Every finding on record at Stonebridge Florissant

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) of nine sampled residents received the necessary care and services including appropriate individualized interventions to prevent the development of three unstageable pressure ulcers that were covered with eschar and required surgical removal of the eschar while the resident was in the hospital for infection in the sacral wound. The facility census was 79.Review of the undated facility policy for Pressure Injury Prevention and Management showed:-This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries;-Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device;-Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate;-Unavoidable means that the resident developed a pressure ulcer/injury even though the facility had evaluated the resident's clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate;-The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions; and modifying the interventions as appropriate;-Licensed nurses will conduct a pressure injury risk assessment, using the (fill in blank for designated tool), on all residents upon admission/re-admission, weekly for four weeks, then quarterly or whenever the resident's condition changes significantly;-The tool will be used in conjunction with other risk factors not captured by the risk assessment such as impaired/decreased mobility and decreased functional ability; impaired diffuse or localized blood flow, resident refusal of care and treatment;-Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record;-Assessments of pressure injuries will be performed by a licensed nurse and documented on the (fill in the blank for designated form). The staging or pressure injuries will be clearly identified to ensure correct coding on the Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff);-Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task;-After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions;-Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include: redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); minimize exposure to moisture and keep skin clean, especially of fecal contamination, provide appropriate, pressure-redistributing, support surfaces, provide non-irritating surfaces and maintain or improve nutrition and hydration status;-Interventions will be documented in the care plan and communicated to all relevant staff;-Compliance with interventions will be documented in the weekly summary charting. 1. Review of Resident #1's face sheet showed the resident was admitted to the facility on [DATE] and a readmission date of 08/17/2026, with diagnoses of stroke, hemiplegia (the total or partial paralysis of one entire side of the body, including the face, arm, and leg), heart failure, hypertension, seizure disorder, aphasia (unable to speak), vascular dementia, osteomyelitis (infection in the bone) of the sacrum, deep vein thrombosis (DVT a serious medical condition where a blood clot forms inside a deep vein, most commonly in the lower leg or thigh), pulmonary embolism, pressure ulcers to the left sacrum, left ankle and left heel. Review of the care plan for skin impairments dated 05/28/26, showed:-At risk for skin impairments due to limited mobility, incontinence and need for assistance with activities of daily living (ADL's);-Goal: will have intact skin, free from redness, blisters or discoloration;-Interventions: follow facility policies/protocols for the prevention/treatment of skin breakdown; monitor nutritional status; Nystatin powder for excoriation; report any skin abnormalities found during showers, and/or peri-care to charge nurse; weekly skin checks. Review of the comprehensive MDS dated [DATE], showed:-The resident is rarely understood and rarely understands others;-Unable to make decisions;-No behaviors;-Impairment on one side, dependent upon staff for activities of daily living (ADL's), rolling from side to side and changing positions;-Incontinent of bowel and bladder;-One fall with major injury;-At risk for the development of pressure ulcers with no pressure ulcers. Review of the skin assessment dated [DATE], at 7:17 A.M. showed:- Left elbow skin tear. New skin Issue: Right popliteal fossa (located behind the knee) bruising. Measurements not documented as part of this assessment. Reason measurements are not documented as Resident refused.Review of the residents' shower sheets (a tool used to document skin issues when providing a resident a shower) dated 06/22/26 showed no skin issues. Review of the skin assessment completed by License Practical Nurse (LPN)/Wound Nurse A dated 06/26/26 at 11:12 P.M., showed: Skin Check: Skin: Skin warm & dry, skin color within normal limits (WNL) and turgor is normal. Right popliteal fossa is healed Left elbow. Is resolved. New skin Issue right popliteal fossa a blister. Area is painful to touch. Length centimeters (cm): 1.5 Width (cm): 1.2 Depth (cm): Left heel Blister. New wound. Wound acquired in-house 06/26/2026. Painful: Length(cm): 3.5 Width (cm): 5 Depth (cm): New skin Issue. Location: Left Achilles and left ankle, open lesion. New wound, wound acquired in-house, exact date: 06/26/2026. No signs or symptoms of infection. Length (cm): 1.5 Width (cm): 1.5 Depth (cm). 100 % Eschar (dead tissue), no drainage. Left gluteus; open new wound. Wound acquired in-house. Exact date: 06/26/2026. Length (cm): 2.5 Width (cm): 2.5 Depth (cm): Granulation: 50%. Eschar: 50%.Skin Issues Note: Left buttock open lesion, right lower extremity (RLE) (intact blister), Left ankle (open lesion), and left heel (intact blister). Review of the shower sheet/skin condition report dated 06/29/26, showed as skin tear documented where and no other skin issues. Review of the resident's medical record from 06/29/26 through 07/02/26, showed no documentation of the residents PU's. Review of the resident's care plan for skin impairment, showed no interventions for the treatment of the PU's or measures put in place for the PU's. Review of the Shower Sheet/ Skin Condition Report dated 07/02/26, showed treatment to buttock, ankle and left lower legs. Review of the skin assessment nurses' note dated 07/03/2026 at 10:38 A.M., as a late entry signed by the Director of Nursing, showed:-Skin: Skin warm & dry, skin color WNL and turgor is normal.No new skin issues identified. Skin Issues : Skin Issue: #001: Skin issue has not been evaluated. Location: Left heel Issue type: Blister. Wound acquired in-house. Exact date: 06/26/26; Skin Issue: #002: Skin issue has not been evaluated. Location: Left Achilles Additional location information: Left ankle Issue type: Open lesion. Wound acquired in-house. Exact date: 06/26/26 Skin Issue: #003: Skin issue has not been evaluated. Location: Right popliteal fossa Issue type: Blister. Wound acquired in-house. Exact date: 06/26/2026. Skin Issue: #004: Skin issue has not been evaluated. Location: Left gluteus. Issue type: Open lesion. Wound acquired in-house. Exact date: 06/26/26. Review of the nurses' notes dated 07/06/26 at 10:58 A.M., signed by LPN C, showed:- Wound/Skin Note: left buttock has red excoriated area noted not open, zinc oxide applied. Resident clean and dry, transferred into broda chair with two assist by charge nurse and certified nurse aide with mechanical lift pad. Review of the nurses' notes dated 07/07/26 at 8:13 A.M., signed by LPN C, showed:-CNA during morning check went in the resident's room and was getting the resident up and notified this nurse that the resident was unresponsive. The resident was assessed, he/she was breathing but unable to get oxygen saturation with machine. The resident's hands were cool to touch. Blood pressure 77/59, respirations 14. Physician call and 911 called due to resident is a full code. DON called and message left for resident status. The responsible party notified. 911 arrived within three minutes, report given. The resident remained unresponsive. Review of the nurses' notes dated 07/07/26 at 6:49 P.M., signed by LPN C, showed:-Resident admitted to the hospital with diagnoses of urinary tract infection, sepsis (a life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection), acute kidney injury (AKI a sudden loss of kidney function that happens within a few hours or a few days) and deep vein thrombosis (blood clot in the leg). Review of the admitting hospital records, showed:-07/07/26 hospital pictures of a large wound to the left ischial/sacrum area covered in eschar with surrounding red tissue with a red colored drainage; left lateral ankle a large area that covered the ankle bone covered with eschar with a smaller wound covered in eschar above this wound, no drainage apparent in the picture;-07/13/26 cat scan (a medical test. It uses a rotating X-ray machine and a computer to make detailed cross-sectional pictures of the inside of the body. Doctors use these images to see bones, organs, and soft tissues clearly) of the pelvis: IMPRESSION:1.Large soft tissue ulceration with soft tissue air posterior medial right gluteal region extending posterior to the distal sacrum and coccyx with bony destruction of the right posterior cortex of distal sacrum at S4-5 suspicious for osteomyelitis. There is alsolow-density soft tissue thickening of the posterior medial right gluteus maximus muscle may represent focal cellulitis;-Assessment:Infected sacral decubitus underlying osteomyelitisLeft ankle wound. During an interview on 08/18/26 at 10:14 A.M., LPN C said:-The resident returned to the facility on [DATE] after several weeks in the hospital. Prior to going to the hospital, the resident was total care from the staff and a mechanical lift transfer. He/She had a fall in June and sustained a fractured leg, and afterwards his/her health deteriorated. He/She was off work for a few days and when he/she returned the resident developed an unstageable PU to the sacrum and the left ankle. The resident was not eating well and was refusing lab work to be drawn. On 07/07/26 Certified Nurse Aide (CNA) D came to him/her in the morning and reported that the resident was not acting right. He/She assessed the resident who had a low blood pressure and was not responding. He/She called 911 and the resident was sent to the hospital. While at the hospital, the wound to the sacrial area was debrided (dead tissue removed) and is very large. The resident has an infection in the wound that required intravenous (IV) antibiotics. The contracted wound doctor will see the resident this afternoon. During an interview on 08/18/26 at 12:00 P.M., the LPN Wound Nurse A said:-He/She took the full-time wound nurse position in June, then went on vacation and returned around June 24th. On June 26, 2026, when he/seen Resident #1 skin for the first time when he/she documented the unstageable area to the sacrum and the left ankle. The resident was not compliant with turning and repositioning and was not getting out of bed much around this time. He/She notified the physician and received orders for the resident to be seen by the contracted wound care provider, but the resident went to the hospital before the wound care provider's next visit. The wound care provider comes weekly and is scheduled to see the resident this afternoon. Prior to him/her taking the wound nurse position he/she was the Assistant Director of Nursing and did rounds with the wound physician. The nurses are responsible for doing the treatments on the wounds. The nurses are responsible to do weekly skin assessments, and if they notice an area, they should call the physician and obtain treatment orders until he/she can evaluate the wound and notify the wound physician. During an interview on 08/18/26 at 1:10 P.M., CNA D said:-He/She took care of the resident. The resident didn't get out of bed often after breaking his/her leg in June. The resident did have a small open area on his/her bottom and does not remember if there was any black tissue. There was an open area on the left ankle that was covered with black tissue. He/she was the one who found the resident not responding, he/she called for the nurse and the resident was sent to the hospital. He/She would put pillows between the legs, and turn and reposition the resident. The resident did not refuse to be turned. Observation on 8/18/26 at approximately 2:25 P.M., showed Physician F debrided the resident's sacral wound during rounds with LPN A. The Physician asks LPN A if there are any residents that he/she would like the wound doctor to come to the facility twice a week to monitor. LPN A states no not with him/her having the wound vac in place. Physician F asks about the resident's other wounds like the necrotic ankle wound that could be monitored twice a week. LPN A declines and states he/she does not think that would be necessary.-Physician F identified the following: Left heel measured 2.4 by 2.5 cm with 100% eschar;-Left ankle, over the ankle bone (malleolus) and above the ankle bone measured 6.2 cm by 2.5 cm and 0.2 cm deep with white tissue exposed to which the wound physician identified as the malleolus;-Sacral wound - stage 4 PU (full-thickness tissue loss involving the epidermis, dermis, subcutaneous tissue, and extending down to include exposed muscle, tendon, bone, or other underlying structures) measured 9.5 cm by 10.0 cm by 2.5 cm depth at deepest point of the wound with undermining (the tissue under the edges of the wound has been destroyed, creating a hidden pocket, shelf, or cave-like space beneath healthy-looking surface skin) at 3.5 cm deep. Red tissue with bruising of the tissue noted. [NAME] slough removed. During an interview on 08/18/26 at 3:00 P.M., the Director of Nursing said:-She does not remember documenting any progress notes in the resident's medical record, she had not seen the residents pressure ulcers. The resident had not been eating well since the fracture and was declining. The wounds could have occurred quickly.-She would expect the nurses to complete weekly skin assessments and document their findings in the medical record. During an interview on 08/18/26 at 3:00 P.M., the Administrator said:-Staff should document wounds, skin assessments in the progress notes and notify the physician of any concerns;-CNA's complete a shower sheet when a shower is given and the nurses will follow up on any concerns. If an area of concern is noted, the wound nurse is notified--Wounds should be noted in the early stages to aid in healing. During an interview on 08/21/26 at 10:55 A.M., Physician E said:-The resident had a fall in June with a fracture this could have expediated the wound to the ankle and the DVT;-He last saw the resident in early June, he was made aware by LPN A of the wounds on 06/26/26 and gave the order for the resident to be seen by the contracted wound physician, but he did not see the wounds himself. During an interview on 08/25/26 at 3:00 P.M., LPN B said:-It has been some time since he/she had worked with the resident;-The resident had wounds on his/her heels, the left ankle area and the buttocks, he/she does not remember if there was any eschar;-He/She signed the shower sheet for 06/29/26, but does not remember if he/she actually assessed the resident's skin. 3072573

Based on interview and record review, the facility failed to ensure residents had access to mail delivered on Saturday. This failure had the potential to affect all residents who received mail at the facility. The census was 66. During a group interview on 8/20/25 at approximately 9:45 A.M., five residents, whom the facility identified as alert and oriented, attended the group meeting. All five residents said mail was no longer delivered on Saturdays. The mail is placed in the office, which was closed on the weekends, then distributed to the residents on Monday. One resident said this was frustrating because packages often arrive, and they can't access it until Monday. During an interview on 8/22/25 at 10:37 A.M., the Activity Director initially said mail was delivered on Saturdays and distributed as it arrived. The main office was closed on the weekend, but the mail carrier delivered it to the East side of the facility. However, they had not received any mail on Saturdays lately. She later clarified she spoke with the receptionist, who confirmed the post office did stop delivering mail on Saturdays because the office was closed, and they could not get the packages to any staff members. The Activity Director said someone from activities was at the facility on the weekend and she would contact the post office to resume mail being delivered on Saturdays. During an interview on 8/22/25 at 3:12 P.M., the Administrator said he expected mail to be delivered to residents on Saturdays.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 66.Review of the facility's Daily Census, dated 8/17/25, showed:-Available beds: 109;-Percent of occupancy: 61.5%. Review of the facility's payroll-based journal (PBJ) report, showed:-No RN hours on Saturday, 1/11/25;-No RN hours on Sunday, 1/12/25;-No RN hours on Saturday, 1/25/25;-No RN hours on Sunday, 3/9/25. During an interview on 8/20/25 at 12:30 P.M., the Administrator said the facility did not have any documentation or time sheets to show the facility had an RN on the days listed on the PBJ report. During an interview on 8/22/25 at 3:13 P.M., the Administrator said he expected to have an RN in the facility at least eight consecutive hours a day, seven days a week.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected two of three sampled residents who expired and had money in their accounts (Residents #74 and #75). The sample size was 17. The census was 66.Review of the facility's Resident Trust Fund Account Policy and Procedure, revised 2/2025, showed:-Policy: It is the policy of the facility to manage personal funds of our residents, upon request, and written authorization of the resident or legal representative. Funds will be managed in accordance with Federal and State Regulations;-Procedure: Upon the death of a resident with a balance in the Resident Trust Fund, the facility will complete a form and submit to Department of Social Services, Missouri Healthnet Division. The form shall be submitted within 30 days from the date of the resident's death. 1.Review of Resident #74's medical record, showed:-Resident expired on [DATE];-An ending balance of $453.14-TPL submitted [DATE]. 2. Review of Resident #75's medical record, showed:-Resident expired on [DATE];-An ending balance of $3547.24;-TPL submitted [DATE]. 3. During an interview on [DATE] at 8:28 A.M., the Business Office Manager (BOM) said TPL notifications should be sent within 60 days of a resident's death. She was busy and sent them in late. 4. During an interview on [DATE] at 3:12 P.M., the Administrator said he expected TPL notifications to be sent within the required time frame.

Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the notice of the bed hold at the time of transfer to the hospital for two of 17 sampled residents (Residents #68 and #32). The census was 66. Review of the facility's Bed Hold policy, dated October, 2017, showed:-Policy Statement: Our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. Bed hold status exists when a resident temporarily leaves the facility for medical or other therapeutic reasons and their return is anticipated. Hospitalizations are examples of leaves;-Policy Interpretation and Implementation; -Upon admission and when a resident is transferred for hospitalization or therapeutic leave, the facility will provide information regarding the bed-hold policy to the resident or representative in a written format that is understood by the resident or representative; -When emergency transfers are necessary, the facility will provide the resident or resident representative with information concerning our bed-hold policy within 24 hours of such transfer. 1.Review of Resident #68's medical record, showed:-discharged to the hospital on 8/7/25;-Returned to the facility on 8/12/25;-No documentation regarding a notice of bed-hold provided to the resident or residents representative. 2. Review of Resident #33's medical record, showed:-discharged to the hospital on 8/10/25;-Returned to the facility on 8/13/25;-No documentation regarding a notice of bed-hold provide to the resident or resident's representative. 3. During an interview on 8/22/25 at 2:00 P.M., the Director of Nursing (DON) said the notice of bed-hold should be sent to with the resident or provided to the resident's representative upon discharge. There was no documentation indicating a bed-hold was provided to Residents #68 and #33. 4. During an interview on 8/22/25 at 3:12 P.M., the Administrator said he expected the notice of bed-hold be sent with the resident and/or communicated with the resident's representative upon discharge to the hospital with an anticipated return to the facility.

