Every finding on record at Sunnyview Nursing Home & Apartments

Based on observation, record review, and interview, the facility failed to protect one cognitively impaired resident (Resident #1) from physical abuse, when Resident #2, who had a history of multiple instances of physical abuse including slapping, grabbing, and pushing Resident #1 and/or staff did not put any interventions in place to prevent further abuse. On 9/26/25, Resident #2 shoved Resident #1 into a bird aviary which caused broken glass to scratch Resident #1's back. Furthermore, the facility failed to provide protection to all other residents, from the potential of physical abuse, when no safety measures were put into place for Resident #2 after the 9/26/25 incident of abuse. The facility census was 58. The Director of Nursing was notified on 10/2/2025 at 2:49 P.M. of an Immediate Jeopardy (IJ) which began on 8/22/25. The IJ was removed on 10/2/2025, as confirmed by surveyor onsite verification. Review of the facility policy Abuse, Neglect, Exploitation, or Misappropriation Prevention Program, dated 3/23/23, showed:-Residents have the right to be free of abuse. This includes but is not limited to freedom from physical abuse;-The resident abuse, neglect, exploitation program consists of a facility wide commitment to: Protect residents from abuse, neglect, exploitation or misappropriation by anyone, including other residents, family members, friends;-Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.-Provide staff orientation and training programs that include topics such as abuse prevention, and handling verbally or physically aggressive resident behavior. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 4/11/23, showed upon receiving any allegation of abuse, the administrator is responsible for determining what actions are needed for the protection of residents. Review of Resident #1's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 8/09/25, showed:-He/She had no cognitive loss; -Needed minimal assistance of staff for activities of daily living (ADLs: things completed in a day to care for oneself);-Diagnoses included: Cognitive communication deficit (a communication challenge resulting from impaired thinking skills, such as memory, attention, and problem-solving, rather than a language disorder), congestive heart failure, muscle weakness, reflux, and use of a cardiac pacemaker. Review of Resident #1's Comprehensive Care Plan, dated 8/21/25, showed: -He/She had a potential for falls;-Needed one staff assistance for ADLs;-Attended activities as he/she chose. Review of Resident #2's Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability Evaluation, dated 7/30/25 showed:-He/She was hard to redirect, was verbally and physically aggressive, wandered into others rooms, was 1:1 with staff and was given multiple as needed medications for aggression and anxiety.-He/She had medication orders due to physical aggression.-He/She had received several doses of medication to control verbal/physical aggression. Intervention was needed due to his/her physical aggression, throwing things, spitting, and wandering into others rooms and refusing to leave. Review of Resident #2's admission MDS, dated [DATE], showed:-He/She had significant cognitive loss;-Needed moderate to extensive assistance for ADLs;-Diagnoses included: Down Syndrome, morbid obesity, reflux, and constipation. Review of Resident #2's Comprehensive Care Plan, dated 8/29/25, showed: -He/She used psychotropic medications (medications that affect the brain and alter mental processes, emotions, and behavior) for behaviors due to Down Syndrome and behaviors;-Assess if his/her behaviors present a danger and intervene as needed; -Set expectations and limits for him/her.-No interventions put into place after incidents of aggression/agitation on 8/22, 8/23, 8/25, 8/28, 9/3, 9/5, and 9/11/25.Review of Resident #2's progress notes, dated 8/20/25 to 9/30/25, showed: -On 8/22/25 at approximately 9:30 P.M., staff heard a noise near the end of the hall. When staff responded, they found Resident #1 in Resident #2's room. Resident #2 grabbed Resident #1 by the arm and pushed him/her into a chair. Resident #2 was assisted to his/her room and checked for injuries. Resident #2 became aggressive and slapped at staff when he/she was not allowed to go into Resident #1's room. Resident #2 remained aggressive to staff while attempting to go into other resident's rooms. Resident #2's primary care physician (PCP) was notified and an order was given for Ativan (a prescription medication used for anxiety and sedation) 1 milligram (mg) by mouth one time only; -On 8/23/25 at 5:06 P.M., Resident #2 and Resident #1 were sitting at the nurse's station. Resident #2 became aggressive with Resident #1. Resident #2 pulled Resident #1's hair and slapped him/her in the face with an open hand. Resident #1 was removed to the Activity Room. Resident #2 kept trying to go after Resident #1. The Director of Nursing (DON) sat with Resident #2 and worked on breathing exercises; -On 8/25/25 at 12:58 A.M., Resident #1 was being domineering to Resident #2. Resident #2 lost his/her temper and hit Resident #1 and lunged at him/her. Certified Nurse Aide (CNA) pulled Resident #1 away and Resident #2 was taken to his/her room; -On 8/25/25 at 5:22 P.M., Resident #2's PCP faxed a note to the facility showing an order for Seroquel (a prescription medication used to treat mental and mood conditions) 25mg twice a day. He/She had concerns about Resident #2's behaviors, safety of Resident #1 and if the facility was appropriate for Resident #2; -On 8/28/25 at 12:54 A.M., Resident #2 attempted to leave the facility and was not easily redirected. Resident #2 grabbed staff by the neck and attempted to throw the staff member down. Administrator was notified and instruction was given to call the emergency room for medication order. Nurse Practitioner (NP) A returned the call and ordered Haldol (a medication used to treat behaviors) 5mg Intramuscularly (IM) one time only. Medication was administered to Resident #2;-On 9/3/25 at 9:30 A.M., Resident #2 went to the nurse's station and threw a chair to the floor; -On 9/5/25 at 12:20 A.M., Resident #2 was sitting at the nurse's station with Resident #1. Resident #2 went to nurse's desk and threw the computer at the nurse, ripped papers up from the desk, threw the computer keyboard and the telephone. Staff had given the resident five sandwiches and two [NAME] bars, but the resident was not redirectable. Resident #1 was taken to the other nurse's station. Resident #2 was assisted to his/her room by staff;-On 9/11/25 at approximately 7:30 P.M., Staff were at the nurse's station talking with another resident family member. Resident #2 pushed the family member aside and grabbed the nurse's station computer. Resident #2 grabbed papers off the desk and ripped them up, and threw things from the nurse's desk. On call physician contacted and orders received for Haldol 5mg IM one time only. Resident #2 was administered the medication in the right arm, with the assistance of three staff members. Resident #2 went to Resident #1's room; -On 9/26/25 at approximately 7:00 P.M., staff were at the nurse's station, heard yelling and a loud bang. When staff arrived at the bird aviary, they found Resident #1 sitting on the floor, his/her back against the aviary and the aviary was broken. Resident #2 was sitting on the couch. Resident #1 said Resident #2 hit him/her and pushed him/her into the bird cage. Resident #1 was assisted off the floor and taken to his/her room. He/She was found to have a scratch to his/her back and no other injuries. Resident #2 remained at the nurse's station and was monitored.Observation and interview on 9/30/25 at 10:30 A.M., showed Resident #2 was in the hallway with staff. Resident #2 said he/she pushed Resident #1 into the bird cage. Resident #2 then walked away to Resident #1's room. Observation on 9/30/25 at 12:30 P.M., showed Resident #1 and Resident #2 were sitting at the dining room table with no staff providing any interventions to ensure the residents safety together or any increased monitoring to ensure resident safety. Observation and interview on 9/30/25 at 3:11 P.M., showed:-Resident #2 was sitting on Resident #1's bed with no staff in room with the residents.-Resident #1 said his/her side was sore and he/she was stiff; He/She knew Resident #2 did not mean to hurt him/her; He/She believed Resident #2 was just overwhelmed. During an interview on 9/30/25 at 3:19 P.M., Resident #2 said: -He/She pushed Resident #1 into the bird cage, because Resident #1 would not give him/her food; -He/She hurt Resident #1 when he/she pushed the resident into the bird cage;-He/She pushed Resident #1 into the bird cage and that was a problem. During an interview on 10/6/25 at 5:00 P.M., Licensed Practical Nurse (LPN) A said: -He/She was the charge nurse on the night of 9/26/25; -He/She did not see the incident and only heard yelling and a loud noise; -When he/she arrived at the bird aviary Resident #1 was on the floor and the glass of the aviary was broken; -Resident #1 was taken to his/her room, Resident #2 was taken to the nurse's station; -Resident #1 had a large scratch to his/her back from the left shoulder blade to the middle of his/her back; -Resident #2 was not placed on checks or monitoring that he/she was aware of; -He/She is afraid Resident #2 would hurt another resident. -The DON would tell staff any interventions to put into place for any resident involved in an altercation; -He/She had not had any residents involved in altercations previously.During an interview on 9/30/25 at 3:55 P.M., the DON said: -He/She was notified of the incident between Resident #1 and #2 on 9/26/25;-The residents were separated and Resident #1 was taken to his/her room;-Resident #2 was not officially placed on increased checks or monitoring after he/she pushed Resident #1 into the bird aviary, but staff did not allow Resident #2 to leave the nurse's station;-He/She believed Resident #1 would pick on Resident #2 until Resident #2 would get angry. -He/She said staff were aware that Resident #2 could go to the MDS office to listen to music or use an ipad when Resident #2 was agitated. No other interventions were put into place.During an interview on 10/2/25 at 8:45 A.M., the Primary Care Provider (PCP) said: -He/She was aware Resident #2 had verbal outbursts by yelling at staff and the resident taking objects and throwing them at staff prior to 9/26/25;-He/She was notified of the altercation between Resident #1 and Resident #2 that occurred on 9/26/25; -He/She did not feel that adequate safety measures were in place to protect Resident #1 after the previous incidents and after this last incident;-He/She was concerned Resident #2 would really hurt Resident #1 sometime -He/She did not feel the facility was an appropriate placement for Resident #2 due to his/her diagnosis and previous behaviors;-He/She would expect the staff to put measures into place after each incident that would prevent other residents, including Resident #1 from injury. During an interview on 10/2/25 at 11:29 A.M., Resident #2's Guardian said: -He/She was aware Resident #2 had behaviors before admission to the facility when the facility told him/her when he/she agreed to take the resident.-He/She felt Resident #2 needed a higher level Department of Mental Health facility not long term care; -Resident #2's behaviors occurred when he/she was told no.-He/She would expect staff to put interventions in place after each incident to protect residents after an incident occurred. Note; At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Incident 2628901

