment had no documentation about the right knee splint or the condition of the skin underneath. Review of the nurse's notes, dated 7/3/11 through 7/11/11, showed no documentation about the resident's right knee splint or the condition of the skin underneath. Review of the resident's admission MDS, dated [DATE], showed the following: -Unclear speech - slurred or mumbled words; -Rarely/Never understands; -Memory problem; -Did not recall current season, location of room and staff names and faces; -Severely impaired decision making skills; -One person extensive assistance required for bed mobility, dressing and personal hygiene; -Total dependence of one person for eating, toilet use and locomotion on/off the unit; -Total dependence of two (+) persons for transfers; -Limited range of motion of both upper and lower extremities; -Indicators of pain or possible pain observed three to four of the last five days. Review of the resident's "Weekly Body Assessment", dated 7/10/11 through 7/16/11, showed the resident had a treatment to the left and right groin and perineal area. The assessment had no documentation about the right knee splint or the condition of the skin underneath. Review of the nurse's notes, dated 7/11/11 through 7/18/11, showed no documentation about the resident's right knee splint or the condition of the skin underneath. Review of the resident's care plan, dated 7/18/11, showed the following: -Dependent on staff for bathing two times weekly; -Extensive assist on staff for repositioning in bed and chair and with dressing; -admitted with open areas to left groin, right upper thigh and left skin; -Maintain right leg splint and observe for toleration; -Observe for any redness or irritation to right leg from splint usage; -Weekly body and heel checks; -Right leg splint to be maintained by nursing and hospice staff; -Monitor right leg for redness, irritation and circulation; -Difficulty making self understood or understanding others; -Cognitive loss and altered behaviors related to depression, mental [MEDICAL CONDITION] and adjustment to new environment. Review of the resident's "Weekly Body Assessment", dated 7/17/11 through 7/23/11, showed the resident had a treatment to a boil on the hairline, right and left groin and right inner thigh and old scars on the coccyx. The assessment had no documentation about the right knee splint or the condition of the skin underneath. Review of the nurse's notes, dated 7/19/11 and 7/20/11, showed no documentation about the resident's right knee splint or the condition of the skin underneath. Review of a nurse's note, dated 7/21/11 at 5:00 P.M., showed the resident's right knee remained in a splint, no concerns noted. The nurse failed to document if he/she removed the right knee splint and assessed the skin underneath. Review of the nurse's notes, dated 7/22/11 through 7/31/11, showed no documentation about the resident's right knee splint or the condition of the skin underneath. Review of the resident's POS, dated 8/1/11 through 8/24/11, showed no order for a right knee splint. Review of the resident's TAR, dated 8/1/11 through 8/24/11, showed no order for a right knee splint. Review of the nurse's notes, dated 8/1/11 through 8/24/11, showed no documentation about the resident's right knee splint or the condition of the skin underneath. Review of a nurse's note, dated 8/25/11 at 8:25 P.M., completed by Nurse A, showed the resident received a whirlpool bath that morning. After removing the right knee splint, he/she noted a 5.0 cm by 2.0 cm unstageable pressure ulcer (slough and/or eschar (dead tissue): Known but not stageable due to coverage of wound bed by slough and/or eschar) to the right outer knee. A scabbed over area to the top of the right knee measured 3.0 cm by 2.5 cm and an unopened abrasion on the right shin. Review of the resident's POS, showed an order dated 8/25/11, for the following: -Cleanse top of right knee, right outer knee and right shin with wound cleanser; -Apply triple antibiotic ointment (TAO) and a dry dressing to the top of the right knee and lower shin daily; -Apply Santyl (enzymatic ointment that removes slough or eschar) to right outer knee, cover with gauze and wrap daily until healed. Review of the resident's TAR, dated 8/25/11, showed the following: -Right outer knee: Unstageable wound, 5.0 cm by 2.0 cm with white, grayish slough; -Top of right knee: 3.0 cm by 2.5 cm scabbed over area; -Right lower shin: skin peeled off after whirlpool; -Right lower shin and top of right knee: Apply triple antibiotic ointment daily until healed; -Unwrap ace wrap and remove splint daily to assess skin. Review of the resident's TAR, dated 8/29/11, showed the following: -Top of right knee: slough, unstageable, 2.8 cm by 2.6 cm. Updated physician; -Right outer knee: remains unstageable, 5.6 cm by 2.4 cm, black necrotic area, yellow slough with pink edges; -No documentation regarding the right shin. Review of the resident's next nurse's notes, showed the following; -8/30/11 at 10:00 A.M., hospice visit; -8/30/11 at 11:30 A.M., seen by the resident's physician's nurse practitioner; -9/7/11 at 4:50 P.M., right knee warm to the touch and had [DIAGNOSES REDACTED] (redness). New order received for Keflex (antibiotic) 500 milligrams (mg) four times a day for 14 days. Review of a nurse's note dated 9/7/11 at 4:58 P.M., showed resident had a right knee pressure ulcer infection and yellow slough in the right lower shin pressure ulcer. Review of the resident's POS, showed an order, dated 9/7/11, for the following: -Discontinue triple antibiotic ointment to the right lower shin and top of right knee; -Start Santyl daily until healed. Review of the facility "Wound Report", dated 9/26/11, showed the following for the resident: -Top of right knee: Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling), 4.0 cm by 3.0 cm, 80% bleeding wound bed with 