Based on interview and record review, the facility failed to document physician orders were verified for one resident (Resident #74) admitted for respite care. The sample was 17. The census was 66. Review of the facility's Admissions and admission Agreement Policy, dated February 2025, showed: Prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: medication orders, including (as necessary) a medical condition or problem associated with each medication; and routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary care plan. Review of the facility's Reconciliation of Medications on admission Policy, dated revised 2017, showed:-Purpose: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility;-Preparation: Gather the information needed to reconcile the medication list: approved medication reconciliation form; admission order sheet; all prescription and supplement information obtained from the resident/family during the medication history;-Steps in procedure: If a medication history has not been obtained from the resident or family, complete this first;-Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous Medication Administration Record (MAR) (if applicable), and the admitting orders (sources);-Review the list carefully to determine if there are discrepancies/conflicts;-If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy;-Document the medication discrepancy on the medication reconciliation form;-Document what actions were taken by the nurse to resolve the discrepancy;-If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift;-If the discrepancy was resolved, document how the discrepancy was resolved. Review of Resident #74's medical record, showed:-Resident was alert with confusion;-admitted [DATE] and left against medical advice (AMA) on 6/15/25;-readmitted on [DATE] for respite care and discharged on 7/28/25;-Diagnoses included diabetes, anoxic brain injury (brain completely loses its oxygen supply, leading to potential brain cell death), polysubstance abuse, history of stroke, seizure disorder, high cholesterol, high blood pressure and chronic end stage renal failure (irreversible kidney disease). Review of the physician order sheet, dated active orders as of 8/22/25, showed: -A physician order for amlodipine besylate oral tablet 5 milligrams (mg), Give 5 mg by mouth one time a day for blood pressure, order date 7/24/25;-A physician order for aspirin tablets chewable 81 mg, give 1 tablet by mouth one time a day for prophylactics, order date 6/13/25;-A physician order for atorvastatin calcium oral tablet (used to treat high cholesterol) 40 mg, give 1 tablet by mouth one time a day for prophylactic, order date 6/13/25;-A physician order for farxiga oral tablet (used to treat diabetes) 10 mg, give 1 tablet by mouth one time a day for give prior to breakfast, order date 6/13/25;-A physician order for hydroxyzine hcl oral tablet 10 mg, give 10 mg by mouth four times a day for anxiety, order date 7/24/25;-A physician order for insulin glargine solution 100 unit/milliliter (ml), inject 14 unit subcutaneously (under the skin) one time a day for diabetes, order date 7/24/25;-A physician order for Keppra tablet 500 mg, give 1 tablet by mouth two times a day for anticonvulsant, order date 6/13/25;-A physician order for metoprolol tartrate oral tablet 50 mg, give 50 mg by mouth two times a day for blood pressure, order date 7/24/25;-A physician order for Novolog flex pen subcutaneous solution pen-injector 100 UNIT/ml, inject as per sliding scale: if 181 - 200 = 1 units; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 -400 = 5 units; 401+ = 6 units 401 and greater give 6 units, subcutaneously three times a day for hyperglycemia (blood glucose levels are elevated above normal), order date 7/24/25;-A physician order for oxycodone hcl oral tablet 5 mg, give 5 mg by mouth as needed for pain take one tablet by mouth as needed two times daily, order date 7/24/25;-A physician order for ramelteon tablet 8 mg, give 1 tablet by mouth at bedtime for insomnia, order date 7/24/25;-A physician order for trazodone hcl tablet 50 mg, give 50 mg by mouth at bedtime for insomnia, order date 7/24/25. Review of the progress notes, dated 7/24/25 at 7:30 P.M., showed no documentation the physician orders were verified with the physician. Review of the hospital records, dated 7/21/25, provided by the Administrator, after the surveyor asked for the information staff used for admitting the resident to the facility, showed there was no discharge summary or after care summary. During an interview on 8/20/25 at 6:34 A.M., Assistant Director of Nursing (ADON) A said if a resident was admitted on respite care, the admission process would be the same as any other admission. The floor nurse was responsible for completing the admission, which included completing the assessments and entering the medications into the computer. The physician orders were verified with the physician. The nurse should make a progress note showing the orders had been verified with the physician. ADON A looked through the hospital records packet, dated 7/21/25, and said there was no discharge summary or after visit summary. If a discharge summary or after care visit summary was not available, she would use the medication summary, medication outpatient medications as of 7/21/25 for the physician orders. ADON A said she did not enter the physician orders into the computer. Review of the Medication Summary, outpatient medication as of 7/21/25, showed:-A physician order for blood glucose sensor, use as directed to test blood sugar and change sensor every 10 days;-A physician order for hydroxyzine 10 mg four times daily;-A physician order for glucagon (glucagon emergency) 1 mg, inject 1 mg subcutaneous injection;-A physician order for hydrochlorothiazide 12.5 mg, no directions;-A physician order for lisinopril 40 mg (used for blood pressure) take 40 mg daily;-A physician order for insulin glargine 100 unit/ml, inject 14 units subcutaneous injection daily with breakfast;-A physician order for insulin Novolog flex pen, inject 5 units by subcutaneous injection three times daily with meals;-A physician order for MiraLAX 17 gram/dose powder (used for constipation), take 1 scoop (17 gm) twice daily, dissolve in 8 ounces of fluid and drink entire liquid;-A physician order for hydrophilic wound dressing (triad, paste that creates a moist wound healing environment, ideal for wounds with light to moderate exudate) apply to affected area twice daily;-A physician order for amlodipine 5 mg, take 5 mg daily;-A physician order for aspirin enteric coated (EC), take 81 mg daily;-A physician order for atorvastatin 40 mg daily;-A physician order for Plavix 75 mg (antiplatelet), take 75 mg daily;-A physician order for farxiga 10 mg, take 10 mg daily;-A physician order for Keppra 500 mg, take 500 mg twice daily;-A physician order for metoprolol tartrate 50 mg, take 50 mg twice daily;-A physician order for oxycodone 5 mg, take 5 mg every 12 hours as needed for pain; -A physician order for ramelteon 8 mg, take 8 mg daily at bedtime;-A physician order for senna (stool softener and laxative), take 2 tablets daily at bedtime;-A physician order for trazodone 50 mg, take 50 mg daily at bedtime. Review of the physician order sheet, dated active orders as of 8/22/25, showed the blood glucose sensor, glucagon, hydrochlorothiazide, lisinopril, Novolog insulin routine three times a day, MiraLAX, hydrophilic wound dressing, Plavix and senna were not on the physician order sheet. Review of the progress notes, dated 7/24/25 through 7/28/25, showed no documentation the physician orders were verified with the physician. During an interview on 8/20/25 at 2:00 P.M., Registered Nurse (RN) D said the floor nurse was responsible for completing the admission assessments and entering the orders into the computer. RN D looked at the hospital packet provided by the facility and dated 7/21/25, and said he/she used the medication list at end of the visit as of 7/10/25 for the physician orders. The family wrote the insulin instructions on a sheet of paper. RN D looked in the packet and said she thought the insulin orders were Novolog 3 units if eats small meal, 4 units if eats medium size meal and 5 units if eats large meal and Lantus insulin 14 units daily. RN D said he/she called the physician and verified the orders and documented it in the medical record. Review of the Medication List at the End of Visit, dated as of 7/10/25, showed:-A physician order for amlodipine 5 mg, take 5 mg daily;-A physician order for aspirin EC, take 1 tablet daily;-A physician order for atorvastatin 40 mg, take 40 mg at bedtime;-A physician order for Plavix 75 mg, take 75 mg daily;-A physician order for farxiga 10 mg, take 1 daily;-A physician order for glucagon .1 mg, inject 1 mg subcutaneous injection;-A physician order for hydrochlorothiazide 12.5 mg, no directions;-A physician order for hydrophilic wound dressing, apply to affected area twice daily;-A physician order for hydroxyzine 10 mg, take 10 mg four times daily;-A physician order for novolog flex pen u-100 insulin, inject 5 units by subcutaneous injection three times daily with meals;-A physician order for Lantus 100 unit/mL, inject 14 units by subcutaneous injection daily with breakfast;-A physician order for Keppra 500 mg, take 500 mg twice daily;-A physician order for lisinopril 40 mg, take 40 mg daily;-A physician order for metoprolol tartrate 50 mg, take 50 mg twice daily;-A physician order for oxycodone 5 mg, take 5 mg every 12 hours as needed;-A physician order MiraLAX 17 gram/dose, take 1 scoop (17 grams) twice daily. Dissolve in 8 ounces of fluid and drink entire liquid;-A physician order ramelteon 8 mg, take 8 mg daily at bedtime;-A physician order for senna-s, take 2 tablets daily at bedtime;-A physician order for trazodone 50 mg, take 50 mg daily at bedtime. Review of the physician order sheet, dated active orders as of 8/22/25, showed glucagon, hydrochlorothiazide, lisinopril, NovoLog insulin routine three times a day, MiraLAX, hydrophilic wound dressing, Plavix and senna s were not on the physician order sheet. During an interview on 8/21/25 at 10:53 A.M., ADON B said the hospital records packet, dated 7/21/25, is not what the facility would have used for the admission physician orders. The packet was the information sent over for the referral. During an interview on 8/21/25 at 12:18 P.M., ADON B said he/she was notified the resident was admitted on [DATE] with a bag that contained home medications and a list of the medications including insulin instructions. The facility did not keep a copy of the list. ADON B said the family may not comply and send the list if requested today since the resident has been discharged from the facility. Whoever the ADON assigned to the resident was expected to review and follow-up after the admitting nurse's admission process. ADON B said RN D and ADON A failed to obtain a copy of the resident's admission information for medical records. ADON B looked at the resident's electronic medical records and said RN D's admission assessment only showed two out eight assessments were completed. He/She said the admission process should be completed upon admission. During an interview on 8/22/25 at 11:35 A.M., the physician said the facility usually calls him when a resident is admitted to the facility to verify the orders. He did not recall if the facility called him to verify the orders. During an interview on 8/22/25 at 11:52 A.M., the Administrator said if a resident is admitted for respite care, the family will bring in the orders or the facility will take the orders from the family. They also often bring the medications from home. The nurse should call the physician to verify orders and document it. During an interview on 8/22/25 at 3:13 P.M., the Administrator said the admission assessment should be completed upon admission. The Regional Nurse said any residents' documents should be part of the medical records. During an interview on 8/22/25 at 4:30 P.M., the Regional Nurse said the resident was here for a very short time. They talked with the staff and the resident did not bring in any paperwork with physician orders. He/She brought a bag with his/her medications in it. If the physician changed the medications when they were verified, the old order would not be on the physician order sheet. The nurse did an assessment when the resident was admitted and it was documented in the progress notes. Review of the progress notes, dated 7/24/25 at 7:30 P.M., showed the patient is [AGE] years old with past medical history of diabetes, anoxic brain injury, polysubstance abuse, stroke history, seizure disorder, hyperlipidemia, hypertension and chronic end stage renal failure. Patient is here at the facility for respite care 7/24 through 7/28. Daughter takes care of patient at home regularly. Patient arrived at the facility in the hour of 1300. Resident was given a lunch tray and insulin was given after intake of 100%. Patient was calm and toileted soon after. In the hour of 1700 patient became combative and repeatedly trying to get out of chair without assistance. The nurse and other nursing staff tried to redirect patient, patient was not directable. The nurse tried to call family and let them know that patient was not taking the change of environment well. Family stated, what do you expect me to do. This nurse stated that, we do not want your (father/mother) to fall, what are some alternatives that you try at home to help redirect (him/her). Family stated to give patient his/her atarax, the nurse proceeded to give patient medication along with trazodone. Patient refused to sit down in the chair and threated to hit this nurse, and verbally got violent with the nurse, patient stood up and urinated on the floor in front of the nurse. Patient presumed to walk to down the hall and had a fall, and it was unwitnessed. Patient then was redirected to have a seat, where he/she then fell again by the central bathroom. Patient refused initial vital signs, the nurse, redirected patient, patient is now sitting at the nurse's station, no further report at this time 2573803

Based on interview and record review, the facility failed to ensure residents received care consistent with professional standards when staff failed to do neurological check (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) after an unwitnessed fall for one resident (Resident #74). The sample was 17. The census was 66. Review of the facility's Fall policy, dated revised April 2022, showed:-The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen and any observations of the events, etc. Review of the facility's Neurological Assessment policy, dated revised October 2010, showed:-Purpose: the purpose of this procedure is to provide guidelines for neurological assessment: when following an unwitnessed fall;-General guidelines: neurological assessments are indicated: following an unwitnessed fall;-When assessing neurological status always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic (top number) and diastolic (bottom number) pressures). This may be indicative of increasing intracranial pressure (ICP, a life-threatening condition that happens when there's an imbalance between your brain tissue, cerebrospinal fluid and brain blood volume);-Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately;-Steps in the procedure: perform neurological checks with the frequency as ordered or per fall protocol; -Determine residents' orientation to time, place and person; -Observe resident's pattern of speech and speech clarity; -Take temperature, pulse, respirations, blood pressure; -Use oral thermometer only if safe with this type of resident; -Respirations are increased and shallow with ICP; -Pulse usually increases with ICP; -Blood pressure usually increases with widening pulse pressure with ICP; -Check pupil reaction; -Determine motor ability; -Have resident move all extremities; -Ask resident to squeeze your fingers. Note strength bilaterally; -Have resident plantar (move the foot downward) and dorsiflex (move foot upward). Note strength bilaterally. Ask resident if he/she has any numbness or tingling in legs/feet/toes and document accordingly;-Determine sensation in extremities. Rub resident's arm at the same time to see if the resident has decreased sensation in either arm. Check sensation in lower extremities and document;-Check gag reflex with tongue depressor, if safe for resident.-Have the resident smile to determine if there is any facial drooping and document accordingly;-Documentation: the following information should be recorded in the resident's medical record: -The date and time the procedure was performed; -The name and title of the induvial(s) who performed the procedure; -All assessment data obtained during the procedure; -If the resident refused the procedure, the reason(s) why and the intervention taken;-Reporting: notify the supervisor if the resident refuses the procedure. Report other information in accordance with the facility's policy and professional standards of practice. Review of the facility's Post Fall 72-Hour Monitoring Report (neuro check form), undated, showed:-This assessment should be completed at the following intervals for follow-up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Any change in resident condition requires a phone call to the primary care physician. Initial assessment; followed by every 15 minutes times four; every 30 minutes times 2; every hour times two; once per shift for 72 hours. Review of Resident #74' s medical record, showed:-Resident was alert with confusion;-Diagnoses included diabetes, anoxic brain injury (brain completely loses its oxygen supply, leading to potential brain cell death), polysubstance abuse, history of stroke, seizure disorder, high cholesterol, high blood pressure and chronic end stage renal failure (irreversible kidney disease). Review of the resident's care plan, in use at the time of survey, showed:-Focus: I have had multiple falls since entry;-Goal: I will not have any injuries related to falls x 90 days;-Interventions: 7/24 referred to therapy; Ensure that resident has appropriate footwear;-Focus: I have a history of falling/falls. Review of the progress notes, dated 7/24/25 at 7:30 P.M., in the hour of 1700 (5:00 P.M.) patient became combative and repeatedly trying to get out of chair without assistance. The nurse and other nursing staff tried to redirect patient; patient was not directable. The nurse tried to call family and let them know that patient was not taking the change of environment well. Family stated, what do you expect me to do. The nurse stated that, we do not want your (father/mother) to fall, what are some alternatives that you try at home to help redirect (him/her). Family stated to give patient his/her atarax (antihistamine), the nurse proceeded to give patient medication along with trazodone (antidepressant). Patient refused to sit down in the chair and threatened to hit the nurse, and verbally got violent with the nurse, patient stood up and urinated on the floor in front of the nurse. Patient presumed to walk to down the hall and had a fall, and it was unwitnessed. Patient then was redirected to have a seat, where he/she then fell again by the central bathroom. Patient refused initial vital signs. The nurse redirected patient; patient was now sitting at the nurse's station. No further report at this time;-No documentation neuro checks were started after the unwitnessed fall. During an interview on 8/20/25 at 5:50 A.M., Certified Nurse Aide (CNA) H said if a resident fell, he/she would notify the nurse, and the nurse would assess the resident and let them know if the resident can get up or not. The nurses complete the vital signs. During an interview on 8/19/25 at 4:30 P.M., Licensed Practical Nurse (LPN) C said if a resident had an unwitnessed fall, he/she would assess the resident and notify the physician and the responsible party. Neuro checks would be started as soon as the incident happened. Neuro checks are completed on paper. If a resident refused to have their vital signs checked, LPN C would complete the rest of the assessment and try again later or when the next neuro check was due. During an interview on 8/20/25 at 2:03 P.M., Registered Nurse (RN) D said the resident had an unwitnessed fall once during his/her shift. Since then, the resident had been monitored and placed by the nurses' station. RN D said the neurological checks were initiated and documented in the resident's electronic health records. He/She said if residents refused neurological checks, staff should re-direct the resident and try the assessment again. The staff were expected to notify the physician and document residents' refusal of care or assessment. Neurological checks should be continued and completed within 72 hours. During an interview on 8/20/25 at 6:34 A.M., Assistant Director of Nursing (ADON) A said if a resident had an unwitnessed fall, staff should assess the resident from head to toe and do neuro checks. The schedule for how often the assessments is completed is on the paper form. The physician and family should be notified. If the resident refused to have vital signs checked, staff should educate the resident, document the refusal and notify the physician. They could also ask another nurse for help. During an interview on 8/21/25 at 9:50 A.M., Certified Medication Technician (CMT) F said the resident's medication was held on 7/25/25 because the resident was sleeping. During an interview on 8/22/25 at 3:13 P.M., the Director of Nursing (DON) said the neurological checks should be initiated and completed during residents' unwitnessed falls. The staff were expected to notify the family and the physician and acquire orders as needed. The Regional Nurse said if the resident refused neurological checks, staff are expected to notify the physician and re-attempt to complete within 72 hours. 257380325770892576585