Based on interview and record review the facility failed to ensure that residents or their responsible party were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers prior to being placed on psychotropic medications for, four of the 14 sampled Residents ( Residents #15, #7, #8, and #34). The facility census was 56.Review of the facility's policy Psychotropic Medication Use undated., showed: A psychotropic medication is any medication that affects brain activity and behavior. These medications would include anti-psychotics, anti-depressants, anti-anxiety, and hypnotic medications. Residents, their families and or representative are to be informed of the indications for use, does, duration, how the resident will be monitored and preventing adverse consequences. Residents or their representative have the right to decline treatment. 1.Review of Resident #34's Quarterly MDS (Minimum Data Set), a federally mandated assessment completed by facility staff, dated 6/21/25., showed: Cognition severely impaired, antipsychotic medications were take during the last 7 days of the assessment period, and dependent on staff for all activities of daily living, including medications provided by licensed staff. Review of physician orders for the month of September 2025 showed: The resident was started on Rexulti 0.25mg (an anti=psychotic medication for the management of behavioral and psychotic mood disturbances) 1 tablet by mouth every day. Order initiated on 12/10/24. Review of the resident's clinical electronic medical record, showed there was no form or documentation of signed consent by the residents guardian for the use of psychotropic medication prior to the start of this medication or at any time. Review of the resident's care plan, dated 1/6/25, showed the resident was taking antipsychotic medication for behaviors. The care plan did not address interventions or safe guards regarding this medication in the care plan or that it was discussed at the care plan meetings. 2. Review of Resident #7's admission MDS, dated [DATE] showed: - Cognitive skills intact. - No behaviors noted. - Diagnoses included cancer, anxiety, chronic kidney disease and low back pain. - Antipsychotic medications were used. Review of the resident's care plan, dated 9/11/25 showed the plan did not address the use of antipsychotic medications. Review of the resident's POS, dated September 2025 showed Start date 8/26/25 - End date, open ended for Haloperidol lactate concentrate 2 milligrams (mg.)/milliliter (ml.) as needed for end-of-life care. Review of the resident's medical records dated 9/18/25 showed no consents or education of risks and benefits for psychotropic medication use was found. 3. Review of the resident #15's care plan, dated 7/28/25, showed: - The resident received antipsychotic medication related to dementia; - The resident had impaired decision making related to dementia. Review of the physician orders for the month of September 2025 showed the resident had an order for Seroquel 75mg twice daily (an anti-psychotic medication for the management of behavioral and psychotic mood disturbances). Order initiated on 8/7/25. Review of the resident's electronic medical record, showed no form or documentation of signed consent by the residents guardian for the use of psychotropic medication prior to the start of this medication. Review of the resident's consent for use of psychotropic medication form, dated 9/12/25, showed the resident verbally consented to being prescribed Seroquel. 4. Review of Resident #8's care plan, dated 7/3/2025, showed: - The resident had impaired decision making related to dementia; -The resident received antipsychotic medication related to anxiety. Review of the physician orders for the month of September showed: -The resident had an order for quetiapine (an anti-psychotic medication for the management of behavioral and psychotic mood disturbances) 25mg once a day. Order initiated on 12/23/2021; -The resident had an order for sertraline (a medication used to manage anxiety) 50mg once a day. Order initiated on 6/8/21; -The resident had an order for trazodone (a medication used to manage anxiety) 50mg once a day. Order initiated on 12/23/21; -The resident had an order for alprazolam (a medication used to manage anxiety) 0.25mg once a day. Order initiated on 12/8/25; -The resident had an order for lorazepam (a medication used to manage anxiety) 0.25ml to 1ml every one hour as needed. Order initiated on 7/30/25. Review of the resident's electronic medical record, showed no form or documentation of signed consent by the residents guardian for the use of psychotropic medication prior to the start of this medication. During an interview on 9/18/25 at 10:39 a.m. and 9/19/2025 at 10:04P.M. , the DON said: - The facility did not have any consents signed for the antipsychotic medications until this week. - He/She was told the consents needed to be completed, so he/she had been working on them. - The consents should have been obtained prior to the resident starting on the psychotropic medication. - Resident #15's responsible party needs to consent to the resident taking psychotropic meds.