20% yellow slough; -Right outer knee: Stage IV pressure ulcer, 5.6 cm by 3/4 cm, 75% bleeding wound bed with 25% yellow slough; -Right lower shin: Unstageable pressure ulcer, 6 cm by 1.8 cm, yellow slough with brownish edges. Review of the resident's POS, dated 9/11, showed an order dated 9/20/11, to continue the Keflex 500 mg four times a day for 14 more days. Review of the resident's POS, showed an order, dated 9/27/11, to discontinue the right knee splint. During an interview on 9/29/11 at 12:45 P.M., the Director of Nurses (DON) said the resident came to the facility with a right knee fracture and a right knee splint. Staff applied the splint by wrapping an ace bandage around it. If staff were not supposed to remove the splint, there would have been a physician's orders [REDACTED]. She reviewed the resident's medical record and weekly skin assessments. She could not find documentation, from the time of the resident's admission, on 6/28/11 until 8/25/11, that staff removed the right knee splint to assess the skin underneath. Staff should have removed the right knee splint daily and assessed the skin. She had no idea how long the resident had pressure ulcers underneath the right knee splint before they were found, on 8/25/11. The DON said the facility Certified Nursing Assistants (CNAs) completed skin assessments on each resident on their bath days, but she could not find any CNA skin assessments for the resident. The facility did not have a policy regarding cast/splint care or assessments. During an interview on 9/29/11 at 2:15 P.M., the assistant administrator said she spoke to the resident's Hospice nurse that day and had been told the hospice staff had not been removing the right knee splint to assess the resident's skin underneath. Observation on 9/29/11 at 1:55 P.M., showed the resident lay in bed. Nurse A removed the resident's right leg dressing which showed the following: -Top of right knee: Stage IV pressure ulcer, 3.2 cm by 4.0 cm, red beefy wound bed; -Right outer knee: Stage IV pressure ulcer, 5.8 cm by 3.8 cm, red beefy wound bed; -Right lower shin: Unstageable pressure ulcer, 5.0 cm by 1.8 cm, white and yellow slough covered 80% of the wound bed. During a telephone interview on 9/30/11 at 8:50 A.M., Nurse B said he/she worked the midnight shift and completed "Weekly Skin Assessments", for 7/24/11 through 7/30/11, 7/31/11 through 8/6/11, 8/7/11 through 8/13/11, 8/14/11 through 8/20/11 and 8/21/11 through 8/27/11. He/She never documented the date he/she completed the skin assessment although he/she now felt he/she should have. He/She did not remove the resident's right knee splint during any of the assessments because the TAR did not show an order to do so. He/She did not ask anyone if the right knee splint could be removed or not for cleaning or skin assessments. Review of a handwritten note, dated 9/30/11, from Nurse A, showed he/she gave the resident a whirlpool bath, possibly within two weeks before finding the pressure ulcers on 8/25/11. He/She had removed the splint and did not observe any skin breakdown at that time. The nurse did not document this information anywhere in the resident's medical record. During a telephone interview on 10/3/11 at 8:15 A.M., the DON said regarding Nurse A's handwritten note, that two weeks was still too long for staff to have waited to remove the right knee splint and complete a skin assessment. During a telephone interview on 9/30/11 at 1:00 P.M., the physician, who provided care for the resident at his/her previous nursing facility, said he remembered the resident and the right knee splint. The right knee splint could have and should have been removed daily to have the underlying skin assessed for breakdown. During a telephone interview on 10/3/11 at 9:25 A.M., the nurse practitioner who currently provided care for the resident, said she assumed the nurses at the facility removed the resident's right knee splint to assess the skin and for bathing. They should have been assessing the skin underneath the right knee splint daily. During an interview on 10/20/11 at 6:25 A.M., the emergency room physician said the coapt splint that they applied to Resident #6 was a form fitting splint that they made in order to ensure the joint did not rock back and forth. They do this for residents who are nonweight bearing. On each side of the leg was the actual hard brace and then padding around it, then wrapped in an ace wrap. He would expect the splint to be removed every other day and especially when staff gave the resident a bath. He thought that was when a full body assessment should be completed. He said it should be removed to assess for skin breakdown and decubitus ulcers. MO 234 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, Resident #6's pressure ulcers showed improvement. Staff documented daily skin assessments of the resident's skin. Skin assessments were completed on five residents at risk for developing pressure ulcers. No new pressure ulcers were identified. The facility had begun to inservice all nursing staff to a newly developed policy addressing casts, splints, braces, podus boots and ace wraps. Inservicing will be completed by October 24, 2011. All new staff will be inserviced upon hire and the facility will include the inservices with staff every six months. Current residents with casts, splints, braces, podus boots and ace wraps had been assessed for skin irritation and pressure ulcers. All of these devices will be removed daily for skin assessments. Orders to remove orthotics for new residents will be obtained at the time of admission. The wound care team (DON, assistant director of nurses, wound care nurse, therapy manager and assistant administrator) will discuss the ongoing interventions in the weekly wound meetings and quarterly quality assurance meetings. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.