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice, when staff failed to document a thorough assessment of a wound weekly and failed to transcribe treatment order for another wound when the resident returned from the hospital for one resident (Resident #33). The sample was 17. The census was 66.Review of the Wound Care policy, dated revised October 2018, showed:-Documentation: the following information should be recorded in the resident's medical record, if the resident refused the treatment and the reason(s) why;-Reporting: Notify the supervisor if the resident refuses the wound care;-Report other information in accordance with facility policy and professional standards of practice. Review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy, dated revised March 2020, showed:-The nurse shall describe and document/report the following: full assessment of the pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue;-The physician will assist the staff to determine etiology (for example, arterial (ulcer caused by decreased blood circulation) or statis ulcer (a non-healing open sore on the lower leg or ankle that results from poor blood circulation) and characteristic (necrotic (dead) tissue, status of wound bed, etc.) of the skin alteration;-Monitoring: weekly skin evaluations should evaluate the skin integrity of residents. Any skin integrity issues shall be reported to the licensed nursing staff. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/4/25, showed:-Ability to express ideas, and wants to consider both verbal and non-verbal expression: rarely/never understood;-Select best description of speech pattern: No speech-absence of spoken words;-Both long- and short-term memory problem;-Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Behavior not exhibited;-Required total care for all activities of daily living (ADLs, grooming, dressing, bathing);-Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device? No;-Is this resident at risk of developing pressure ulcers/injuries? Yes;-Does this resident have one or more unhealed pressure ulcers/injuries? No;-Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion)? Yes;-Pressure ulcer/injury care? No;-Application of dressings to feet (with or without topical medications)? No;-Diagnoses included Down's Syndrome (a genetic condition where a person has an extra copy of chromosome 21, leading to distinct physical and developmental characteristics and intellectual disability), non-Alzheimer's dementia, and non-traumatic brain dysfunction (occurs when a medical condition or internal disease damages the brain). Review of the care plan, in use at the time of survey, showed:-Focus: resident was incontinent of bowel and bladder. Resident was dependent on staff for all peri-care (cleansing between the legs and buttocks area). Resident was at risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction). open area to lateral malleolus (bony bump on outer side of ankle) added to wound doctor rounds, revised 8/18/25;-Goal: skin will remain intact X 90 days;-Interventions: incontinent, monitor for signs and symptoms of skin breakdown/excoriation. Report if noted, weekly skin assessment per protocol. Review of the facility's wound report, dated 7/23/25 through 8/13/25, showed the resident was not on the wound report. Review of the progress notes, dated 7/22/25 at 1:30 P.M., showed open area non pressure injury (any localize injury to the skin or under lying tissue caused by something other than sustained pressure) to right lateral ankle noted. Appears as though patient rubbed or hit his/her foot along the foot pedal of wheelchair. Area measured about 1.1-centimeter (cm) length x 1.2 cm width x 0.5cm depth. No odor noted. Minimal bleeding noted. No signs and symptoms of pain during assessment. Cleansed with wound cleanser, calcium alginate and dry dressing applied. Heel protector/boots applied. Physician and family made aware. Review of the skin assessment, dated 7/29/25 at 1:49 P.M., showed skin issue has not been evaluated.-Location: Right lateral foot;-Additional location information: ankle;-Issue type: Pressure ulcer/injury;-Wound acquired in-house.-Wound is new;-Staged by: In-house nursing;-No undermining and no tunneling;-Skin Issues Note: No new skin issues noted;-The assessment did not include the measurements, description of the wound bed, and the stage of the pressure ulcer/injury. Review of the Treatment Administration Record (TAR), dated 7/1/25 through 7/31/25, showed:-A physician order for cleanse area to right outer lateral with normal saline. Apply calcium alginate and dry dressing every other day until healed, order date 7/22/25;-Documentation on 7/24, 7/26, 7/28 and 7/30 as blank;-A physician order for heel protectors/boots to be worn at all times every shift for skin breakdown prevention, start date was 7/23/25;-Documentation of 18 out of 18 opportunities as blank. Review of the progress notes, dated 7/22/25 through 8/10/25, showed:-7/22/25 through 7/31/25, no documentation the physician orders were changed and no documentation the resident refused;-On 8/5/25 at 1:12 P.M., Skin issue has not been evaluated;-Location: Right lateral foot;- Additional location information: ankle;-Tissue type: pressure ulcer/ injury;-Wound acquired in-house;-Wound is new;-Staged by in-house nursing;-No undermining, no tunneling;-Skin Issues Note: Skin issues remain. Treatments in progress;-The assessment failed to include the measurements, description of the wound bed, and the stage of the pressure ulcer/injury;-On 8/10/25, resident was sent to the hospital. Review of the TAR, dated 8/1/25 through 8/9/25, showed:-A physician order for heel protectors/boots to be worn at all times every shift for skin breakdown prevention;-Documentation of 18 out of 18 opportunities as blank. Review of the hospital records, dated 8/10/25, showed:-Active wounds assessment: wound 8/10/25 pressure injury left heel-posterior (back);-Date rst assessed 8/10/25;-Present on admission: yes;-Primary wound type: pressure injury;-Wound 8/11/25 pressure injury ankle/malleolus anterior (front) right;-Date rst assessed: 8/11/25;-Present on admission: yes;-Primary wound type: pressure injury;-Wound 8/11/25 pressure injury left heel lateral (outer side):-Date rst assessed: 8/11/25,-Present on admission: yes:-Primary wound type: pressure injury. Review of the after-summary care, dated 8/10/25 through 8/13/25, showed:-Wound care instructions: post discharge dressing care:-Right ankle/malleolus anterior, cleanse with Vashe (wound cleanser) and apply moist aquacel alginate (absorbent wound dressing) and cover with foam dressing every 3 days and as needed;-Left posterior heel, cleanse with Vashe and paint with betadine daily. Review of the clinical assessment, dated 8/13/25, showed:-Location: right lateral foot;-Laterality/orientation: right lateral;-Additional location information: ankle;-Skin issue: pressure injury;-Acquired: in house;-Onset: new;-Staged by: in house nursing;-Undermining: no;-Tunneling: no;--The assessment did not include the measurements, description of the wound bed, and the stage of the pressure ulcer/injury;-No documentation identifying the wound on the left heel. Review of the progress notes, dated 8/13/25 through 8/20/25, showed:-On 8/13/25 at 5:14 P.M., head to toe assessment complete. Open area to right lateral ankle treatment in place. Wore podus (used to manage and prevent heel pressure) boots at all times;-On 8/13/25 at 5:59 P.M., Skin issue has not been evaluated;-Location: Right lateral foot;-Right. Additional location information: ankle;-Tissue type: pressure ulcer / injury;-Wound acquired in-house;-Wound is new;-Staged by in-house nursing;-No undermining, no tunneling;-Skin Issues Note: open area to right lateral ankle to be treated with calcium alginate with silver (highly absorbent antimicrobial dressing that promotes healing) to be changed every other day;-The assessment failed to include the measurements, description of the wound bed, and the stage of the pressure ulcer/injury;-On 8/18/25 at 8:04 A.M., Skin issue has not been evaluated;-Location: Right lateral foot;-Additional location information: ankle;-Tissue type: Pressure ulcer / injury;-Wound acquired in-house;-Wound is new;-Staged by in-house nursing;-No undermining, no tunneling;-Skin Issues Note: skin measures 1.5 cm x 1.0 cm, open area located in lateral malleolus. Treatment completed and added to wound doctor rounds.-The note did not describe the wound bed and include the stage of the wound. Review of the order sheet summary, dated active orders as of 8/22/25, showed:-A physician order for heel protectors (used to relief pressure of the heel) to be worn at all times for skin breakdown preventions;-A physician order for wound doctor to evaluate and treat, order date 8/18/25;-A physician order for calcium alginate (highly absorbent dressing that promotes healing), cleanse area with wound cleanser, apply calcium alginate to lateral right ankle, cover with dry dressing every day and as needed, order date 8/18/25;-A physician order for skin prep (fast drying skin protectant) to left heel topically daily for wound care, order date 8/20/25; Review of the TAR, dated 8/13/25 through 8/20/25, showed:-A physician order for cleanse area to right outer lateral ankle with normal saline. Apply calcium alginate and dry dressing every other day until healed, order date 8/13/25, discontinue date 8/20/25;-The order failed to show calcium alginate was with silver;-A physician order for heel protectors/boots to be worn at all times every shift for skin breakdown prevention;-Documentation showed 8/1/25 through 8/9/25, 18 out of 18 opportunities were blank; and 8/14/25 through 8/20/25, 14 out of 14 opportunities were blank.-A physician order for skin prep to left heel every day for wound care, start date was 8/20/25;-There were no treatment orders for the left heel prior to 8/20/25. Observation on 8/20/25 at 7:58 A.M., showed the resident was up in his/her wheelchair in the hall by the nurse's station. The resident wore slipper socks. At 8:45 A.M., the resident ate breakfast in the assisted dining room and wore heel protectors. During an interview on 8/22/25 at 11:50 A.M., ADON A said she checked the resident's hospital records when he/she returned to the facility. In the hospital, they used the aquacel alginate but when he/she came back to the facility, it was changed to calcium alginate. She did not recall seeing an order for betadine for the resident's heel. Observation and interview on 8/20/25 at 1:35 P.M., showed the resident lying in bed. The resident had a dark purplish colored irregular shaped area on his/her left heel. There was a small open area on the right lateral ankle. The wound doctor said today was the rst time she saw the resident. She described the left heel as a deep tissue injury (DTI, (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood- lled blister) size was 1.7 x 2.6, depth not measured. The cause of the DTI was pressure. She ordered skin prep to the area daily. The right lateral ankle was a Stage 3 pressure ulcer/injury (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) size was 0.9 x 1.1 x 0.1 cm. Review of the wound physician's note, dated 8/20/25, showed:-This was the resident's initial wound evaluation and management summary;-Chief complaint: presents with wounds on his/her left heel and right lateral ankle;-Site 1: unstageable DTI of the left heel undetermined thickness;-Etiology: pressure;-Wound size: 1.7 cm X 2.6 cm X not measurable cm;-Primary dressing: skin prep applies daily and as needed, if saturated, soiled, or dislodged. For 30 days;-Site 2: Stage 3 pressure wound of the right lateral ankle full thickness;-Etiology: pressure;-Stage: 3;-Duration: > 8 days, noted to be present on admission per staff;Size: 0.9 cm X 1.1 cm X 0.1 cm;-Exudate: moderate sero-sanguinous (light pink or yellowish thin uid);-Granulation tissue: 100%;-Dressing treatment: primary dressing: calcium alginate applies once daily and as needed; if saturated, soiled or dislodged. For 30 days; Secondary dressing: gauze island with border applies once daily and as needed, if saturated, soiled or dislodged. For 30 days. During an interview on 8/21/25 at 12:18 P.M., Assistant Director of Nursing (ADON) B said the nurse on the oor completes a weekly skin assessment. If a wound is noted, the nurse should describe and measure the wound. The wound doctor stages the wound. Staff used the measurements and description to determine if the wound was getting better or worse. During an interview on 8/21/25 at 3:25 P.M., ADON A said when the wound on the resident's right outer ankle was discovered, she measured it and obtained treatment orders. She documented the wound as a non-pressure area. The treatment was placed on the wound TAR, in place of the regular TAR, not the proper spot. The treatments were completed and that's why the wound did not get worse. During an interview on 8/21/25 at 3:25 P.M., the Director of Nursing (DON) said the oor nurse completes a weekly skin assessment. If an area is noted, the nurse management will check the wound. The physician is noti ed, and orders are obtained. The wound doctor visited the facility weekly. The wound doctor measured and staged the wounds. The oor nurse is responsible for completing the treatments and documenting the treatment was completed. If a treatment is not documented, it would mean it was not done. The nurse should go see the resident to see if the area has healed. The ADON should investigate why the treatment was not completed, and document their nding, and notify the physician. The DON expected the nurse to document a description of the wound bed, peri-wound (the surrounding edges of the wound) and the measurements when a wound is discovered so they can determine if the wound is better or worse. During an interview on 8/22/25 at 11:52 A.M., the Administrator said if the resident had a pressure ulcer/injury, staff should notify the physician and obtain orders. A description of what the wound looks like, and the measurements should be documented weekly. If the resident was seen by the wound doctor, the wound doctor will do the weekly documentation. If the resident is not seen by the wound doctor, the facility should complete the weekly documentation. Once an order is obtained for the wound doctor, the wound doctor will usually see the resident the next week. During an interview on 8/22/25 at 3:12 P.M., the DON expected the staff to identify residents' skin issues during the skin assessment and to document in the medical records. Skin assessments were to be done and documented weekly. The staff were expected to follow physician's orders and follow the facility's policies and procedures.