Based on observations and interviews, the facility failed to post nurse staffing data in a prominent place, readily accessible to all residents and visitors on a daily basis at the beginning of each shift. The facility census was 56. Review of the facility's policy for posting direct care daily staffing numbers, revised August 2022 showed:Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.Within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurse (RN), Licensed Practical Nurse (LPN) and Licensed Vocational Nurse (LVN) and the number of unlicensed nursing personnel (Certified Nurse Aide (CNA), and Nurse Aides (NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: the name of the facility, the current date (the date for which the information is posted), the resident census at the beginning of the shift for which the information is posted, 24 hour shift schedule operated by the facility, the shift for which the information is posted, type (RN, LPN, LVN, CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff), the actual time worked during that shift for each category and type of nursing staff and the total number of licensed and non-licensed nursing staff working for the posted shift.Within two hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the nurse staffing information form. The charge nurse completes the form and posts the staffing information in the locations designated by the administrator.The form may be typed or handwritten. If completed electronically, the recorded information will be a minimum font size of 12 points. If the information is handwritten, it must be legible printed in black ink and written so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in the facility's daily staffing information. The previous shift's forms are maintained with the current shift form for a total of 24 hours of staffing information in a single location. Once a form is removed, it is forwarded to the office of the director of nursing services (DNS) and filed as a permanent record.Records of staffing information for each shift are kept for a minimum of 18 months or as required by state law (whichever is greater). Observations on all days of the survey, September 16, 2025, through September 19, 2025, showed unknown staff documented the staffing data on a white board at the entrance of the facility and on the 200 halls. During an interview on 9/19/25 at 8:39 A.M., the Director of Nursing (DON) said the daily staffing sheets should be on paper and posted daily in plain view and updated on each shift.

Based on observations, interviews and record review, the facility failed to discard expired medications and biologicals stored in the medication cart and the medication room, failed to date two opened vials of Lorazepam (used to treat anxiety) for two of the 14 sampled residents, (Resident #26 and #62) and failed to ensure medication had a pharmacy label to indicate who it belonged to. The facility census was 56. Review of the facility's policy for medication labeling and storage, revised February 2023 showed:- Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.- The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date, when applicable; resident's name; route of administration; and appropriate instructions and precautions.- Only the dispensing pharmacy may label or alter the label on a medication container or package.- Liquid medications are to be dated when opened. Review of the facility's policy for discarding and destroying medications, revised November 20222 showed:- Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.- Non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. Review of liquid Lorazepam undated manufacture guidelines showed Lorazepam oral solution is supplied in a 30 mL multi-dose bottle requiring protection from light and refrigeration, with a beyond use date of 90 days once the bottle is opened. 1.Observation and interview on 9/17/25 at 10:31 A.M., of the 200-hall medication room showed:- Resident #26 had an opened vial of Lorazepam intensol oral concentrate without a date to indicate when it was opened.- Resident #62 had an opened vial of Lorazepam intensol oral concentrate without a date to indicate when it was opened.- Licensed Practical Nurse (LPN) A said all medications should be dated when opened. - Ipratropium and albuterol sulfate inhalation solution used to treat and manage bronchospasms (airway narrowing), without a pharmacy label to indicate which resident it belonged to. - An unopened bottle of Ocular vitamins, expired 6/25.- An unopened bottle of Vitamin D 10 micrograms (mcg.), expired 5/25.- An unopened tube of Medi Honey gel, expired 9/1/24.- An unopened box of Extra Strength gas relief, expired 6/25.- An unopened bottle of Geri-Tussin DM, expired 7/25.- Resident #15 had 19-unit doses of Formoterol Fumarate inhalation 20 mcg. /2 milliliters (ml.), expired 5/25. - LPN A said medications should have a pharmacy label to indicate which resident it belonged to and expired medication should not be used; they should be properly discarded. The nurses check the medication room and medication carts whenever they get a chance. During an interview on 9/19/25 at 8:39 A.M., the Director of Nursing (DON) said:- Lorazepam should be dated when it is opened. It is good for 90 days after it is opened.- Medication should have a pharmacy label if it belonged to a resident.- Expired medication should be destroyed and should not be used.- The nursing staff was responsible to check the medication room and the medication carts for expired medications and should be checked at least weekly.

Based on interview and record review, the facility failed to use the correct form to provide one resident out of 14 sampled residents notification of changes in coverage to items and services covered by Medicare and/or by the Medicaid State plan, the facility additionally failed to provide notice to residents of the change as soon as is reasonably possible. The facility census was 54.Review of facility's Medicare Advance Beneficiary and Medicare Notice, policy undated showed:-Residents are informed in advance when changes occur to their bills. -CMS (Center for Medicare/Medicaid Services) form 10055 will be provided to the resident prior to discharging from Medicare part A. 1. Review of Resident #31's face sheet showed the Resident was admitted to Medicare part A on 2/19/25 with a diagnosis included COPD, renal failure, and heart failure. Review of the facility's ABN (the advanced beneficiary notice of non-coverage) form dated 5/7/2025, showed the facility used an outdated form, titled CMS-R-131. The form did not include the date that Medicare part A coverage would be ending. The facility did not have the current CMS-10055 ABN form.Review of resident's medical record showed no CMS-10055 ABN form located anywhere within the medical record.During an interview on 09/18/2025 at 3:23 P.M. The SSD (Social Service Director) said she was unaware that she was using the incorrect CMS form to notify residents about discontinuing of Medicare part A benefits and should be using CMS 10055 form. During an interview on 9/19/25 at 12.38 P.M. the Administrator said that she was unaware that the facility was utilizing the wrong ABN CMS form.

Based on observation, interview, and record review, the facility failed to ensure residents who used psychotropic drugs did not exceed 14 days of use without a physician evaluation and renewal of the medication, and documentation of the rationale, in the resident's medical record, to indicate the duration for the PRN order, which affected two of the 14 sampled residents, (Resident #7 and #8). The facility census was 56.Review of the facility's policy for psychotropic medications use, dated July 2022 showed: - Residents will not receive medications that are not clinically indicated to treat a specific condition. - A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. - Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. - PRN orders for psychotropic medications are limited to 14 days. - For psychotropic medications that are NOT antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he/she will document the rationale for extending the PRN order. - For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. 1. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/2/25 showed: - Cognitive skills intact. - No behaviors. - Diagnoses included cancer, anxiety, low back pain and chronic kidney disease. - Had opioids in the last seven days. - No antipsychotic medication used. Review of the resident's care plan dated 9/11/25 showed it did not address the use of Haloperidol (an antipsychotic medication used to treat various psychiatric and behavioral disorders). Review of the resident's physician order sheet (POS), dated September 2025 showed Start date: 8/26/25. End date: open ended. Haloperidol lactate concentrate, 2 milligrams (mg.)/milliliter (ml.), give 0.5 mg. - 2 mg. as needed. During an interview on 9/19/25 at 8:12 A.M., Licensed Practical Nurse (LPN) B said he/she did not anything about stop dates for antipsychotic medications. During an interview on 9/19/25 at 8:39 A.M., the Director of Nursing (DON) said PRN antipsychotics should only be for 14 days. It was her responsibility to ensure it had been completed. 2. Review of Resident #8's care plan, dated 07/03/2025, showed: The resident received hospice care; The resident had a diagnosis of anxiety; The resident had impaired decision making related to dementia. Review of the resident's physician order report, dated September 2025, showed Lorazepam Intensol concentrate; 2mg/mL; give 0.25ml to 1ml every hour as needed. Start date: 7/30/2025. End date: Open Ended.

Based on record review and interview the facility failed to ensure staff followed facility's policy to timely update one Resident's care plan (Resident #15) out of the 14 sampled residents after the resident eloped from the facility. The facility census was 56. Review of the facilities Emergency Procedure- Missing Resident policy, not dated, showed:-Nursing staff is tasked with updating the care plan after a resident who eloped is found;-The DON is to ensure the care plan is updated. 1.Review of Resident #15's care plan, updated on 08/03/2025, showed:-The resident was at an increased risk for wandering related to repeated attempts to exit the facility;-The resident had impaired decision making related to dementia;-The resident had a diagnosis of depression;-The resident's care plan had not been updated after the resident eloped on 09/13/2025. Review of nursing progress notes, dated 9/19/25 at 8:00 P.M showed the resident eloped out the door on the 100 hall without his/her walker. The resident was then later found behind the facility 25 minutes later without his/her wander guard bracelet ( A device that alarms when getting to close to an exit door. ) on. During an interview on 9/19/2025 at 9:04 A.M., RN A said that he/she was there the night that resident had eloped and had seen him that night on 9/13/25 on the 100 hall around 8:00 P.M. with his/her walker, later that night he/she went to give him his/her medications and could not find him/her. RN A said there was an order on the resident's MAR (Medication Administration Record) to check the wonder guard shiftily and during report he/she was notified that the resident had a wander guard, but he/she had not had a chance to check it that night. During an interview on 09/19/2025 at 10:04 A.M. the DON (Director of Nursing) said no new measures to prevent the resident from eloping again had been put into place on the care plan after the resident eloped on 09/13/2025. The residents care plan should have been updated regarding the resident's new exit seeking behaviors. During an interview on 09/19/2025 at 10:41 A.M. the MDS (Minimum Data Set) Coordinator said:-The care plan was not updated after the resident eloped on 09/13/2025 and should have been;-The charge nurse on duty during the event was responsible for updating the care plan when an elopement occurs.

Based on observation and interviews, the facility failed to ensure they maintained a safe, clean, comfortable environment for the residents, when staff failed to keep all areas of the facility clean and free from mold-like substance throughout areas in the building. The facility census was 46. No policy regarding housekeeping or maintaining the environment was provided. Observation of the facility on 9/10/24 at 6:30 A.M. showed a strong, damp and musty (having a stale, moldy or damp smell) smell outside of a resident room [ROOM NUMBER]. Observation of the facility on 9/10/24 at 11:45 A.M. showed a black, mold-like substance on the outside of the air return vents above the nurse's station on the 300 hall; above the kitchenette on the ceiling of the closed wing; on the return air vents in the kitchen area on the 300 hall; and on the ceiling tile behind kitchen freezer in dry storeroom. Observation of the facility on 9/10/24 at 11:50 A.M. showed there was a strong, damp and musty smell in the dining room adjacent to nursing station number three. Observation of the facility on 9/10/24 at 12:00 P.M. showed a black, mold-like substance was found on the heating/cooling unit in the activity room between the nurse's station's two and three; on the heating/cooling unit between the nurse's stations two and three; and heating/cooling unit in occupied resident rooms #208, #311, #307 , and # 213. Observation of the facility on 9/10/24 at 12:04 P.M. showed a black, mold-like substance was found on the floor against the wall next to nightstand in resident room [ROOM NUMBER] and on the ceiling tile in an unoccupied room [ROOM NUMBER]. During an interview on 9/10/24 at 5:45 A.M., the administrator said she was not aware of any mold but there has been leaks in the roof for sometime and the board approved a new roof to be installed. During an interview on 9/10/24 at 1:00 P.M., CMT 2 said he/she had not noticed mold, but does not look for it. During an interview on 9/10/24 at 1:05 P.M., CMT 1 said he/she has not noticed mold and is not in the habit of looking for mold. During an interview on 9/10/24 at 1:15 P.M., housekeeper 1 said there is no policy that includes mold mitigation or training for staff on the prevention of mold. MO241310