Based on interview and record review, the facility failed to provide necessary medications as ordered by the physician. In addition, they failed to notify and document the physician was made aware of the missed medications for one of 17 sampled residents (Resident #74). The census was 66. Review of the facility's Administering Medications Policy, dated revised December 2012, showed:-Medications shall be administered in a safe and timely manner, and as prescribed;-Medications must be administered in accordance with the orders, including any required time frame;-Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meals);-If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administrating the medication shall document appropriately in the clinical chart. Review of the facility's Obtaining a Fingerstick Glucose Level, dated revised October 2011, showed:-Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level;-Documentation: The person performing this procedure should record the following information in the resident's medical record:-If the resident refused the procedure, the reason(s) why and the intervention taken;-The blood sugar results;-The signature and title of the person recording the data;-Reporting: Report results promptly to the supervisor and the attending physician;-Notify the supervisor if the resident refuses the procedure;-Report other information in accordance with facility policy and professional standards of practice. Review of the facility's Adverse Consequences and Medication Errors Policy, dated revised April 2017, showed:-A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professional(s) providing services. Examples of medication errors include omission-a drug is ordered but not administered. Review of Resident #74's medical record, showed:-Resident was alert with confusion, he/she could make needs known;-Was readmitted on [DATE] for respite care and discharged on 7/28/25; -Diagnoses included diabetes, anoxic brain injury (brain completely loses its oxygen supply, leading to potential brain cell death), polysubstance abuse, history of stroke, seizure disorder, high cholesterol, high blood pressure and chronic end stage renal failure (irreversible kidney disease). Review of the physician order sheet, dated active orders as of 8/22/25, showed: -A physician order for amlodipine besylate oral tablet 5 milligrams (mg), give 5 mg by mouth one time a day for blood pressure, order date 7/24/25;-A physician order for aspirin tablets chewable 81 mg, give 1 tablet by mouth one time a day for prophylactics, order date 6/13/25;-A physician order for farxiga oral tablet 10 mg, give 1 tablet by mouth one time a day for give prior to breakfast, order date 6/13/25;-A physician order for hydroxyzine hcl oral tablet 10 mg, give 10 mg by mouth four times a day for anxiety, order date 7/24/25;-A physician order for insulin glargine solution 100 unit/milliliter (ml), inject 14 units subcutaneously (under the skin) one time a day for diabetes, order date 7/24/25;-A physician order for keppra tablet 500 mg, give 1 tablet by mouth two times a day for anticonvulsant, order date 6/13/25;-A physician order for metoprolol tartrate oral tablet 50 mg, give 50 mg by mouth two times a day for blood pressure, order date 7/24/25;-A physician order for novolog flex pen subcutaneous solution pen-injector 100 UNIT/ML, inject as per sliding scale: if 181 - 200 = 1 units; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 -400 = 5 units; 401+ = 6 units 401 and greater give 6 units, subcutaneously three times a day for hyperglycemia, order date 7/24/25. Review of the Medication Administration Record (MAR), dated 7/24/25 through 7/25/25, showed:-A physician order for amlodipine besylate oral tablet 5 milligrams (mg), Give 5 mg by mouth one time a day for blood pressure; -7/25/25, A.M., HD (hold, see progress notes) was documented; -A physician order for aspirin tablets chewable 81 mg, give 1 tablet by mouth one time a day for prophylactics; -7/25/25, 8 A.M., HD was documented; -A physician order for farxiga oral tablet 10 mg, give 1 tablet by mouth one time a day, give prior to breakfast; -7/25/25, 8 A.M., HD was documented; -A physician order for hydroxyzine hcl oral tablet 10 mg, give 10 mg by mouth four times a day for anxiety; -7/25/25 at 8 A.M., 12:00 P.M. and 4:00 P.M., HD was documented;-A physician order for keppra tablet 500 mg, give 1 tablet by mouth two times a day for anticonvulsant; -7/25/25 at 8 A.M. and 4:00 P.M., HD was documented;-A physician order for metoprolol tartrate oral tablet 50 mg, give 50 mg by mouth two times a day for blood pressure; -7/25/25 at 4:00 P.M., HD was documented;-A physician order for novolog flex pen subcutaneous solution pen-injector 100 unit/ml, inject as per sliding scale: if 181 - 200 = 1 units; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 -400 = 5 units; 401+ = 6 units 401 and greater give 6 units, subcutaneously three times a day for hyperglycemia; -Documentation showed:-On 7/24/25, was blocked off for medication to start on 7/25/25;-On 7/25/25 at 8 A.M., 12:00 P.M., 4:00 P.M. HD was documented; -On 7/26/25 at 8 A.M. and 12:00 P.M. were blank, at 5:00 P.M. the blood sugar was 400. Review of the progress notes, dated 7/24/25 through 7/25/25, showed:-On 7/24/25 at 7:30 P.M., patient arrived at the facility in the hour of 1300. Resident was given a lunch tray, and insulin was given after intake of 100%;-No documentation the results of the blood sugar or the type and amount of insulin administered. In addition, no documentation the physician was notified when the medications were held. During an interview on 8/19/25 at 4:30 P.M., Licensed Practical Nurse (LPN) C said the resident slept the first day he/she was at the facility. The second day, the resident would arouse to eat and take medications. The Certified Medication Technicians (CMTs) administer the scheduled medications, and the nurses complete the finger stick blood sugars and administered the insulin. The fingerstick blood sugars are documented on the MAR. If a medication was not administered or held, it should be documented on the MAR and the physician should be notified. The physician should be notified for each dose of medication not administered. During an interview on 8/20/25 at 10:28 A.M., CMT E said if a medication was held, it should be documented. The nurses are responsible for doing the fingerstick blood sugars and administering the insulin. During an interview on 8/21/25 at 9:50 A.M., CMT F said if the doctor held a medication, the nurse would enter it in the computer. The resident's medications were held because the resident was sleeping. Typically, the resident would go to bed at the beginning of day shift and sleep until lunch. He/She did not know if the resident was diabetic or not. The nurse would do the fingerstick blood sugars and the insulin. Sometimes, something for the nurses will pop up on the CMT MAR, but he/she never saw anything for the resident pop up on the CMT MAR. During an interview on 8/20/25 at 6:34 A.M., Assistant Director of Nursing (ADON) A said finger stick blood sugars should be documented on the MAR. If a medication was not administered, it should be documented in the progress notes and the physician should be notified. The physician is notified for each missed dose of medication. If a medication was held, it should be documented why the medication was held. She did not know what a blank on the MAR meant. During an interview on 8/21/25 at 12:18 P.M., ADON B said he/she was not sure why the staff held the medications. CMT F was not supposed to do fingerstick and insulin administration. ADON B looked at the resident's records and said that on 7/26/25, it looked like the resident did not receive the insulin because of the hole in the MAR. There's no documentation in the progress notes related to the medications being held and fingerstick results. Upon further review of the resident's record, ADON B said Registered Nurse (RN) D transcribed the insulin order incorrectly into the MAR. RN D entered the orders into the CMT MAR instead of the nurse MAR. The nurse did not see the insulin order until RN I revised and entered the insulin in the nurse MAR. ADON B said he/she expected the CMT to report to the nurse any medications held and to document in the MAR and progress notes. During an interview on 8/22/25 at 11:35 A.M., the physician said he could not recall if the facility called to report the resident's medications were not administered. During an interview on 8/22/25 at 11:52 A.M., the Administrator said residents who are admitted on respite care usually bring their medications from home. He expected staff to follow physician orders. If staff was unable to follow the orders, they should notify the physician and document it. Fingerstick blood sugars results should be documented. During an interview on 8/22/25 at 3:13 P.M., the Director of Nursing (DON) said she expected staff to notify the physician if medications were held or not given and to document appropriately. The Regional Nurse said fingerstick results should be documented anywhere in the residents' medical record, typically in the MAR. 25770892573803

Based on interview and record review, the facility failed to keep residents free of accidents and injuries when a Certified Nurse Assistant (CNA) left a resident (Resident #7) unattended, rolled to his/her side on a low air loss mattress (LAL, a mattress designed with a system of air cells that are constantly inflated and deflated to prevent and treat pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on skin)), causing the resident to fall out of his/her bed on to a fall mat. The facility also failed to ensure residents were assessed immediately after a fall for injury and failed notify the Primary Care Physician (PCP), the resident's responsible party (RRP) and a member of the Interdisciplinary Team (IDT) after a fall because the CNA failed to immediately report the fall to the charge nurse for one resident (Resident #7) who sustained a head injury. The sample size was three. The census was 70. The Administrator was notified on 4/21/25, of the past non-compliance. The facility responded appropriately when they were made aware of the resident's fall. The resident was assessed for injury and the resident was sent out to the hospital for evaluation. Education was provided to nursing staff on caring for the resident in pairs and to report falls immediately. The deficiency was corrected on 1/17/25. Review of the facility's Accident and Incident - Investigating and Reporting Policy, dated 9/20/24, showed: -Policy Statement: All accidents or incidents involving residents, employees, visitor, vendors, etc., occurring on the facility premises shall be investigated and reported to the Administrator; -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document the investigation of the accident or incident; -The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident; -Incident/Accident Reports will be reviewed by the Interdisciplinary Team. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/24, showed: -Cognitively intact; -Makes self understood; -Impairment on both sides of upper and lower body; -Total dependence on staff for all activities of daily living (ADLs); -Always incontinent of bowel and bladder; -Diagnoses included traumatic brain injury (TBI), quadriplegia (paralysis of all four limbs) and seizure disorder. Review of the resident's skin check dated 1/17/25 at 9:06 A.M., showed there were no skin issues present. Review of the resident's progress notes, showed: -On 1/17/25 at 10:10 A.M., the resident stated he/she fell out of bed last night while the CNA was changing him/her. He/She said he/she fell out of the right side of the bed, hurting his/her neck. The resident said the CNA placed him/her back into his/her bed. The resident was complaining of neck pain. There was no swelling or redness noted at the site. The resident was lying supine (on the back) in bed; -On 1/17/25 at 10:16 A.M., the resident was alert and able to give details on what happened; -On 1/17/25 at 10:19 A.M., the resident's blood pressure (read in milliliters of mercury (mmHg) when referring to systolic (SBP, top number, normal is below 140), diastolic (DBP, bottom number, normal is below 90) was 109/90, pulse rate (rate of heart beat, normal range is between 60 to 100 beats per minute) was 89 beats per minute, body temperature (measured in degrees of Fahrenheit (F), normal range is 97 to 99 degrees F) was 98.1 degrees F and the resident had a blood oxygen saturation (amount of oxygen in blood) rate of 93% on room air; -On 1/17/25 at 10:25 A.M., the resident's responsible party was made aware; -On 1/17/25 at 10:40 A.M., the ambulance service was notified to transport the resident to the emergency department (ED) for evaluation; -On 1/17/25 at 11:12 A.M., the PCP was present to see the resident before the resident left for the ED. The resident was resting in bed with no visible injuries noted to the neck or upper or lower torso; -On 1/17/25 at 11:25 A.M., the ambulance was present to transport the resident to the ED; -On 1/17/25 at 4:06 P.M., the Registered Nurse (RN) at the ED said that there was no injury noted yet. They were waiting on one more test result; -On 1/17/25 at 10:44 P.M., the resident returned from the hospital via ambulance. There were no new orders. The resident's skin remains intact. Vital signs were normal. The resident was in bed resting in a low bed with fall mats on either side. The RRP was aware the resident had arrived back at the facility; -On 1/18/25 at 6:17 P.M., the resident remained on incident follow up observation. The resident had no signs or symptoms of distress or discomfort. The resident was resting in bed in the lowest position with call button in place. Review of the resident's 72 hour post fall monitoring report, dated 1/17/25, showed: -The assessment should be completed at the following intervals for all falls. A fall that is unwitnessed or in which the head is struck, required neurological checks (an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status); -Documentation showed the nursing staff completed neurological checks for 72 hours. Review of the resident's hospital discharge papers, dated 1/17/25, showed: -Reason for visit: Neck pain; -Diagnoses at discharge: Fall, initial encounter and injury of head, initial encounter. Review of the facility's investigation report, dated 1/17/25, showed: -A statement from CNA B, dated 1/17/25 at 4:54 P.M., on 1/17/25 at 1:00 A.M., after giving the resident a bed bath, the resident fell on to the floor. The resident was fully clothed and bathed, left lying on his/her side when CNA B left the resident's room to care for other residents. CNA B returned to the resident's room to retrieve the Hoyer Lift (mechanical device used to assist in transferring individuals with limited mobility from one place to another) and saw the resident had fallen to the floor. There was no other staff around, so CNA B asked the resident if he/she was ok and checked the resident's body parts to see if he/she was hurt. CNA B then returned the resident back into his/her bed with the Hoyer lift; -On 1/17/25, education was given to nursing staff to reiterate falls must be reported immediately to the charge nurse; -On 1/17/25, education was given to nursing staff to place fall mats on both sides of the resident's bed (while the resident was in bed) and to position the resident's blow call light so he/she could operate it at all times. The resident's bed was relocated so that it was up against one wall with the use of one fall mat; -On 1/17/25, the Assistant Director of Nursing (ADON), addressed CNA B with a teachable moment; -On 1/20/25, the IDT met to discuss the event that involved the resident rolling from the bed while the CNA was providing care. The Team discussed the totality of the resident falls and reviewed the interventions that the resident had in place at the time. Investigation of the event revealed the resident did have two fall mats in place and was on a low air loss mattress, which was inflated per manufacturer's recommendations. The Team had previously spoken to the RRP, recommending the removal of the LAL mattress for the resident's safety. The RRP had refused. The Team was going to call the resident's family again with the recommendation of removal of the LAL mattress for the resident's safety; -Inservice sign in sheet, dated 1/17/25, for education on caring in pairs and keeping the resident's blow call light in reach. In-services were given to nursing staff; -Inservice sign in sheet, dated 1/17/25, for education on the fall policy and reporting falls immediately to nurses. In-services were given to nursing staff. Review of the resident's care plan, dated 3/21/25, showed: -Problem: The resident was dependent of all Activities of Daily Living (ADLs) and was totally dependent on staff. Interventions included: Care in pairs; Two staff were required for repositioning and turning in bed; Two staff were required to use Hoyer lift at all times for transfers; -Problem: The resident had multiple falls and was at risk for falls. Interventions included: Anticipate and meet resident needs; Follow facility fall protocol; The resident used a blow call light. Ensure it was in place, near the resident's face for use. Observation on 4/16/25 at 10:34 A.M., showed the resident asleep in his/her bed. The mattress had raised edges which scooped upwards. The resident's bed side table had a blow call light attached which was positioned near the resident's head. The bed was positioned on the right side against a wall and there was a fall mat in place on the left side of the bed. The bed was in a lowered position. During an interview on 4/16/25 at 12:58 P.M., Licensed Practical Nurse (LPN) A said: -He/She came to work on 1/17/25 at approximately 5:00 A.M.; -He/She received report from LPN C, who was the night shift nurse in care of the resident; -LPN C reported a CNA said he/she had dropped the resident to the floor and then got the resident up off the floor, using a Hoyer lift back into the resident's bed; -LPN A was not sure what time the incident occurred or when the CNA notified the night nurse; -He/She went and assessed the resident. The resident was free of injury, there were no bumps, swelling or redness to the resident's head and the resident's vital signs were normal; -The resident did not complain of any pain; -He/She asked the resident what occurred and the resident was able to tell LPN A what had happened; -LPN A notified the Director of Nursing (DON) and the PCP of the incident and assessment; -He/She asked LPN C to call the RRP; -He/She advised LPN C when he/she found out the resident had fallen to the floor, LPN C should have immediately assessed the resident for injury, notified the PCP and then send the resident out to the hospital for evaluation; -He/She received education from the ADON on the facility's fall policy, to report incidents/falls immediately, and to always transfer residents with two people when using a Hoyer Lift. During an interview on 4/16/25 at 1:29 P.M., the ADON said: -She was notified on 1/17/25 (unsure of the time) the resident had fallen from his/her bed during night shift, when CNA B was rolling the resident back and forth in his/her bed during care; -She interviewed LPN C and CNA B who were assigned to the resident's care during night shift on 1/17/25; -CNA B said he/she was providing care to the resident, rolling him/her to his/her side, when the resident fell to the floor; -CNA B was a relatively new CNA and did not know to only care for the resident with a partner, to care in pairs, for safety; -LPN C said the same thing as CNA B; -He/She was not sure when CNA B notified LPN C the resident had fallen to the floor; -The facility investigated the incident and provided education to nursing staff on caring in pairs for the resident, the fall policy, and to report falls timely to the Administrative team, the PCP and the RRP. During an interview on 4/17/25 at 9:33 A.M., CNA B said: -He/She was providing incontinence care to the resident on 1/17/25, sometime in the middle of the night; -He/She positioned the resident onto his/her side, on top of his/her mattress, before leaving the room; -He/She came back into the room and found the resident had fallen from his/her bed onto the floor, on top of a fall mat; -The bed was not lowered to the lowest position; -He/She asked the resident if he/was hurt anywhere and felt his/her limbs and head to see if the resident was in pain; -The resident denied any pain; -He/She positioned the resident onto a Hoyer pad and used the Hoyer to put the resident back into bed; -He/She did not ask anyone for help because the other CNAs were on break at the time; -He/She thinks he/she may have told someone about the incident the next morning. He/She did not recall who he/she told and denied telling a nurse about the incident; -The ADON called him/her the next day (1/18/25) to ask about the incident; -He/She received education from the ADON regarding not leaving the resident on his/her side at any time, to care for the resident with another staff, to always have a second person when operating a Hoyer lift and to always notify the nurse immediately after a resident falls. During an interview on 4/17/25 at 12:04 P.M., LPN A said: -He/She interviewed the resident on 1/17/25 and the resident was able to say he/she fell out of bed with a few details; -The resident was difficult to understand but could answer questions and make him/herself understood; -The resident was sent out to the hospital on 1/17/25 and when he/she had returned, the nurses completed 72 hour neurological checks on the resident; -He/She was not aware the resident had a diagnosis of a head injury from the hospital and there were no new orders from the PCP regarding treatment for a head injury. During an interview on 4/17/25 at 12:30 P.M., the resident said: -He/She fell out of bed one night; -A staff member changed him/her, walked away and he/she fell out of bed; -The staff member did not catch him/her before he/she fell out of the bed; -He/She hit his/her head on the floor and it hurt. During an interview on 4/17/25 at 1:24 P.M., the Administrator and DON said: -They expected staff to have knowledge of and to follow policies; -They expected staff to notify nurses of any incidents or falls immediately; -They expected nurses to assess residents after a fall, get their vitals, notify the PCP, DON, and RRP, put any new orders into the electronic medical record and to document what they did in either a progress note or incident report; -They were informed of the resident's fall on 1/17/25 and completed an investigation; -The ADON educated staff on the facility's fall policy, to care for the resident in pairs, to always have a second person when operating an Hoyer lift and to report falls immediately to nurses or Administrative staff for safety; -CNA B was newly hired on 1/2/25 and they addressed the incident as a teachable moment; -They have not had any other issues with CNA B and residents reported they liked working with CNA B; -The IDT met, discussed the event and reviewed the interventions in the care plan for appropriateness. MO00249317