Based on observation, record review, and staff interview, the facility failed to ensure resident were appropriately assessed and had documentation to support the use of wander guards for two of two residents (Residents (R) 34 and R12) reviewed for wander guards of 16 sample residents. This failure could result in residents with unwarranted use of wander guards. Findings include: During an interview on 07/25/24 at 2:45 PM, the Director of Nursing (DON) stated the facility did not have a policy related to wander guard use. 1. Review of R34's Resident Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R34 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R34's quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 06/09/24 revealed R34 had short-term and long-term memory problems with cognitive skills for daily decision making rated as severely impaired. Further review of the MDS revealed R34 had not exhibited physical, verbal, or other behavioral symptoms not directed toward others and had not exhibited wandering. The resident was marked as having a wander guard. Review of R34's Care Plan located under the Care Plan tab of the EMR, last revised 06/21/24, revealed a problem category Cognitive Loss/Dementia related to wandering and risk for elopement. Interventions included to equip the resident with a device that alarms when resident wanders and to check for proper functioning of device every shift. Review of R34's Active Orders located under the Orders tab in the EMR, dated 02/08/24, revealed an open-ended order for Wander Guard Special Instructions: Place wander guard on res [resident] d/t [due to] elopement risk. Review of R34's Observations located under the Observations tab in the EMR, from 12/09/22 to 07/24/24, revealed no assessments for elopement risk. Review of R34's Progress Notes located under the Progress Notes tab in the EMR, from 08/22/23 to 07/24/24, revealed no assessments for elopement risk or notes indicating R34 exhibited wandering or elopement behaviors. During an observation on 07/24/24 at 10:37 AM, R34 was observed quietly sitting in a recliner in his room and eating a breakfast bar. R34 smiled pleasantly and appeared in no acute distress. During an observation on 07/24/24 at 11:50 AM, R34 was observed ambulating down the hall to the main dining room, assisted by a male staff member. R34 appeared calm and compliant with going to the dining room. During an observation on 07/24/24 at 1:00 PM, R34 was observed ambulating down the hall from the main dining room back toward his room, assisted by a female staff member. R34 appeared calm and compliant with following staff direction/redirection. During an interview on 07/24/24 at 11:58 AM, the Infection Preventionist (IP) stated the elopement evaluations were located under the Observations tab in the EMR. She stated that was the only place so if there were no elopement evaluations there then there was not one done. During an interview on 07/23/24 at 2:00 PM the MDS Coordinator (MDSC) stated R34 previously lived at the assisted living and had wandered across the street in the middle of the night. It was decided R34 needed to be moved to the nursing facility and the wander guard was placed. The MDS nurse stated R34 had the wander guard in place since admission because of that incident. During an interview on 07/23/24 at 2:30 PM, Licensed Practical Nurse (LPN) 2 stated R34 did not exit seek. During an interview on 07/23/24 at 2:33 PM, Certified Medication Technician (CMT) 3 stated R34 did not exit seek or leave his room. During an interview on 07/23/24 at 2:38 PM, Certified Nurse Aide (CNA) 1 stated R34 did not wander, or exit seek. 2. Review of R12's Resident Face Sheet located in the Face Sheet tab of the EMR revealed R12 was admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R12's quarterly MDS located in the MDS tab of the EMR, with an ARD of 06/18/24 revealed R12 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident had severe cognitive impairment. Further review revealed no physical, verbal, or other behavioral symptoms not directed toward others and no presence of wandering. The was marked as having a wander guard. Review of R12's Care Plan located under the Care Plan tab of the EMR, last revised 07/07/24 revealed a problem category Behavioral Symptoms related to R12 wandering and attempting to go outside unsupervised in the past. Interventions included to equip the resident with a device that alarms when resident wanders and to check for proper functioning of device every shift. Review of R12's Active Orders located under the Orders tab in the EMR, dated 03/11/24, revealed an open-ended order for Wander Guard Check Special Instructions: Ensure wander guard is in place, skin is intact surrounding wander guard, check function of wander guard with tool provided in treatment cart. Review of R12's Observations located under the Observations tab in the EMR, from 11/30/22 to 07/24/24, revealed no assessments for elopement risk. Review of R12's Progress Notes located under the Progress Notes tab in the EMR, from 03/01/24 to 07/24/24, revealed no assessments for elopement risk. Review revealed a note dated 03/08/24, indicating R12 attempted to leave the facility by following a visitor out the front door and stated, get me out of here. During an observation on 07/24/24 at 10:10 AM, R12 was observed sitting quietly in her room in no apparent distress. During an observation on 07/24/24 at 11:50 AM, staff were observed assisting R12 to the dining room in her wheelchair. R12 appeared calm and in good spirits. During observation on 07/24/24 at 3:37 PM, R12 was observed sitting calmly in her wheelchair in front of the nurse's station. During an interview on 07/25/24 at 3:30 PM, LPN 1 stated R12 did not exit seek or wander any longer since R12 has been in a wheelchair. During an interview on 07/25/24 at 3:36 PM, CNA2 stated the resident did not exit seek or wander any longer since R12 has been in a wheelchair. During an interview on 07/25/24 at 3:45 PM, CMT2 indicated resident did not exit seek or wander any longer since R12 has been in a wheelchair. She estimated R12 has been in a wheelchair a little over a month ago. The facility census was 46. During an interview on 07/25/24 at 11:47 AM, the Rehabilitation Director stated the rehabilitation staff did not conduct evaluations for wander guard use. During an interview on 07/24/24 at 1:05 PM, the DON stated the facility did not have a formal evaluation for elopement risk or wander guard use. She stated for R34 specifically, the wander guard was placed because R34 had eloped when R34 resided at the assisted living. The DON stated the facility received an Immediate Jeopardy (IJ) for the elopement and it was decided R34 would be safer in long term care with the wander guard. The DON stated the residents with wander guards have them because they either had an elopement, near elopement, or were exit seeking. When asked again about a formal evaluation for elopement she stated they only looked at behaviors. When asked if R34 had behavior monitoring, she stated R34 did not have behavior monitoring because R34 did not exhibit behaviors. The DON stated the wander guard order for R34 was renewed on 02/08/24 because the facility had received an IJ for the elopement before R34 admitted to long term care, and they felt it was best R34 remain with the wander guard. During an interview on 07/25/24 at 5:22 PM, the Administrator stated the facility placed the wander guard on R34 because the facility received an IJ for the elopement incident.

Based on observation, interview, record review, facility policy review, and review of manufacturer's instructions, the facility failed to provide respiratory care in accordance with professional standards for two of two residents (Residents (R) 3 and R99) reviewed for respiratory care out of 16 sample residents. This failure has the potential for the residents to be subjected to contaminated respiratory equipment and to not receive proper airflow. The facility census was 46. Findings include: Review of the facility's policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, dated 11/11, documented: .8. Keep oxygen cannula and tubing used as needed (PRN) in a plastic bag when not in use. 9. Wash filters from oxygen concentrators every seven (7) days with soap and water. Rinse and squeeze dry. Review of the undated Maintenance instruction sheet, provided by the facility, revealed remove the filter and clean at least once a week depending on environmental conditions. 1. Review of R3's Admission Record located under the Resident tab of the electronic medical record (EMR), revealed R3 was admitted on [DATE] with diagnoses of unspecified dementia, nasal congestion, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of R3's significant change Minimum Data Set (MDS), dated [DATE] and located in the EMR under the MDS tab, revealed R3 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R3 had severe cognitive impairment. Review of R3's Physician Orders Sheet, located in the EMR under the Orders tab, revealed the following order, dated 07/03/24, oxygen - apply per nasal cannula PRN if oxygen saturation (O2) sats less than 90 %. May titrate as needed. Review of R3's Care Plan, dated 04/24/24 and located in the EMR under the Care Plan tab, revealed the following: At risk for decreased cardiac output related to (R/T) chronic diastolic congestive heart failure (CHF). Interventions included the following, monitor O2 saturation as needed. The care plan and interventions did not include the use of oxygen for R3. During an observation on 07/22/24 at 10:27 AM, the nasal cannula was on the floor beside the resident's bed. During an observation on 07/22/24 at 11:05 AM, the oxygen tubing and cannula were on the floor beside the resident's bed. During an observation on 07/23/24 at 8:18 AM, the date on the tubing indicated it was changed on 07/16/24. The resident was using oxygen at this time. During an interview on 07/23/24 at 12:25 PM, Registered Nurse (RN) 1 verified R3's nasal cannula and tubing and stated it should not have been on the floor. During an interview on 07/23/24 at 12:27 PM, the Director of Nursing (DON) stated oxygen tubing and cannulas should not have been on the floor. The DON stated they should have been stored in a plastic bag when not in use. 2. Review of R99's Admission Record, located under the Resident tab of the EMR, revealed R99 was admitted [DATE] with diagnoses of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure and hypertension. Review of R99's admission MDS located in the EMR under the MDS tab, dated 06/24/24, revealed the resident had a BIMS of 11 out of 15, indicating R99 had moderately impaired cognition. Review of R99's Physician Orders Sheet, located in the EMR under the Orders tab, revealed the following order, dated 06/19/24: apply oxygen 1-5 liters as needed. Review of R99's Care Plan located in the EMR under the Care Plan tab, dated 06/21/24, did not address R99 being on oxygen therapy. During an observation on 07/22/24 at 9:55 AM, R99 had a dirty oxygen filter covered with white dust, and the oxygen tubing and cannula were on the floor. During an observation on 07/22/24 at 12:35 PM, the oxygen tubing was still on the floor, and the oxygen filter was still covered with thick white dust. During an observation on 07/23/24 at 8:11 AM, the oxygen filter was still covered with a thick white dust. During an observation on 07/23/24 at 12:07 PM, the oxygen tubing and cannula were on the floor and the filter still was covered with a build-up of white dust. During an interview on 07/23/24 at 12:22 PM, RN1 verified R99's oxygen concentrator tubing was on the floor and, the oxygen filter was covered with white dust. RN1 stated she thought the filters were supposed to be cleaned weekly when the oxygen tubing was changed. During an interview on 07/23/24 at 12:27 PM, the DON stated the oxygen concentrator filters should have been cleaned monthly on the night shift. During an interview on 07/23/24 at 1:05 PM, the DON verified the filters should have been cleaned weekly during the tubing change. The DON provided manufacturer guidelines for cleaning and maintenance.

40902 Based on observation, interview, record review, and facility policy review, the facility failed to ensure nursing staff properly stored nebulizer masks when not in use for two of two residents (Resident (R) 35 and R7) reviewed for nebulizers and ensure proper wound care procedures for one of one resident (R99) reviewed for wound care of 16 sample residents. This failure had the potential to contribute to the potential of contamination and spread of infection. The facility census was 46. Findings include: Review of the facility's policy titled, Wound Care, dated 10/10, under the Steps in Procedure section revealed, 1. Use disposable cloth (paper towel is adequate) to establish clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Arrange the supplies so they can be easily reached .3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 1. Review of R35's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and with diagnosis of paroxysmal atrial fibrillation. Review of R35's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 06/22/24 revealed the Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated severe cognitive impairment. During observations on 07/23/24 at 12:30 PM and on 07/24/24 at 12:05 PM, the resident's nebulizer machine and mask were lying on top of paper towels by the sink in the resident's room, uncovered. 2. Review of R7's Admission Record located in the Profile tab of the EMR revealed admission to the facility on [DATE] and with diagnosis of mild intermittent asthma. Review of R7's quarterly MDS under the MDS tab of the EMR with an ARD of 04/08/24 revealed the BIMS could not be completed due to resident rarely being understood. During observations on 07/23/24 at 12:30 PM and on 07/24/24 at 12:05 PM, the resident's nebulizer machine and mask were lying on top of paper towels by the sink and top of dresser by the resident's bed uncovered. During an interview on 07/24/24 at 12:08 PM, Registered Nurse (RN) 1 verified that both residents nebulizer masks were uncovered and not stored properly. RN1 stated nebulizer masks should not be left and they should be covered in a plastic bag. She stated the Certified Medication Technician (CMT) administered the nebulizer treatments, and they were responsible for storing them properly between use. During an interview on 07/24/24 at 3:55 PM, CMT4 stated after she finished administering a nebulizer treatment to a resident she was supposed to wash it, place it on a towel to dry, and place another paper towel over while it was drying. She stated she only tried to leave it to dry for about 15 minutes, but sometimes she forgot to go back. She stated she was just informed today that they should be storing the masks inside a plastic bag and that she did not know that before. During an interview on 07/25/24 at 12:59 PM, the Director of Nursing (DON) stated the nebulizer masks were supposed to be stored in clear plastic bags to keep them from getting dirt or debris on the mask and contain anything the resident had left on the mask. 3. Review of R99's Face Sheet, located under the Resident Tab of the EMR revealed admission to the facility on [DATE] with diagnoses including anxiety disorder, unspecified, acute on chronic combined systolic and diastolic congestive heart failure, and chronic kidney disease, stage three. Review of R99's admission MDS with an ARD of 06/24/24 located under the MDS tab in the EMR revealed a BIMS of 11 out of 15 indicating moderate cognitive impairment. Review of R99's Orders located under the Resident tab of the EMR revealed a physician order, dated 07/02/24,cleanse upper right coccyx wound with normal saline (NS) wound cleanser, apply Xeroform gauze, cover with four-by-four Mepilex and sacral Mepilex once a day. Review of R99's Orders located under the Resident tab in the EMR revealed a physician order, dated 07/03/24, cleanse skin tear to inner areas of right lower extremity (RLE) et left lower extremity (LLE) inner calf with NS wound cleanser, pat dry, cover with Xeroform gauze, cover with supper absorbent dressing, secure with gauze wrap and Coban. Review of R99's Care plan, dated 07/05/24 and located under the Care plan tab in the EMR, revealed I entered the facility with 2 skin tears. one on my right calf and one on my right shin, and a stage one pressure ulcer on my gluteal fold. Interventions in the care plan included monitor and report signs of localized infection, such as localized swelling, redness, pain or tenderness, heat at the infected area, purulent drainage, [or] loss of function. During an observation on 07/24/24 at 10:45 AM, Licensed Practical Nurse (LPN)3 provided wound care to R99. LPN3 placed wound care supplies on the floor. The supplies placed on the floor included: Kerlix, four-by-four gauze pads, wound cleanser, Xeroform dressing, Coban, and scissors. The wound on the right leg was cleansed and covered with a small piece of Xeroform, Kerlix gauze, and Coban. The same procedure and supplies were used on the left leg. A protective barrier was not placed under R99's left heel. LPN3 cleansed the heel wound with wound cleanser, and R99 placed her bare foot on the floor. A protective barrier was not placed under R99's feet. At 11:02 AM, LPN3 placed her scissors on the floor. At 11:07 AM, LPN3 used the scissors to cut a piece of Xeroform dressing and then placed the scissors in a Ziplock bag with unused wound care supplies. LPN3 also placed the Xeroform dressing back in the Ziplock bag. During an observation on 07/24/24 at 11:09 AM, LPN3 placed all wound care supplies in the treatment cart. During an interview on 07/24/24 at 11:10 AM, LPN3 stated she should have placed a protective barrier on the ground under her supplies and under R99's feet. LPN3 stated her scissors should have been cleansed after being on the floor and prior to using them again. LPN3 stated the wound care supplies should not have been placed back in the treatment cart after they were placed on the floor. LPN3 stated she needed to throw away the opened Xeroform dressing that she returned to the treatment cart. During an interview on 07/24/24 1:37 PM, the DON stated nurses should have gathered the wound care supplies, introduced themselves to the resident, washed their hands prior to beginning the treatment, and placed a protective barrier under the supplies and under the resident. The DON stated wound care supplies should never be placed on the floor, dirty supplies should not be placed in a bag with clean supplies, and any contaminated items should not be placed back in the treatment cart.

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to complete a significant change assessment after a resident was started on hospice services for one of two residents (Resident (R) 7) reviewed for hospice of 16 sample residents. This has the potential to affect all residents with a Minimum Data Set (MDS) assessment ensuring proper care and services. The facility census was 46. Findings include: Review of the undated Minimum Data Set Resident Assessment Instrument (RAI) revealed Guidelines for determining the need for an SCSA [significant change in status assessment] for residents with terminal conditions. The key in determining if an SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected well-defined part of the disease course and is consequently being addressed as part of the overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration, an SCSA assessment is required. Similarly, if the resident enrolls in a hospice (Medicare Hospice program or other structured hospice program), but remains a resident at the facility, an SCSA should be performed if the terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration. The facility is responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. Review of R7's Admission Record located in the Profile tab of the electronic medical record (EMR), revealed re-admission to the facility on [DATE] and with diagnosis of mild intermittent asthma. Review of R7's quarterly MDS under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 04/08/24, revealed the Brief Interview for Mental Status (BIMS) could not be completed due to resident rarely being understood. Review of R7's Physician Orders located under the Orders tab of the EMR, dated 07/09/24, revealed an order for hospice. During an interview on 07/25/24 at 11:16 AM, the MDS coordinator (MDSC) stated she was new to the position and has only been doing this for two weeks. She stated a significant change assessment needed to be completed anytime someone went on hospice. She stated she found out on the 11th during a care plan meeting that R7 went onto hospice, and there was a quarterly assessment open, so she was confused if a significant change assessment needed to be completed. During an interview on 07/25/24 at 12:59 PM, the Director of Nursing (DON) stated R7's wife spoke with the provider directly and requested the resident be placed on hospice. She agreed the facility became aware on the 11th and that a significant change assessment should have been completed.