Based on observation, interview and record review, the facility failed to implement timely and appropriate interventions to prevent potential falls and injury for one resident (Resident #1) who had one fall mat next to the left side of the bed. Resident #1 had a fall from the right side of the bed that did not have a fall mat, which resulted in injury. The facility additionally failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when the facility failed to complete post (after) fall 72 hour monitoring report (neurological (neuro) checks - pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; and equality of hand grip strength) if the fall was unwitnessed or if the resident had an incident in hitting their head for three residents (Residents #2, #3 and #4), post fall initial clinical assessments for four residents (Resident #1, #2, #3 and #4), skin assessments for two residents (Resident #2 and #4), complete incident follow up documentation (IFU) for 72 hour post fall in the progress notes each shift for five residents (Residents #1, #2, #3, #4 and #5), document notification to physician for one resident (Resident #4), document notification of resident representative (RR) for two residents (Residents #4 and #5), update the residents' care plan with interventions for two residents (Residents #1 and #2), and update the kardex (nursing worksheet that includes a summary of patient information such as how many staff is needed to assist with care, if a fall risk would include interventions for falls, information on any specialized equipment resident may use, and other daily care information) binder located at the nurses' station with interventions for the nursing staff for four residents (Residents #1, #2, #3 and #4). The sample was 5. The census was 82. Review of the facility's Managing Falls and Fall Risk policy, revised 12/19, showed: -Policy statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -Prioritizing approaches to managing falls and fall risk: -1. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once); -2. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication is suspected as a possible cause of a resident's falling, the initial intervention might be to taper or stop that medication; -3. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period; -4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -6. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis (condition in which bones become weak and brittle), as applicable) to try to minimize serious consequences of falling; -Monitoring subsequent falls and fall risk: -1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; -2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved; -3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified; -4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the facility's Fall Documentation Policy, undated, showed: -Whenever a resident has a fall, the following must occur: -A. An initial full body assessment, including neurological, must be documented; -B. 72 hr. follow-up must be completed; -C. The Initial post fall assessment must be initiated; -a. The link for this assessment is in the risk report, and, or, it can be found under the resident assessment tab: Post Fall Initial Assessment V5-to be completed one time, directly after each fall. All questions must be completed; -b. Post Fall 72 hr. Monitoring version (V) three is to be completed once each shift post fall for three days if witnessed fall. Please see attachment for appropriate assessment to complete after a fall; -D. An updated fall risk assessment must be completed after each fall; -E. All Interventions must be placed on the care plan; -F. Interventions must be placed on the resident kardex for floor staff knowledge; -When following up on falls, please ensure the above process in being followed by staff. If you are requiring a hard copy of the post fall neuro assessment, know and follow your plan for monitoring for completion, and uploading into medical records. Follow your process for ensuring direct care staff are aware of any new interventions implemented for your residents; -Post fall step by step: -1. Incident description: -Complete a full body (head to toe) assessment prior to moving the resident off the floor. This will ensure the resident does not have severe injuries. This includes pupillary response. Example: No injuries noted. Pupils are equal, round and reactive to light and accommodation (PERRLA). Full range of motion (ROM) to all extremities. Legs equal in length. Hand grips and foot pushes/pulls equal in strength. No complaints of (c/o) pain. BP (Is read in milliliters of mercury (mmHg) when referring to Systolic (SBP, top number, normal is below 140), diastolic (DBP, bottom number, normal is below 90) 122/64, R (breaths per minute, normal is 12 - 18) 16, T (normal 98.6 degrees Fahrenheit (F)) 98.6, oxygen saturation (Sp02, measures amount of oxygen in the blood, normal SpO2 is between 90 and 100 percent (%)) 97% on room air. No c/o shortness of breath (SOB). Capillary refill (used for assessing the blood flow through peripheral (away from the center) tissues by compressing the nail bed until it blanches (temporary whitening of the skin) and record the time taken for the color to return to the nail bed. Normal capillary refill is less than 3 seconds) less than three sec. No edema (swelling) noted to any extremities. No other abnormalities noted; -Please include the last time staff laid eyes on the resident, last time toileted, if the call light was on or off, where the resident's walker, cane, or wheelchair was located at the time of the fall. We have to have a very complete story on what occurred; -Describe exactly how the resident's body was when you were alerted to fall, if the fall was or was not witnessed, what the resident and/or others say occurred, and any other information you may know that contributed to the fall. This includes exact location. Do not just write resident's room. Example: Resident on left side facing bed with blanket wrapped around legs and still connected to end of bed, Wheelchair to right of resident's face not coming in contact with resident. Breaks still locked on wheelchair. Call light was in reach of resident and not turned on. Staff last assisted resident to bathroom [ROOM NUMBER] minutes prior to fall. Resident states he/she rolled out of bed. Roommate states he/she saw resident roll out of bed. -2. Resident's Description: Ask the resident: -1. What were you trying to do when you fell ? Where were you trying to go?; -2. What made you fall? Did you trip, loose your balance, slide, etc.?; -Chart whatever the resident says even if it doesn't make sense to you. This is their reality and will show what they were trying to do; -3. Immediate Action Taken: This means what immediate action did you take to prevent this fall from occurring again. Immediate action taken does not refer to: got resident up off floor. This is not an intervention. If anything, the resident was safer on the floor. Examples: -Resident attempting to go to the bathroom - Assisted resident to bathroom. If they are alert and oriented (A&O) times (x) 4 (Level of awareness of (1) self, (2) place, (3) time, and (4) situation. The higher the number, the better oriented a person is considered. Healthcare providers score a person's orientation on a scale of 1 to 4.) A & O x 3 - 4, educate them to call for assistance for the next few days as they are more likely to fall again in the next few days. If resident is not alert- take them to the bathroom and then have the aids assist them to the bathroom every 1-2 hours. Anticipate their needs. If it is new for the resident to wake up for the bathroom, maybe it is a urinary tract infection (UTI). Assess their urine; -Is it their footwear? Are they having increased edema so their shoes are too tight, or they can't feel their feet as well? If so, intervention would be to address the edema and remove the shoes for the time being. Give them slipper/gripper socks for now; -Is the resident having increased confusion causing increased falls? Ask for labs and/or urine analysis (UA). Has there been a recent medication change that could be causing the confusion related to the side effects?; -Resident rolled out of bed-request a bed with bolstered edges, low bed, floor mats. If the fall is occurring at night and there is no one to get a different bed from, utilize pillows under the sheet to act as a bolstered edge; -Find the root cause and fix it or the falls will continue. It is never ok to do nothing and wait for others to fix the problem. Do not utilize any type of personal alarm or bed rail. Only the Director of Nursing (DON) and Administrator can authorize the use of a positioning device as a very last resort. It is used to help the resident reposition, not to keep them in bed as that is a restraint; -Injuries: -1. Injuries observed at time of incident: A full body assessment must be completed. Even if there are no injuries, you must chart the level of pain, level of consciousness, mobility, and mental status. This will show if they have a change in mental status and how alert they were at the time of the fall to tell us what happened. Utilize the notes box to chart if any finding is different from their baseline; -All injuries must be measured and described fully. Example: Bruise to left upper arm. 3 x 3 centimeters (cm) dark purple in color 100% intact skin. pain scale 0 -10 (0 = No pain, 1 - 3 mild pain, 4 - 7 moderate pain, 8 - 9 is severe pain, 10 = Worst pain possible) 4 out of 10 pain with touch. Ice applied. Pain relieved with ice; -2. Injuries report post incident: This is where staff should chart all injuries that become visible after the initial assessment and are related to the fall; -Factors: All sections need completed. Check all that apply. If you check the box other on any of these sections, you must type in the other information box what you mean by other; -1. Predisposing environmental - This is looking at the environment where they fell . If you chart anything negative such as poor lightening, please explain as every room should have adequate lighting. Ex. Resident failed to turn light on in bathroom prior to entering; -2. Predisposing physiological - This is looking at the resident's condition prior to the fall that could have contributed to the fall. If they have a diagnosis of advanced dementia, confused and impaired memory should be checked; -3. Predisposing situation - This section looks at what situation could have contributed to the fall such as being new; -Witnesses: If anyone (staff, resident, visitor, etc.) witnessed the fall a statement should be obtained and charted here; -Check the box to show incident was witnessed and then click on the new box. Use the drop-down boxes to fully fill in: Relation, name, position, date, and who took the statement. If they are not a staff member, you will need to type in their full name and phone number as it will not be listed in the name section. We will need the full name and number in case further follow up is needed at a later date; -Action: This is where we bring everything together: -1. Agency/People notified: It does not matter the time of day/night. It is the nurse's responsibility on duty, when the fall occurred, to alert the responsible party (RP, or RR resident representative) and physician. If the fall does not have a major injury, the DON or a nurse manager can be notified during regular office hours. If the resident is their own RP, ask the resident if they want their emergency contact called and chart what they request. Everyone notified must have the full first and last name charted; -2. Progress Note: This is where you chart the fall. This progress note connects with the resident's chart. All other sections of the risk management are not in the resident's chart. Therefore, this progress note must bring the complete fall together. Who, what, when, where, why, outcome/intervention all must be listed. Please make sure to include your body assessment here along with neuros (PERRLA). Recommend: Copy and paste your description note from the first tab as it should have the full picture charted there as well; -3. Triggered user defined assessments (UDAs) - This will list any triggered assessments. You do not need to chart anything here; -4. Care plan reviewed - every fall should have the care plan reviewed box checked as this is done in the initial fall assessment; -5. Unusual occurrence report (completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff) - this box is checked if a claims report is completed; -6. Care Conference Required- check this box if it applies; -Notes: This is where you can chart any concerns or things you would not want in the chart. Example: call light was on for extended time. CNA, [NAME] Doe, counseled on answering call lights more promptly; -Signatures: The nurse on duty at the time of the fall must sign Licensed Nurse section of every fall. The DON and Administrator will also sign this section after they have reviewed the fall. Once the fall is completed with all charting done, the risk management incident is printed to the QA Reader and closed; -Post Fall Assessments: Follow the following steps: -Clinical tab - resident- assessment tab under resident's name- New- -1st: Post Fall Initial Clinical Assessment V5 (SPN}: completed one time directly after each fall ------2nd: Post Fall 72-hour monitoring V3: If no head injury-complete once a shift x 3 days post fall, -With head injury - complete assessments in order (b through i and then j for 72 hours: b= 15 min post, c=30 min post, d=45 min post, e= 1 hr post, f= 90 min post, g= 2 hr post, h=3 hr post, i= 4 hr post, j=Q shift x 72 hours); -Post Fall Initial Clinical Assessment- V5: All questions must be completed: -1. Description of fall - if checking other, you must describe in box that pops up; -2. Clinical Assessment - do not use old vitals from prior to fall; -3. Notification and Communication - if charting no to notified, please explain Why; -4. Baseline neurological checks; -5. Care planning- this will appear on the care plan. All falls need this section completed. If there is an option to edit a box you select, you need to edit to make it resident specific; -6. Additional information - only section that can be left blank, if needed; -Save, Sign, Lock, and Exit as soon as you complete this assessment; -Post Fall 72-hour monitoring V3 - change type of assessment to b-j (depending on the time assessment you are completing)- Edit: -a. Assessment: complete all questions except: 21, 22, 23, 24, ZS, 25a, 25b do not have to be completed if there is no change in condition; -c) Additional Comment: may be left blank if you have nothing new to add; -Save, Sign, lock, and exit as soon as you complete this assessment. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/30/24, showed: -Moderate cognitive impairment; -Upper and lower extremity impairment on both sides; -Always incontinent of bladder and bowel; -No falls since admission or the prior assessment; -Diagnoses included traumatic brain injury (TBI), quadriplegia (paralysis of all four limbs), insomnia (sleep disorder of trouble falling asleep or staying asleep), seizure disorder, contracture (chronic loss of joint motion due to structural changes in non-bony tissue. These non-bony tissues include muscles, ligaments and tendons) of left hand, left wrist, right hand right wrist. Review of the resident's progress notes, showed: -9/13/24 at 12:09 A.M., resident noted lying on the floor next to low bed and wall on right side of bed. Resident appears to have a bruise on right cheek measuring 2 x 2 cm and an abrasion to left side of lower lip. Complaints of pain and discomfort. Tylenol given as ordered. ROM tolerated to all extremities; -9/13/24 at 6:47 A.M., resident requested to be sent to hospital for further observation. RR and physician aware. Ambulance called for transportation. Emergency Medical Technicians (EMTs) arrived and transported resident to hospital; -9/13/24 3:23 P.M., resident returned from hospital, diagnosis fall, acute (sudden in onset) pain of right knee, spastic quadriparesis (muscles appear unusually stiff, tight, or unable to move freely, loss of motor control). Resident has bruising noted to right cheek with slight swelling; -No documentation of progress notes each shift for 72 hours after fall. Review of the resident's care plan, on 9/16/24 at 12:15 P.M., showed: -Focus: Activities of daily living (ADLs, activities related to personal care bathing, toileting, dressing, etc.) Resident requires total assist per staff with ADLs and mobility to actively participate related to weakness and fatigues easily; -Goal: Resident's needs will be met per staff daily with some participation as tolerated this review period; -Interventions: -Assist resident with dressing grooming; -Resident is a feeder with all meals and needs total assistance; -Focus: Resident had actual falls on 10/13/23 and 10/21/23 with no injury; -Goal: Identify possible contributing factors and reduce the risk of additional falls; -Interventions: -Check ROM (specify #) times daily; -Keep bed in low position; -Fall mat was not listed on the resident's care plan. Review of the resident's assessments, dated 9/12/24 through 9/16/24, showed no post fall initial clinical assessment completed. Review of the resident's MDS kardex report located in a binder at the nurses' station, dated 9/15/24 at 1:45 P.M., showed: -Accidents/Fall Risk: falls since admission or prior assessment not marked, no assistive devices listed; -No interventions were listed. During an observation and interview on 9/16/24 at 10:39 A.M., the resident lay in a flat position on the bed on a low air loss mattress with four bolsters (raised area on outer edge of mattress to limit the likelihood of rolling off the bed), one bolster on each side of the head of the bed on right and left and one on each side of the foot of the bed one on left and right. The bed height was positioned with the bottom of the bed approximately two feet high and was not in lowest position. A fall mat lay on the floor on the right side of the resident's bed between the bed and the window, no fall mat was on the left side of the resident's bed. Certified Nursing Assistant (CNA) A was in the resident's room and said the resident did have a fall recently. He/She was unsure how the resident fell . CNA A said the resident fell on the floor on the right side of the bed. CNA A said he/she would know what interventions are in place for a resident by looking in the resident binder at the nurse's station that have all the resident's kardexes printed out. CNA A said the resident has one fall mat and it was located on the left side of the resident's bed but after the resident fell out of the right side of the bed the one fall mat was moved to the right side of the bed. CNA A said if a resident fell , he/she would make sure the resident is alright and not bleeding. CNA A would not move the resident and he/she would notify the nurse, and then provide any assistance the nurse needs. CNA A said he/she would fill out a witness statement if needed but a witness statement is not filled out for every fall. During an observation and interview on 9/16/24 at 12:54 P.M., the resident lay flat in bed, with the bed in the lowest position with one fall mat on the right side of the bed and no fall mat on the left side of the resident's bed. CNA A said it is the responsibility of the staff who moves the fall mat to put the fall mat back in place. CNA A said he/she was not sure why the resident only had one fall mat. CNA A said the resident has only had one fall mat since he/she started, and it was always on the left side of the bed until the resident had the recent fall and then it was moved to the right side. CNA A said he/she would not know which side of the bed the resident would fall from. CNA A said he/she was not at the facility when the resident had the fall. CNA A said the resident can turn himself/herself in bed without assistance. Observation on 9/17/24 at 8:39 A.M., showed the resident reclined in a Broda chair (a specialized reclining chair propelled by staff). One fall mat was on the right side of the resident's bed, no fall mat on the left side of the resident's bed. During an interview on 9/17/24 at 8:54 A.M., CNA B said he/she would know a resident is a fall risk and what interventions are in place for a resident by looking in the kardex binder at the nurse's station. CNA B retrieved the kardex binder from behind the nurse's station. In the kardex binder, the resident had an MDS kardex report dated 9/15/24 at 1:45 P.M. The sections for Accidents/Fall Risk had no falls since admission or prior assessment marked, no assistive devices listed. No interventions were listed on the MDS kardex report. CNA A said the Maintenance Director (MD) was responsible for placing fall mat/mats in resident rooms. After the fall mat/mats are placed in the resident's room, it is the responsibility of the staff who moves the fall mat to put the fall mat back in place. CNA B said he/she does not know what side of the bed the resident would fall from. CNA B said if a resident's bed is not against the wall, then the resident should have a fall mat on both sides of the bed. CNA B said the resident did not have two fall mats. The DON told the MD this morning to get the resident a second fall mat and he/she is getting a second fall mat for the resident's room and will be placing it in the resident's room. During an observation and interview on 9/17/24 at 9:27 A.M., CNA B said the MD just put the second fall mat in the resident's room. The resident was reclined in Broda chair. Fall mats were located on both sides of the resident's bed. During an interview and observation on 9/17/24 at 9:57 A.M., Licensed Practical Nurse (LPN) C said he/she would know a resident is a fall risk when they are admitted to the facility and by the fall risk assessment. CNAs know when they finish providing care, all residents' beds should be placed in the lowest position. LPN C said he/she informs the CNAs who is a fall risk. LPN C said nursing informs the MD to get the fall mats and then it is nursing's responsibility to move the mats and then put them back in place after care is provided. LPN C thought the resident had two fall mats in his/her room. LPN C said he/she relieved the night nurse, LPN D, the morning after the resident fell on night shift. LPN D informed LPN C the resident fell out of bed on the right side. LPN D said the resident's low air loss mattress had deflated and the resident rolled off the right side of the bed. LPN D said he/she noticed the low air loss mattress was only partially plugged into the wall. LPN C said it is not typical for residents to only have one fall mat. LPN C said he/she does not believe the resident has rolled out of the bed prior to the last time because the resident has bolsters on the mattress. LPN C said the fall mats would have been put in place for a fall intervention. LPN C would not know which side a resident would fall from. If one fall mat was placed, it may be because a resident was getting out of bed on one side, staff could put a fall mat on that side and then if the resident starts to get out on the other side, they would put a second fall mat down on that side. LPN C said CNAs would know what interventions the residents have in place by looking in the kardex binder at the nurse's station. LPN C said if a resident has a fall he/she would go to the resident and do an assessment that included a head to toe assessment, looking for any redness, tenderness, bruising, bleeding, vital signs that would include blood pressure (BP), pulse, respirations, temperature, pain, ROM, and if the resident hit their head or it was an unwitnessed fall, would do neuro checks. If the resident was alright, he/she would transfer the resident into the resident's bed. LPN C would call the resident's physician and RR. All assessments, vital signs and notifications would be documented in risk management and a progress note. Neuros would be documented on a paper neuro sheet for 72 hours. Incident follow up (IFU) fall documentation should also be completed each shift in a progress note for 72 hours. The IFU progress notes should include the vital signs and if the resident had any changes like bruising that showed up after the fall, new pain, change in neuro checks. If a change was noted the physician and RR would to be notified and this would be documented in a progress note. LPN C said the resident had bruising on his/her right cheek and a small laceration to the lower right lip after the fall. During an interview on 9/17/24 at 11:05 A.M., the DON said she was aware of the resident falling the night of 9/12/24. DON said instead of moving the fall mat from the left side to the right side, the staff should have requested an additional fall mat for the other side of the bed. The DON said the RR called after the fall, on 9/13/24, and requested the resident's bed to be placed against the wall or to have a second fall mat put between the bed and the wall. The intervention that was put in place was a second fall mat because the resident is total care and the bed against the wall would make resident care difficult. The DON requested the MD to make sure the second fall mat was in place yesterday on 9/16/24 and to follow up on it. The second fall mat should have been put in the resident's room on 9/13/24. Fall mats are placed to mitigate a serious injury. The DON said you do not know what side of the bed the resident will fall from so there should be a fall mat on both sides of the bed if the bed is not against a wall. During an interview on 9/18/24 at 12:54 P.M., the MD said he was asked to place a second fall mat in the resident's room. The MD did not recall who instructed him to do it because it was text to him. He was unsure when it was texted to him, but when he noticed the text, he placed the mat in the resident's room at that time. During an interview on 9/19/24 at 7:45 A.M., LPN D said he/she worked the night the resident fell out of bed. The resident only had one fall mat at the time of the fall. The resident fell out of the right side of the bed, and this was the side without a fall mat. The resident sustained injuries from the fall that included a 2 x 2 cm bruise to his/her right cheek and an abrasion to his/her lip. When LPN D entered the room after the resident fell , he/she noticed the resident's low air loss mattress was deflated, and LPN D believed this is why/how the resident fell out of bed. LPN D said the low air loss mattress was partially unplugged from the wall and this caused the low air loss mattress to deflate. After he/she plugged the low air loss mattress completely in, the low air loss mattress reinflated. When a resident falls, the nurse should assess the resident for any injuries, take vial signs, ROM, and do neuro checks if it was an unwitnessed fall or if the resident hit their head, notify the physician and RR. The fall, assessment and notifications should be documented in risk management and in a progress note. The progress note should also list if there was any abnormality in the neuro check and the vital signs that were taken should be listed in the progress note. A skin assessment should be completed to document if the resident had any injuries. IFU 72 hour follow up documentation is completed in a progress note once per shift for 72 hours listing if there is any change in condition with the resident like new pain, new bruising, or change in mental status, the resident's current vital signs for that shift would also be listed in the progress note. LPN D said residents with fall mat's need a fall mat on both sides of the bed if the bed is not against a wall. There is no way to know what side the resident could fall from. LPN D said the resident should have had two fall mats. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Upper and lower impairment on one side; -Frequently incontinent of bladder and bowel; -Falls since admission or the prior assessment, yes; -Number of falls since admission or the prior assessment, two or more with no injury; -Diagnoses included stroke, heart failure, high blood pressure, aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (paralysis on one side of the body) affecting right side, seizures, unsteadiness on feet, reduced mobility, repeated falls, and need for assistance with personal care. Review of the resident's care plan during the survey, showed: -Focus: Resident requires assist per staff with ADLs and mobility with ability to actively participate related to stroke and right sided weakness; -Goal: Mobility status will improve as evidence by increased independence and mobility participation this review period; -Interventions: Transfer assist x one to two staff; -Focus: Resident has history of falls and remain at risk for future falls due to hemiparesis post stroke and cognitive deficits. Interdisciplinary team (IDT) unable to educate due to resident inability to recall education; -Goal: Be free from minor/major injury through the review date; -Interventions: -8/11/24 referred to therapy for physical therapy (PT) and occupational therapy (OT) evaluation; -8/9/24 staff to ask resident if he/she wants to be toileted routinely after meals to mitigate falls related to self-transfer attempts; -Ensure resident is wearing appropriate footwear (specify and describe correct client footwear: brown leather shoes, bedroom slippers, black nonskid socks) when ambulating or mobilizing in wheelchair; -Focus: Risk for injury: fall occurred on 11/4/23 and on 1/22/24; -Goal: Resident will resume daily activities without further incidents