Based on record review and interview, the facility failed to develop and implement a care plan for a resident receiving hospice services for one of two residents (Resident (R) 7) reviewed for hospice services of 16 sample residents. This has the potential to affect all residents receiving hospice services. The facility census was 46. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised March 2023, revealed the comprehensive, person-centered care plan was developed within seven days of the required MDS [Minimum Data Set] assessment. Review of R7's Admission Record located in the Profile tab of the electronic medical record (EMR), revealed re-admission to the facility on [DATE] and with diagnosis of mild intermittent asthma. Review of R7's quarterly MDS under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 04/08/24, revealed the Brief Interview for Mental Status (BIMS) could not be completed due to resident rarely being understood. Review of R7's care plan located under the ''Care Plan'' tab of the EMR and dated 04/10/24, revealed the resident was not care planned for hospice services. Review of R7's Physician Orders located under the Orders tab of the EMR, dated 07/09/24, revealed an order for hospice. During an interview on 07/25/24 at 11:16 AM the MDS coordinator (MDSC) stated she was new to the position and there were two residents who went on hospice. She stated she must have care planned the other resident and forgot to implement R7's care plan for hospice, but it should have been done. She stated it was important to care plan it so that staff were aware he was hospice and did not require any medical treatment if he got sick. During an interview on 07/25/24 at 12:59 PM, the Director of Nursing (DON) stated R7's wife spoke with the provider directly and requested the resident be placed on hospice. But agreed the facility became aware on the 11th and that hospice should have been implemented on the care plan.

Based on record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for one of two residents (Resident (R) 22 and R37) reviewed for side rails of 16 sample residents. The lack of alternative side rail measures could lead to potential restraint or side rail entrapment. The facility census was 46. Findings include: 1. Review of R22's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed re-admission to the facility on [DATE] with a diagnosis of muscle weakness. Review of R22's annual Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 04/21/24 revealed a Brief Interview for Mental Status (BIMS) score could not be completed due to the resident rarely understood. Review of R22's care plan located under the ''Care Plan'' tab of the EMR and dated 07/08/22, revealed ''The resident had 1/2 side rails on bed for bed mobility. Review of R22's Physician Orders located under the Orders tab of the EMR, dated 06/29/23, revealed an order for side rails. Review of R22's Side Rail Assessment located under the Observations tab of the EMR, dated 06/16/24, revealed no documentation of alternative measures. Further review revealed only risk and benefits and consent were obtained. 2. Review of R37's Admission Record located in the Profile tab of the EMR revealed re-admission to the facility on [DATE] with a diagnosis of chronic kidney disease. Review of R37's quarterly MDS under the MDS tab of the EMR with an ARD of 05/03/24 revealed the BIMS indicated a score of two of 15 which indicated severe cognitive impairment. Review of R37's care plan located under the ''Care Plan'' tab of the EMR and dated 02/02/23, revealed ''The resident had 1/2 side rails on bed for bed mobility. Further review revealed the resident requested the use of side rails as a fall prevention. Review of R37's Physician Orders located under the Orders tab of the EMR, dated 02/01/23, revealed an order for side rails. Review of R37's Side rail Assessment located under the Observations tab of the EMR, dated 05/01/24, revealed no documentation of alternative measures. Further review revealed only risk and benefits and consent were obtained. During an interview on 07/25/24 at 11:16 AM, the MDS coordinator (MDSC) stated if they identified that a resident would benefit from side rails they would have therapy evaluate the resident and if they decided to go forward they would get a physician order. She stated they would have a side rail assessment completed. But she said she was not aware that staff had to look at alternatives and document those attempts prior to using bedrails for a resident. She stated they were assessing for entrapment, and they had documentation for that. During an interview on 07/24/24 at 5:00 PM, the Administrator stated she was unaware that alternatives had to be attempted prior to installing bedrails and asked what type of alternates could be tried. During an interview on 07/25/24 at 12:59 PM, the Director of Nursing (DON) stated she was unaware staff needed to explore alternatives. She stated she knew to use the least restrictive but did not know about the alternatives. She stated she did not know what to do when a family or resident requested or insisted on having bedrails.

Based on record review, interview, and facility policy review, the facility failed to ensure residents received the correct medication as ordered by the physician for two of eight residents (Resident (R) 20 and R38) reviewed for medications of 16 sample residents. This failure could result in unwarranted medication side effects and mismanaged medical conditions. The facility census was 46. Findings include: Review of the facility's policy titled, Administering Medications, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. 1. Review of R20's Resident Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R20 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure and essential (primary) hypertension. Review of R20's quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 05/28/24, revealed R20 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated the resident had severe cognitive impairment. Review of R20's Care Plan located under the Care Plan tab of the EMR, last revised 06/19/24, revealed a problem category ADLs [activities of daily living] Functional Status/Rehabilitation Potential related to a diagnosis of hypertension. However, this problem category did not include any specific intervention related to medication administration. Review of an Event Report, dated 03/22/24 and provided by the facility, revealed a hospital discharge order for R20 for metoprolol succinate [blood pressure medication] 25 mg [milligrams] 24 hr [hour] tablet, Take 3 tablets (75 mg total) by mouth daily. Review of the Event Report indicated an order for metoprolol tartrate 25 mg (75 mg) Administer 3 tablets twice daily was entered in error. The Type of Error was checked off as Incorrect Dose, Incorrect Medication, and Incorrect Time. Review of R20's Order located under the Orders tab in the EMR, revealed an order with a start date of 03/19/24 and a discontinue date of 03/22/24 for metoprolol tartrate 75 mg twice a day. Review of R20's Medication Administration Record (MAR), dated 03/24 and located under the Reports tab in the EMR, revealed R20 received four days of metoprolol tartrate 75 mg twice daily. During an interview on 07/25/24 at 1:21 PM the Director of Nursing (DON) stated she entered the metoprolol succinate order incorrectly and, as a result, R20 received at least three days of twice daily dosing of metoprolol tartrate instead of once daily of the tartrate. 2. Review of R38's Admission Record, located in the Profile tab of the EMR revealed re-admission to the facility on [DATE] with a diagnosis of muscle Parkinson's. Review of R38's quarterly MDS under the MDS tab of the EMR, with an ARD of 06/12/24, revealed the BIMS score of 13 out of 15 which indicated the resident had intact cognition. Review of R38's care plan located under the ''Care Plan'' tab of the EMR and dated 02/04/23, revealed ''The resident had a diagnosis of Parkinson's disease. Review of R38's Progress Note located under the Progress Notes tab of the EMR, dated 05/17/24, written by Registered Nurse (RN) 2, revealed received order to decrease from two tablets to 1.5 tablets QID [four times a day] for carbidopa-levodopa. Review of R38's Physician Order Clarification located under the Documents tab of the EMR, dated 06/11/24, revealed on 05/17/24 that resident's carbidopa-levodopa was decreased from 2 tablets to 1.5 QID but the order was entered wrong and has only been given TID. Review of R38's Medication Administration Record (MAR) located under the Reports tab of the EMR, dated 05/16/24 through 06/17/24, revealed R38 received 1.5 tablets of carbidopa-levodopa three times daily between 05/17/24-06/12/24. During an interview on 07/25/24 at 10:23 AM, RN2 stated when staff received a verbal order, they wrote the order down in their fax orders binder, faxed it to the pharmacy, made a progress note, entered the order in computer and notified the family. RN2 stated she could not recall the progress note she wrote on 05/17/24, but she did remember something about the ear but nothing else. She stated she must have just missed that one piece of the order and did not enter it correctly, but she was not sure what happened. During an interview on 07/25/24 at 12:59 PM, the Director of Nursing (DON) stated they identified an issue with nursing staff taking phone orders which has led to these types of situations where orders were not put into the EMR accurately. She stated their process was a two-step process that required two nurses to sign off for accuracy. The DON stated staff were just taking the orders verbally and putting them directly into the EMR which omitted the 2nd check. She stated she expected staff to input orders accurately and follow them. 40902