Based on interview and record review, the facility failed to provide eight hours of Registered Nurse (RN) coverage on 18 out of 38 days reviewed for staffing. This had the potential to cause unmet health needs for all residents. The census was 85. Review of the Nursing Services and Sufficient Staff Policy, dated revised 1/31/23, showed: -Except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. Review of the facility's daily staffing patterns, dated 1/22/24 through 2/28/24, showed: -On 1/22/24, 1/23/24, 1/26/24, 1/27/24, 1/28/24, 1/30/24, 2/2/24, 2/6/24, 2/9/24, 2/10/24, 2/11/24, 2/13/24, 2/16/24, 2/20/24, 2/23/24, 2/24/24, 2/25/24 and 2/27/24, there was no RN coverage. During an interview on 2/27/24 at approximately at 9:30 A.M., the scheduler said the facility had one RN and when he/she was off, the Director of Nursing or the Minimum Data Set (MDS) Nurse would cover. During an interview on 2/27/24 at 1:03 P.M., the Administrator said the facility had one RN and, in their absence, the facility did not have an RN. The facility had posted an ad for an RN. The facility did not have any resident care needs that a Licensed Practical Nurse (LPN) could not provide. The Administrator said she expected for the facility to have RN coverage eight hours a day.

Based on interview and record review, the facility failed to develop and implement a water management program to reduce the growth/spread of Legionella (a bacterium that can live and grow in water systems and causes Legionnaires Disease (a severe form of pneumonia caused by Legionella bacteria)) and other opportunistic pathogens in the building's water system. This failure had the potential to affect all residents who reside in the facility. The sample was 24. The census was 85. Review of the facility's Water Management Policy, dated September 2022, showed: -Policy: It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards; -Definitions: - Legionellosis refers to two clinically and epidemiologically distinct illnesses: Legionnaires' disease, which is typically characterized by fever, myalgia (muscle aches and pain), cough, and clinical or radiographic pneumonia; and Pontiac fever (a mild flu-like illness caused by exposure to Legionella bacteria). Legionellosis is caused by Legionella bacteria; - Water management plans refer to the documents that contain all the information pertaining to the development and implementation of the facility's water management activities for reducing risk of Legionella and other opportunistic pathogens; -The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder; -A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements: -Premise plumbing: This includes water system components as described in the documentation of the facility's water system; -Clinical equipment: This includes medical devices and other equipment utilized in the facility that can spread Legionella through aerosols or aspiration. -At-risk population: This facility's entire population is at risk. High risk areas shall be identified through the risk assessment process. Supporting documentation of any areas or resident population that exhibit greater risk than the general population shall be kept in the water management program binder. -Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder. During an interview on 2/27/24 at 7:29 A.M., the Administrator said the facility did not have the water management program binder. The facility checked water temperatures daily. If the water temperature fell outside the water temperature range, the facility would call in an outside company. Housekeeping cleans and disinfects daily plus they look for stagnant water. During an interview on 2/28/24 at 5:23 P.M., the Administrator said she expected the facility to have the water management program binder.

Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure common areas were free from strong urine odors that did not dissipate throughout the investigative process. The census was 85. Review of the facility's Facility Responsibilities Policy, dated September 2022, showed: -Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment; -The facility will provide: a safe, clean, comfortable, and homelike environment, allowing the resident to use his/her personal belonging to the extent possible; -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 2/22/24 at 8:35 A.M. and at 9:44 A.M., showed a large yellow soiled utility bin outside of room [ROOM NUMBER]. A strong smell of urine was present in the hallway from room [ROOM NUMBER] to the nurse's station, outside of room [ROOM NUMBER]. Observation on 2/23/24 at 8:31 A.M., showed a strong smell of urine in the hallways of rooms 101 through 125. Observation and interview on 2/23/24 at 10:50 A.M., showed a coded keypad on the door to get into the laundry. Laundry Aide M said staff had the code to door and they were able to come into the laundry and get supplies. The dirty laundry should be put into a round yellow barrel, then the yellow barrels go to the laundry to be washed. Observation on 2/26/24 at 4:46 A.M., showed a large yellow soiled utility bin outside of room [ROOM NUMBER]. A strong smell of urine was present in the hallway. The bin remained outside of room [ROOM NUMBER] at 5:07 A.M., 5:09 A.M. and 5:54 A.M. and the strong smell of urine remained. During an interview on 2/26/24 at 6:00 A.M., Certified Nurse Aide (CNA) N said staff are not allowed to go into the laundry to get supplies and would get written up if they went into the laundry room. The barrels for dirty laundry and trash fill up fast. He/She was not sure what to do with the barrels once they were full. During an interview on 2/26/24 at 7:23 A.M., Nurse D said the soiled utility bin was in the hallway and he/she could smell it. It had been in the area all night and the aides were expected to empty it as they worked and move it from the area. It was not supposed to sit in the hallway. Nurse D said the hallway smelled of urine. Observation on 2/27/24 at 7:40 A.M., showed a large yellow soiled utility bin in the hallway outside of room [ROOM NUMBER]. A strong smell of urine was present. During an interview on 2/28/24 at 10:44 A.M., a visitor said he/she smelled urine outside of rooms 101 to 106. The smell was usually there in the morning but would disappear as day shift arrived and cleaned. The yellow soiled utility bin was usually there in the early mornings. During an interview on 2/28/24 at 11:28 A.M., CNA C said he/she worked on all floors and noticed odors outside of rooms 100 to 125 on some days. The smell was of old, soiled linen. There was a soiled utility bin the aides used but it was not supposed to be kept in the hallways. The soiled utility closet is near the nurse's station and it should be kept in there. If an aide does not have extra bags, they will just keep the yellow bin and empty the soiled linen in the bin instead of putting it in a bag and taking it down to the soiled utility room. During an interview on 2/28/24 at 11:59 A.M., CNA I said he/she usually worked the day shift on the East side of the facility (100 halls) and when he/she arrived at his/her shift, he/she smelled urine. The bins were usually out from night shift. When day shift arrives, they place the bin inside the soiled utility room. During an interview on 2/28/24 at 12:11 P.M., CNA F said he/she noticed the smell of urine on the East side of the facility when he/she arrived at his/her shift first thing in the morning. During an interview on 2/28/24 at 2:41 P.M., the Housekeeping Supervisor said she did not notice any odors when she entered the facility. She worked 8:00 A.M. to 4:30 P.M. and is present on both halls of the facility. Housekeeping staff were available at all times. Staff had access to the soiled utility room to place soiled linen in there. Staff also had access to the clean utility room to get clean supplies. During an interview on 2/28/24 at 5:23 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing said they expected the facility to be comfortable, homelike and free of offensive odors. Staff had access to the laundry room, and they could go in to get supplies. MO00228997

37681 Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs when one resident was observed with a soiled brief for an extended amount of time (Resident #46). In addition, the facility failed to provide showers for two residents (Residents #20 and #41) and failed to properly wash one resident's dentures (Resident #29). The sample size was 24. The census was 85. Review of the facility's ADL Care of the Resident Policy, revised December 2018, showed: -It is the policy of this facility to provide ADL care to residents to ensure needs are met daily; -Policy Explanation and Compliance Guidelines: -Each resident's physical functioning will be assessed in accordance with the facility's assessment procedures; -The resident, to the extent possible, and/or the family/representative will be included in setting goals of care related to ADLs/physical functioning; -The care plan will describe potential distress triggers or behaviors as related to the completion of ADLs, if applicable and necessary; -A variety of approaches, such as task segmentation, will be utilized in assisting the dementia unit residents with ADLs; -The care plan interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary; -Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in physical functioning (i.e. physician, restorative nurse, physical/occupational therapist, social worker, mental health provider). Review of the facility Hand Hygiene Policy, dated 2021, showed: -Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. -Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); -Standards of practice; -Hand hygiene technique when using soap and water: -Wet hands with water. A void using hot water to prevent drying of skin; -Apply to hands the amount of soap recommended by the manufacturer; -Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers; -Rinse hands with water; -Dry thoroughly with a single-use towel; -Use clean towel to turn off the faucet; -Between resident contacts; -Before performing resident care procedures. 1. Review of Resident #46's Admission Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/23, showed: -Cognitively intact; -Exhibited no behaviors; -Dependent on staff for toileting hygiene. Helper does all of the effort; -Continent of bowel and bladder; -Diagnoses included anemia, diabetes, end stage renal disease and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, revised on 2/23/24, in use during the time of the investigation, showed no information regarding the resident's ADL care. Observation on 2/26/24 at 4:55 A.M., showed the resident's call light was pressed. The resident said he/she had a bowel movement and had been waiting all night for someone to change him/her. The resident's brief was down to his/her knees and filled with bowel. He/She said he/she had to go to dialysis and wanted to be cleaned before he/she left. The resident began to cry loudly and said he/she needed to be changed. At 5:02 A.M., the Admission's Director (AD) entered the resident's room and asked if the resident needed anything. The resident showed the AD his/her soiled brief and said he/she needed to be changed. At 5:05 A.M., the AD turned off the resident's call light and said she would notify staff the resident needed assistance, and walked out of the resident's room. At 5:12 A.M., a staff member walked past the resident's room. The resident yelled out he/she needed to be changed. The staff member did not stop to check on the resident. At 5:17 A.M., another staff member walked past the resident's room and did not check on him/her. At this point, two other call lights were going off and the staff member kept walking past the resident rooms. At 5:19 A.M., Nurse A arrived from outside and turned the hallway lights on and sat his/her bag at the nurse's station. The call lights in room [ROOM NUMBER] and 128 were going off. At 5:23 A.M., Nurse A left the nurse's station. The resident yelled he/she needed to be changed and began to cry. At 5:29 A.M., the resident cried out as Certified Medication Technician (CMT) Q walked past the resident's room. CMT Q asked the resident if he/she needed anything. The resident said he/she needed to be changed and waited all night to be changed. CMT Q said he/she would change the resident after he/she was done checking and changing another resident. CMT Q entered another resident's room, who's call light was not going off. At 5:38 A.M., CMT Q entered the resident's room to clean and change him/her. During an interview on 2/26/24 at 7:23 A.M., Nurse D said he/she initially had two aides scheduled on the 100 hall. One aide left at 3:00 A.M. and CMT Q was supposed to fill in for the aide who left. CMT Q may have been on the other side of the building passing medication if he/she wasn't available on the 100 hall. If a resident pressed the call light, it should have been answered within 30 minutes. Nurse D was in another resident's room doing a skin assessment when the AD entered the room and said a Medication Technician would be coming over to the 100 hall to assist. The AD did not mention the resident needed assistance. The AD should have told the nurse the resident lay in bowel and needed to be changed immediately. The AD should not have turned the resident's call light off without ensuring the resident was assisted. CMT Q should have been present on the unit, and when he/she saw the resident needed to be changed, he/she should have changed the resident immediately instead of going into another resident's room. It was unacceptable for the resident to lay in bowel for an extended amount of time. 2. Review of Resident #20's shower sheets, showed showers provided or offered on 1/5/24, 1/20/24 (refused), 2/2/24 (refused) and 2/9/24. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitive impairment; -No rejection of care; -Required substantial/maximal assistance for showers/bathing. Helper does more than half the effort; -Diagnoses included neurogenic bladder (urinary condition in individuals who lack bladder control due to a brain, spinal cord or nerve problem), multiple sclerosis (MS, a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech and bladder control) and dementia. Review of the resident's care plan, revised 2/10/24, showed: -Focus: The resident has an ADL self care performance deficit related to activity intolerance and limited mobility; -Goal: The resident will maintain current level of function in toilet use and personal hygiene through the review date; -Interventions: The resident requires one staff participation with bathing and personal hygiene. Review of the resident's shower sheets, showed showers provided or offered on 2/17/24 (refused), with a note indicating resident was a self-shower and shower was given on 2/21/24. Observation and interview on 2/22/24 at approximately 9:44 A.M., showed the resident in his/her wheelchair in his/her room. The resident had food items on his/her shirt and emitted a strong scent of urine. The resident said staff did not provide or offer showers. The resident said, I am lucky to get one shower a week. During observation and interview on 2/23/24 at 8:34 A.M., the resident said he/she was not offered a shower. The resident had a strong scent of urine. Observation an interview on 2/26/24 at 4:49 A.M., showed the resident lay in bed. He/She said he/she was not offered a shower over the weekend. During an interview on 2/28/24 at 8:54 A.M., the resident said he/she could shower on his/her own, but needed assistance in getting to the shower room, and staff had to set him/her up and provide what was needed for a shower. Staff never offered. He/She would not refuse a shower if it was offered. Staff might say the resident refused, but he/she felt it was because they were short-staffed. During an interview on 2/28/24 at 11:28 A.M., Certified Nursing Assistant (CNA) C said the resident was a heavy wetter and preferred to shower him/herself. The resident has odors and should be offered a shower twice a week. CNA C had been at the facility for about a month and offered and provided the resident with two showers. The resident never refused a shower when he/she offered it. When a resident received or refused a shower, staff were required to document it on the shower sheets. During an interview on 2/28/24 at 12:11 P.M., CNA F said the resident was heavy wetter and used a urinal and would knock it over. The resident refused care, but CNA F never offered the resident a shower. During an interview on 2/28/24 at 2:05 P.M., Nurse T said he/she was an agency nurse and this was his/her fourth time at the facility. He/She could not answer any questions about any of the residents. 3. Review of Resident #41's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Shower/bathe self: partial/moderate assist, helper does less than half of the effort; -Functional limitations in range of motion: the upper and lower extremity on one side; -Diagnoses included hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm, or face, it can also be paralysis on one side of the body). Review of the care plan in use at the time of survey, showed: -Focus: ADLs - Resident requires assist per staff with ADLs and mobility with ability to actively participate related to weakness and fatigues easily; -Goal: Mobility status will improve as evidenced by increased independence and mobility participation this review period; -Interventions: Assist resident with dressing/ grooming times 1 staff; Ensure resident is groomed appropriately - neat, clean. During an interview on 2/22/24 at 10:19 A.M., the resident said he/she was not getting his/her showers. Review of the shower book located on the counter at the nurse's station, showed the resident's shower days were Tuesday and Fridays on the day shift. Review of the shower sheets, provided by the facility for the past 30 days (1/26/24 through 2/22/24), showed: -There was no shower sheet for 1/30/24, 2/6/24 and 2/9/24. During an interview on 2/27/24 at 4:43 P.M., the resident said he/she had his/her call light on because today was his/her shower day and there had been no mention of a shower today. His/Her shower time varied depending on which staff was giving the shower. Typically, he/she was given a shower before supper but if a staff member asked him/her to take a shower at another time, he/she said, you better go then, or you won't get your shower. During an interview on 2/28/24 at 9:16 A.M., the resident said he/she did not get a shower yesterday. No one ever came and offered a shower. CNA J checked the shower book and verified the resident's shower days were Tuesday and Friday. Then, CNA J said the aide who had the resident yesterday had an emergency. 4. During an interview on 2/28/24 at 11:28 A.M., CNA C said the nurse made the room schedule for the shift. On the schedule, the nurse would mark who got a shower. Also, there was a shower book on the desk with the shower schedule on it. Residents get showers two to three times a week and as needed. A shower sheet was completed for all showers. If a resident received a shower, that will be marked on the shower sheet. If a resident refused a shower, that also would be noted on the shower sheet. 5. During an interview on 2/28/24 at 12:00 P.M., CNA I said residents get showers every other day. A shower sheet was used every time a resident was offered a shower. The shower sheet would show if the resident took the shower or refused the shower. 6. Review of Resident #29's annual MDS, dated [DATE], showed: -Cognitively impaired; -Dental, blank; -ADLs/oral health, staff to set up/cleanup. Resident completes activity; -Diagnoses included dementia, seizure disorder, anxiety and depression. Review of the resident's care plan, revision date of 11/14/23, showed: -Focus, requires assist of one staff with ADLs; -Intervention, ensure resident is groomed appropriately, neat, clean. Assist resident with dressing/ grooming; -No direction for staff regarding dentures and/or denture care. Observation and interview on 2/22/24 at 9:37 A.M., showed the resident sat in bed, with his/her bedside table over his/her lap, and his/her breakfast was uneaten. The resident said he/she couldn't eat breakfast because he/she didn't have his/her dentures in, as they were over on the counter. CNA R walked in as the resident was speaking and walked over to counter. CNA R, without washing his/her hands, pulled a paper towel from the dispenser and used the paper towel to hold onto the side of the resident's denture cup. CNA R rinsed the dentures under running water and tipped the cup to allow the water to run off the side of the cup. CNA R then walked over to the resident and held the denture cup in front of the resident. The resident reached into the denture cup, removed his/her dentures and placed them into his/her mouth. During an interview on 2/23/24 at 9:03 A.M., the resident said staff did not brush his/her dentures this morning and they normally don't. He/She said he/she will brush them when he/she is able to get to the sink. During an interview on 2/28/24 at 11:29 A.M., CNA C said he/she thought the resident wore dentures. He/She said denture care involved putting the resident's dentures in a cup at night. They sit in the container overnight, then you take them out, rinse the dentures, and wash the resident's face. 7. During an interview on 2/28/24 at 5:29 P.M., the Administrator said she expected ADL care to be completed for all dependent residents and for staff to wash their hands prior to providing care. When resident call lights were pressed, staff were expected to answer call lights in a timely manner. It was unacceptable to leave a resident in a soiled brief for an extended amount of time. MO00212297 MO00214259 42247 .

42247 Based on observation, interview and record review, the facility failed to ensure appropriate and competent staffing to meet the needs of residents when call lights were not answered in a timely manner for residents, including Resident #46 and #41. The sample size was 24. The census was 85. Review of the facility's Nursing Services and Sufficient Staff Policy, dated revised 1/31/23, showed: -The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans; -Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Review of the facility's Facility Assessment, updated 1/19/24, showed: -The facility had two nursing units, an East and [NAME] wing; -Based on the current population as of 1/31/24, showed: -Bathing: 67 residents needed assistance of 1-2 staff and 13 were dependent; -Dressing: 57 residents needed 1-2 assistance of staff and 14 were dependent; -Transferring: 50 residents needed 1-2 assistance of staff and 9 were dependent; -Toilet use: 41 residents needed 1-2 assistance of staff and 19 were dependent; -Eating: 46 residents needed 1-2 assistance of staff and 5 were dependent; -Hours per shift/day: Night shift for [NAME] wing: Licensed Practical Nurse (LPN) 12 to 18; Nurse Aide: greater than 12; Medication Aide/Tech: 4 to 6; Night shift for East wing: LPN 8 to 12; Nurse Aide: greater than 12; Medication Aide/Tech: 4 to 6. -Plan: Based on the resident population and their needs for care and support, describe the facility's general approach to staffing to ensure sufficient staff to meet the needs of the residents at any given time: the facility utilized a Patients Per Day (PPD) formula for staff assignments. This PPD formula is based upon the expected Five Star Staffing PPD data. This is evaluated at least annually along with the typical resident population served over the past year and adjusted accordingly. Our facility aims to achieve consistent staffing patterns to support consistency and continuity of care. We also aim for consistent staffing model to support the relationships between our residents, families and the staff that serves them. Consistent staffing also facilitates a culture supportive of teamwork. 1. Review of the facility's Resident Council Minutes, dated February 2023 through January 2024, showed, residents voiced concerns with staffing in 4/23, 6/23 and 7/23 and voiced concerns about call bells not being answered timely in 5/23, 6/23, 7/23, 9/23, 10/23 and 12/23; -Facility resolution, showed the facility hired some new night shift staff and educated the staff numerous times regarding answering the call bells timely. 2. Review of the facility's daily staffing pattern, dated 2/25/24, showed: -Night shift: East wing: one nurse and two Certified Nursing Assistants (CNAs); -Night shift: [NAME] wing: one nurse and one Certified Medication Technicians (CMT) and two CNAs. Observation on 2/26/24 at 4:55 A.M., showed Resident #46's door was opened and the call light was pressed. The call light sounded at the nurse's station, across from the resident's room. The resident said he/she had a bowel movement and had been waiting all night for someone to change him/her. The resident's brief was down to his/her knees and filled with bowel. He/She said he/she had to go to dialysis and wanted to be cleaned before he/she left. The resident began to cry loudly and said he/she needed to be changed. At 5:02 A.M., the Admissions Director (AD) entered the resident's room and asked if the resident needed anything. The resident showed the AD his/her soiled brief and said he/she needed to be changed. At 5:05 A.M., the AD turned off the resident's call light and said she would notify staff the resident needed assistance, and walked out of the resident's room. At 5:12 A.M., a staff member walked past the resident's room. The resident yelled out he/she needed to be changed. The staff member did not stop to check on the resident. At 5:17 A.M., another staff member walked past the resident's room and did not check on him/her. At this time, two other call lights, (including Resident #41's) were going off and the staff member kept walking past the resident rooms. At 5:19 A.M., Nurse A arrived from outside and turned the hallway lights on and sat his/her bag at the nurse's station. The call lights in room [ROOM NUMBER] (Resident #41) and 128 were going off. At 5:23 A.M., Nurse A left the nurse's station. The resident yelled he/she needed to be changed and began to cry. At 5:29 A.M., the resident cried out as CMT Q walked past the resident's room. CMT Q asked the resident if he/she needed anything. The resident said he/she needed to be changed and waited all night to be changed. CMT Q said he/she would change the resident after he/she was done checking and changing another resident. CMT Q entered another resident's room, whose call light was not going off. At 5:38 A.M., CMT Q entered the resident's room to clean and change him/her. During an interview on 2/26/24 at 8:19 A.M., Resident #41 said he/she could not get any help last night. He/She was on his/her call light all night long. During an interview on 2/26/24 at 4:56 A.M., CNA S said the facility did not have enough staff. One of the CNAs who was working left at 3:00 A.M. The workload was do-able because there were no baths to be completed. During an interview on 2/26/24 at 7:23 A.M., Nurse D said last night there was two CNAs and one nurse to care for 45 to 46 residents. One of the aides left at 3:00 A.M., the CMT from the other hall came over to help care for the residents not long after the aide left. Nurse D did not know what time the CMT arrived on the wing. The CMT had to pass medications on the other wing hall before he/she could come over to help. Nurse D said call lights should be answered within 30 minutes. The AD stuck her head in a resident's room, while Nurse D and CNA S provided care to a resident, and did not say a resident was needing assistance, or call lights were going off. If residents needed care, she should have told them. 3. During an interview on 2/23/24 at approximately 10:22 A.M., and 11:02 A.M. CNA G said usually there were three aides on the East wing but today there were only two aides. He/She was responsible to provide care for 16 to 20 residents depending on the number of aides. Typically, he/she was assigned three to four showers daily. When there were only two aides, he/she was not able to provide all showers assigned to him/her. Therefore, some residents might have to get a bed bath or if he/she was not able to complete the task, it would be passed on to the next shift. All residents who required assistance with meals got assistance, but the other residents had to wait, if they needed something. Call lights were answered when staff could get there, which makes the residents frustrated and sometimes when staff gets to them, they don't want the help. Residents who required a Hoyer lift must wait until the other staff member was available to help with the transfer, which also frustrates some of the residents. There was one resident who required assistance of three staff members. When the facility was short staffed, staff do the best they can. 4. During an interview on 2/28/24 at 11:28 A.M., CNA C said the number of residents he/she had to care for depends on the number of staff on duty that shift. He/She had care for anywhere between 12 residents and for the whole hall. When he/she cared for all the residents on the hall, it took the entire shift to get the care done and residents may have to wait. 5. During an interview on 2/28/24 at 12:00 P.M., CNA I said if there are two aides on the wing, it takes longer to provide care. 6. During an interview on 2/28/24 at 2:05 P.M., Nurse T said he/she was an agency nurse and this was his/her fourth time at the facility, and could not answer any questions about any of the residents. 7. During an interview on 2/26/23 at 1:03 P.M. and on 2/28/24 at 5:23 P.M., the Administrator said call lights should be answered within 5-10 minutes. Anyone can answer the call light. If the resident needed something a non-clinical staff could do, such as giving the resident their remote control for the tv, a non-clinical staff could do that. If the resident needed care, the non-clinical staff should report it to the nursing staff. The Administrator expected call bells to be answered timely, and if the staff member who answered the call light was unable to provide the care the resident needed, she expected staff to report it to the nursing staff. She expected staff to be competent and the facility to be sufficiently staffed. MO00231729 MO00212297 MO00214259

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified eight medication/treatment carts and two medication rooms. Four of the eight carts and one medication room were checked for medication storage. Issues were found in one medication room, two medication carts and one treatment cart. Staff failed to date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution, artificial tears (eye drops used to lubricate dry eyes and help keep moisture on the outer surface of eyes), and Miralax polyethylene glycol powder (used as a laxative to treat occasional constipation or irregular bowel movements). In addition, the staff failed to keep one treatment cart clean from spilled iodine solution (antiseptic for minor cuts and abrasions). The census was 85. Review of the facility's Storage of Medication Policy, revised 7/10/22, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Medication storage areas are kept clean, well-lit; and free of clutter and extreme temperatures and humidity; -Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified; -Medications in multi-dose packaging will have beyond-use dating of 60 days or manufacturer's expiration date if less than 60 days; -Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: -In a multi-dose injectable vial; -An ophthalmic medication; -An item for which the manufacturer has specified a usable life after opening; -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated; -The nurse shall date the new date of expiration; -The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating; -The nurse will check the expiration date of each medication before administering it; -No expired medication will be administered to a resident; -All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining; -The medication will be destroyed in the usual manner; -Disposal of any medications prior to the expiration dating will be required if contamination or decomposition is apparent; -Nursing staff should consult with the dispensing pharmacist for any questions related to medication expiration dates. 1. Observation of the medication room refrigerator in Hall 200 on 2/23/24 at 9:12 A.M., showed an opened PPD vial placed in the refrigerator door. The item was not dated. During an interview on 2/23/24 at 9:12 A.M., Nurse K said the vial should be discarded when not properly labeled or dated, per facility's protocol. He/She said PPD solutions are to be discarded through their drug destroyer solution the facility currently used. 2. Observation of the nurse medication cart in Hall 200 on 2/23/24 at 9:20 A.M., showed: -Artificial tears eye drops bottle, dated 11/30/23; -Miralax powder bottle, opened and undated. Review of the manufacturer guidelines for artificial tears, showed a bottle which has been opened and in use for 30 days should be discarded. Do not use after expiration date. During an interview on 2/23/24 at 9:20 A.M., Nurse K said the items should be discarded. 3. Observation of the treatment cart in Hall 200 on 2/23/24 at 9:27 A.M., showed the cart's second drawer was heavily stained with dried iodine solution. A medicated shampoo bottle in a sealed plastic bag got stuck in the drawer with iodine solution. The dried stains dripped on the outside parts of all the cart's drawers. The most bottom drawer was heavily stained with the dried solution, soiling a box of tubigrip bandages. During an interview on 2/23/24 at 9:27 A.M., Nurse K said he/she does not use the treatment carts and said the staff should keep the carts clean at all times. 4. Observation of the nurse medication cart in Hall 100 on 2/23/24 at 9:38 A.M., showed an opened and undated bottle of Miralax. The lid of the bottle was also missing. During an interview on 2/23/24 at 9:20 A.M., Nurse O said the item should be discarded. 5. During an interview on 02/28/24 1:09 P.M., Nurse B said the medications are to be dated per facility's protocol. He/She said the nurses and Certified Medication Technicians (CMTs) are responsible for medication storage in their assigned carts. Nurses and CMTs are also responsible for keeping the medication/treatment carts clean. 6. During an interview on 2/28/24 at 5:24 P.M., the Administrator said she expected staff to date opened medications and keep the medication carts clean and free of stains.

Based on interview and record review, the facility failed to explicitly inform the resident or his or her representative of their right not to sign an arbitration agreement (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) as a condition of admission, or as a requirement to continue to receive care at the facility, for three of 25 sampled residents (Residents #87, #82 and #26). The census was 85. Review of the facility's Arbitration Agreements Policy, dated September 2022, showed: -Policy: This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility; -Definition: -Arbitration is a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments; -Binding Arbitration is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds; -When explaining the arbitration agreement, the facility shall: -Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at the facility; -Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; -Ensure the resident or his or her representative acknowledges that he or she understands the agreement. 1. During an interview on 2/28/24 at 2:28 P.M., the Admissions Director said the arbitration agreement is a settlement agreement with the facility. If a situation occurs, someone would represent the facility, and they, or their family member would represent themselves. She said she didn't know how legal it is, and didn't know if there is a timeframe for revoking it. If someone has an issue, it can be reviewed without lawyers and judges, it's a process when admitting a resident. If they are their own person, they sign their contracts. The Admissions Director said upon admission, she uploads information in the the computer, including arbitration agreements. It is the resident's choice to sign or not sign it, if they don't agree, they don't sign. 2. Review of Resident #87's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 12/28/23, showed: -admitted on [DATE]; -Cognitively intact; -Exhibited no behaviors; -Diagnoses included anemia and malnutrition. Review of the resident's Voluntary Agreement to Arbitration, showed the resident signed the form on 12/22/23. During an interview on 2/28/24 at 1:50 P.M., the resident was asked if he/she signed an arbitration agreement form. He/She said he/she did not sign and would not sign a contract agreeing to arbitration. When shown the form and his/her signature, the resident said it was his/her signature but did not remember being explained what the agreement was about. He/She then recalled being in the dining room during a meal when asked to sign the agreement. He/She signed because he/she trusted the staff person and did not want to get him/her in trouble. 3. Review of Resident #82's admission MDS, dated [DATE], showed; -admitted on [DATE]; -Cognitively intact; -Exhibited no behaviors; -Diagnoses included heart failure, liver damage and elevated cholesterol. Review of the resident's facility's Voluntary Agreement to Arbitration, dated 12/22/23, showed: -At the bottom of the page, the resident's printed name; -The resident's signature line, Resident/Resident Representative, signed by the facility Admissions Director; -A box accepting the legal terms and conditions, checked. During an interview on 2/28/24 at 9:35 A.M., the resident looked at the Voluntary Agreement to Arbitration form and said he/she had never seen that form. He/She said he/she didn't sign that and he/she never allowed any one to sign for him/her. He/She threw his/her arms up in the air and said he/she never saw that piece of paper before. During an interview on 2/28/24 at 2:28 P.M., the Admissions Director said it must have been a computer error and the resident's name carried over on the signature line. At 3:32 P.M., the Admissions Director said she spoke with the resident regarding the form and he/she declined to sign the form. She provided a copy of the Voluntary Agreement to Arbitration form, which included the resident's printed name with a handwritten Decline beside the resident's signature. 4. Review of Resident #26's admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's voluntary agreement to arbitration, showed the resident signed the agreement on 12/19/23. During an interview on 2/28/24 at 8:53 A.M., the resident said he/she had never heard of arbitration, and did not know what arbitration was. As far as he/she knew, he/she had never signed an arbitration agreement. If he/she did sign it, he/she would hope someone would have explained what an arbitration was. 5. During an interview on 2/23/24 at 10:00 A.M., all seven attendees of the resident council meeting, identified by the Activities Director as cognitively intact, said they were not aware of the facility arbitration agreement and did not recall signing one. 6. During an interview on 2/28/24 at 5:38 P.M., the Administrator said she expected arbitration agreements to be explained to the residents. 37681 42247

Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as a part of a regular maintenance program to identify areas of possible entrapment for four of 24 sampled residents (Residents #29, #61, #20 and #41). The census was 85. Review of the facility Proper use of Side Rails Policy, dated September 2022, showed; -Statement: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails; -Definitions: -Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars; -Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail; -Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control; -Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the resident's body. Cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body; -Removes easily means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff; -Direct care staff will be responsible for care and treatment in accordance with the plan of care; -A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail; -Responsibilities of ongoing monitoring and supervision are specified as follows: -The interdisciplinary team will make decisions regarding when the bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the bed rail; -The Maintenance Director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails; -The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. 1. Review of Resident #29's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/1/23, showed: -Cognitively impaired; -Side rail not used; -Diagnoses included dementia, seizure disorder, anxiety and depression. Review of the resident's quarterly side rail assessment, dated 2/16/24, showed: -Resident request/bed mobility; -Assistive device/left upper; -Bed safety assessment has been completed/no entrapment concerns. Observation and interview on 2/23/24 at 9:15 A.M., showed the resident sat in his/her wheelchair beside his/her bed. The left quarter rail was raised. The resident said he/she never used his/her bed rail, he/she just used it to hang his/her remote. 2. Review of Resident #61's quarterly MDS, dated [DATE], showed: -Cognitive impairment; -Side rail not used; -Required maximum staff assistance for all ADLs; -Diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language, expression and comprehension, stroke, hemiplegia (paralysis on one side of the body) and seizure disorder. Review of the resident's care plan, dated 10/2/23, showed: -Focus: ADLs, resident requires one person assist per staff with ADLs and mobility with ability to actively participate weakness and fatigues easily. Transfer assist of two staff . Electrical wheelchair used for mobility; -Interventions: Encourage resident's active participation to complete tasks as able. Provide/offer rest periods as needed. Ensure resident is groomed appropriately, neat, and clean; -No direction for staff regarding the use of side rails. Observation on 2/23/24 at 8:54 A.M., showed the resident sat in his/her bed. Licensed Practical Nurse (LPN) V, sat at his/her beside, assisting the resident with his/her meal. The resident's left quarter rail raised. Review of the resident's medical record, showed no maintenance assessment for the use of side rails. 3. Review of Resident #20's Side Rail Assessment, dated 1/18/24, showed resident uses assistive device to assist with defining the parameters of the bed, Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitive impairment; -No behaviors; -Required partial/moderate assistance for transfers. Helper does less than half the effort; -Diagnoses included dementia and multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination and problems with vision, speech and bladder control. Review of the resident's care plan, revised 2/16/24, showed: -Focus: Resident uses a left assist bar on the bed to assist with defining parameters of bed while asleep and trunk support with transfers; -Goal: Resident will remain free of any complications through next reporting period; -Interventions: The resident will be monitored daily, reassessed quarterly and as needed for significant change in status to determine continued appropriateness of use. Safety concerns with assist rails will be reported and addressed immediately. Review of the resident's medical record, showed no maintenance assessment for the use of side rails. Observation and interview on 2/22/24 at 9:44 A.M., showed the resident sat in his/her wheelchair in his/her room. The resident's bed showed a raised quarter length U-rail on the left side of the bed. The resident said he/she used the rail for positioning. Observation on 2/23/24 at 8:34 A.M., 2/26/24 at 4:49 A.M. and 2/28/24 at 8:54 A.M., showed the resident lay in bed. A quarter sized U-rail was raised on the left side. 4. Review of Resident #41's side rail assessment, dated 2/16/24, showed: -Please indicate the recommended type of side rail(s) or assistive device: 3/4 rail; -Please indicate what area the bed side rails, or assistive device should be placed: both upper sides. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 12/22/23, showed: -Cognitively intact; -Functional limitation in range of motion in upper and lower extremities on one side; -Diagnoses included: hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm, or face, it can also be paralysis on one side of the body) Review of the care plan in use at the time of survey, showed: -Focus: I use devices on my bed, Bilateral 3/4 side rails to provide parameters while in bed, assist with transfers and bed mobility; -Goal: I will remain safe with no complications thru next review; -Interventions: have 3/4 side rails, I use assistive devices. Observation and interview on 2/22/24 at 10:22 A.M., showed the resident sat in his/her wheelchair. The top 3/4 side rail was in the raised position on both sides of the bed. The resident said he/she used the side rails for pulling him/herself up and to help position while in bed. Observation on 2/23/24 at 10:35 A.M., showed LPN A asked the resident to lie down in bed while he/she provided care for the resident. The resident propelled his/her wheelchair to the side of the bed and reached for the side rail to help pull him/herself up. The resident sat on the side of the bed and staff assisted the resident into bed. The resident rolled side to side using the side rails to help pull him/herself over while staff provided care. 5. During an interview on 2/28/24 at 2:45 P.M., the Maintenance Director said the Director of Nursing tells him who needs side rails on their bed, and he installs them. The facility had two types of side rails, one had bolts and one had slides. The beds have a series of holes. They just select one and install the rail, and they don't have to measure them. Maintenance checks the bed monthly during the room checks to be sure the bolts are intact, and the beds are functioning. 6. During an interview on 2/28/24 at 5:23 P.M., the Administrator said she expected the maintenance assessments to be completed. 37681 42247

37681 Based on observation, interview and record review, the facility failed to uphold one resident's rights (Resident #46) by turning off the resident's call light without providing assistance to the resident or notifying staff the resident needed assistance, resulting in the resident having to wait an extended amount of time before staff provided assistance. In addition, the facility failed to ensure a resident was treated with dignity when a staff member interacted inappropriately with a resident who required assistance with his/her clothing (Resident #40). The sample size was 24. The census was 85. Review of the facility's Resident Right's policy, dated September 2022, showed: -Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all the rules and regulations governing resident conduct and responsibilities during the stay in the facility; -Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -Respect and Dignity: The resident has a right to be treated with respect and dignity, including: -The right to reside and receive services in the facility with reasonable accommodations of needs and preferences; -Safe environment: -The resident has a right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and support for daily living safely. 1. Review of Resident #46's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/23, showed: -Cognitively intact; -Exhibited no behaviors; -Dependent on staff for toileting hygiene. Helper does all of the effort; -Continent of bowel and bladder; -Diagnoses included anemia, diabetes, end stage renal disease and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, revised on 2/23/24, in use during the time of the investigation, showed no information regarding the resident's activities of daily living (ADL) care. Observation on 2/26/24 at 4:55 A.M., showed the resident's door was opened and the call light was pressed. The call light sounded at the nurse's station, across from the resident's room. The resident said he/she had a bowel movement and had been waiting all night for someone to change him/her. The resident's brief was down to his/her knees and filled with bowel. He/She said he/she had to go to dialysis and wanted to be cleaned before he/she left. The resident began to cry loudly and said he/she needed to be changed. At 5:02 A.M., the Admissions Director (AD) entered the resident's room and asked if the resident needed anything. The resident showed the AD his/her soiled brief and said he/she needed to be changed. At 5:05 A.M., the AD turned off the resident's call light and said she would notify staff the resident needed assistance, and walked out of the resident's room. At 5:12 A.M., a staff member walked past the resident's room. The resident yelled out he/she needed to be changed. The staff member did not stop to check on the resident. At 5:17 A.M., another staff member walked past the resident's room and did not check on him/her. At this time, two other call lights were going off and the staff member kept walking past the resident rooms. At 5:19 A.M., Nurse A arrived from outside and turned the hallway lights on and sat his/her bag at the nurse's station. The call lights in room [ROOM NUMBER] and 128 were going off. At 5:23 A.M., Nurse A left the nurse's station. Resident #46 yelled he/she needed to be changed and began to cry. At 5:29 A.M., the resident cried out as Certified Medication Technician (CMT) Q walked past the resident's room. CMT Q asked the resident if he/she needed anything. The resident said he/she needed to be changed and was waiting all night to be changed. CMT Q said he/she would change the resident after he/she was done checking and changing another resident. CMT Q entered another resident's room, whose call light was not going off. At 5:38 A.M., CMT Q entered the resident's room to clean and change him/her. During an interview on 2/26/24 at 7:23 A.M., Nurse D said he/she initially had two aides scheduled on the 100 hall. One aide left at 3:00 A.M. and CMT Q was supposed to fill in for the aide who left. CMT Q may have been on the other side of the building passing medication if he/she wasn't available on the 100 hall. If a resident pressed the call light, it should have been answered within 30 minutes. Nurse D was in another resident's room doing a skin assessment when the AD entered the room and said a Medication Technician would be coming over to the 100 hall to assist. The AD did not mention Resident #46 needed assistance. The AD should have told the nurse the resident was laying in bowel and needed to be changed immediately. The AD should not have turned the resident's call light off without ensuring the resident was assisted. CMT Q should have been present on the unit, and when he/she saw the resident needed to be changed, he/she should have changed the resident immediately instead of going into another resident's room. It was unacceptable for the resident to lay in bowel for an extended amount of time. During an interview on 2/27/24 at 1:06 P.M., the Administrator said any staff could answer call lights. However, if the staff was a non-clinical staff, she expected staff to inform clinical staff the resident needed assistance and should have left the call light on until the resident's needs were addressed. The Administrator expected staff to be on the floor to answer call lights. Staff should have changed the resident immediately after finding out the resident needed to be changed. 2. Review of Resident #40's annual MDS, dated [DATE], showed: -Cognitively impaired; -No behaviors; -Substantial/maximum assistance with all ADLs; -Upper extremity/lower extremity, impairment on one side; -Diagnoses included stroke, dementia, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and high blood pressure. Review of the resident's care plan, undated and in use during the survey, showed: -Focus: Cognitive/memory problems, decision making ability is impaired due to diagnoses of dementia. Able to make needs known, encourage to talk during care; -Interventions: Encourage decisions by offering simple choices. Encourage to participate in conversation; -Focus: Dependent on staff for activities, cognitive stimulation/social interaction due to cognitive deficits; -Interventions: All staff to converse with resident while providing care. Requires assistance/escort to activity functions. Observation and interview on 2/26/24 at 12:12 P.M., showed the resident say in his/her wheelchair in the doorway of his/her room. He/She appeared to have something spilled on the front of his/her shirt. Nurse A stood in front of the resident, attempting to enter the room and repeatedly said to the resident in a firm voice, push yourself back, push yourself back!. While the resident attempted to maneuver him/herself backward in his/her wheelchair, his/her right foot drug on the ground and his/her right slipper slid off. Nurse A used his/her foot, tapping the shoe back towards the resident's bare foot in an attempt to push the resident's slipper back onto the resident's foot, while he/she continued to tell the resident to push him/herself backwards. When Nurse A exited the resident's room, he/she said the resident had spilled something on his/her shirt and he/she took the resident into his/her room to change his/her shirt. During an interview on 2/28/24 at 9:11 A.M., the resident said he/she recalled a staff person telling him to back up and trying to kick his/her shoe back on, but it didn't hurt his/her feelings. He/She had spilled something on his/her shirt and they wanted to clean it up. During an interview on 2/28/24 at 3:23 P.M., Nurse B said it would never be acceptable for staff to tell a resident to back up and use their foot to try to push their shoe back on. Nurse B said he/she hoped no one did that. He/She said staff should assist the resident with their wheelchair and use their hands to put their shoes back on. During an interview on 2/28/24 at 3:30 P.M., Certified Nurse Aide (CNA) C said the resident can't pick his/her foot up and it would never be acceptable to try push his/her slipper back on his/her foot using your own foot. CNA C said staff are supposed to assist the residents and explain procedures prior to assisting them. During an interview on 2/28/24 at 5:24 P.M., the Administrator said she expected residents to be treated with dignity and respect. MO00231046 45083