Based on record review, interview, and facility policy review, the facility failed to ensure there was documented rationale and a stop date for a PRN (as needed) psychotropic medication for one of eight residents (Resident (R) 12) reviewed for medications of 16 sample residents. This failure has the potential to lead to unwarranted medication side effects. The facility census was 46. Findings include: Review of the facility's policy titled, Psychotropic Medication Use, dated July 2022, revealed PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Review of R12's Resident Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R12 was admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R12's quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 06/18/24, revealed R12 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident had severe cognitive impairment. Further review revealed no physical, verbal or other behavioral symptoms directed toward others. Review of R12's Care Plan located under the Care Plan tab of the EMR, last revised 07/07/24, revealed a problem category Psychotropic Drug Use related to antianxiety medication with interventions which included Attempt a gradual dose reduction as needed and ordered by PCP [primary care physician] .monitor for drug use effectiveness and adverse consequences, and pharmacy consultant review as needed and appropriate. Review of R12's Orders located under the Orders tab in the EMR, revealed an order for lorazepam (anti-anxiety medication) tablet 0.5 mg (milligrams) give one tablet by mouth twice daily as needed for anxiety. The order indicated it was started on 03/11/24 and discontinued on 06/07/24. Review of R12's March 2024, April 2024, May 2024, and June 2024 Medication Administration Record (MAR) revealed the lorazepam 0.5 mg give one tablet by mouth twice daily as needed for anxiety order remained active from 03/11/24 to the discontinuation date of 06/07/24. Review of R12's Progress Notes located under the Progress Notes tab in the EMR, revealed three notes by the clinical pharmacist referencing the pharmacy consultation requesting a review and resolution to the lorazepam order, specifically requesting to discontinue or continue the order with justification and a duration of use. The first note was dated 03/24/24, the second follow up note was dated 04/25/24, and the third follow up note was dated 05/21/24. Review of R12's pharmacy consultations revealed a note titled Note to Attending Physician/Prescriber, dated 3/26/24, notifying the prescriber of the lorazepam PRN order and the 14-day limit, with a request to either discontinue the order or extend the order with clinical rationale for a specified duration of use. The prescriber responded on 04/02/24 to continue the lorazepam PRN order but did not provide a rationale or duration of use. During an interview on 07/25/24 at 1:08 PM the Director of Nursing (DON) stated she recalled the issue with R12's lorazepam order. She stated the prescriber insisted on continuing the order. The staff was using the medication to help with giving R12 showers due to R12 becoming combative. The DON stated she asked if the physician would consider changing the order to give 30 minutes before showers, but it was denied. The DON stated during the three months where the PRN order was still in place; the facility was going back and forth with the prescriber trying to have the prescriber document justification and provide a stop date for the order. During an interview on 07/25/24 at 2:07 PM, the consulting Pharmacist stated she had conducted a review for R12 in March and again in May addressing the PRN lorazepam order. She stated the prescriber had not provided a rationale or end date to continue the PRN order.

Based on interviews, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R) 99) was free from significant medication errors when the facility administered R99 someone else's medication, out of 16 sample residents. This medication error had the potential to cause R99 to become hypotensive (low blood pressure). The facility census was 46. Findings include: Review of the facility's policy titled Administering Medications, dated 04/19, revealed Medications are administered in a safe and timely manner, and as prescribed .9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (a) checking identification band; (b) checking photograph attached to medical record; and (c) if necessary, verifying resident identification with other facility personnel. Review of a professional reference titled Hypotension, dated 02/19/23 and retrieved from www.ncbi.nlm.nih.gov, revealed hypotension is classified based on the biometric parameters of the blood pressure measurement. It may be absolute with changes in systolic blood pressure to less than 90 millimeters of mercury (mm Hg) or mean arterial pressure less than 65 mm Hg. It may be relative to a decrease in diastolic blood pressure to less than 40 mm Hg. Review of R99's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed admission to the facility on [DATE] with diagnoses including anxiety disorder, unspecified, acute on chronic combined systolic and diastolic congestive heart failure, and chronic kidney disease, stage three. Review of R99's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/24 located under the Resident tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderately impaired cognition. Review of the facility's Event Report located in the EMR under the Resident tab, dated 06/24/24 and time stamped at 8:40 AM, revealed R99 received Amlodipine 5 mg (medication used to treat high blood pressure), Atorvastatin 20 mg (medication used to treat high cholesterol), Hydralazine 50 mg (medication used to treat high blood pressure), Lisinopril 20 mg (medication used to treat high blood pressure and heart failure), Metoprolol 200 mg (a medication used to treat high blood pressure), Omeprazole 20 mg (medication used to treat gastroesophageal reflux disease), and Vitamin D3 125 mcg (supplement used to help the body absorb calcium and phosphorus). R99's blood pressure at 7:59 AM was 110/58. The event report revealed R99 was given another resident's medications during AM med pass. Review of R99's Orders located under the Resident tab of the EMR, revealed a physician order, dated 06/24/24, for lisinopril tablet 2.5 mg; 1 tab, hold if systolic blood pressure (SBP) less than 90 once a day, and metoprolol tartrate tablet; 100 mg, 1 tab, hold if SBP less than 90 and heart rate (HR) less than 50. Review of R99's vital signs report located under the Resident tab of the EMR, revealed the following blood pressure readings: 06/24/2024 at 12:31 AM 120/90 06/24/2024 at 7:35 AM 114/75 06/24/2024 at 7:59 AM 110/58 Review of R99's blood pressure (BP) readings for 06/24/24, between 7:35 AM and 7:59 AM, revealed the systolic blood pressure dropped 15 mm of Hg and the diastolic blood pressure dropped 20 mm of Hg. Review of R99's After Visit Summary (AVS) from [Name] Health System, dated 06/25/24, revealed R99 presented to [hospital name] ED [emergency department] on 06/24 with complaint of accidental medication ingestion. She resides at [Name] nursing home and was incorrectly given someone else's medications. She was given metoprolol 200 mg, lisinopril 20 mg, hydralazine 50 mg, and amlodipine 5 mg. She usually takes only metoprolol 100 mg and lisinopril 2.5 mg. In the ED she received a 500 ml fluid bolus. Work up in the ED revealed .BP 94/43. She was admitted to observation for further evaluation and treatment of hypotension secondary to medication. BP meds were held, and her hypotension resolved without further intervention. During an interview on 07/23/24 at 3:03 PM, the Director of Nursing (DON) stated R99 received R13's morning medications. She stated the medications were administered by a student nurse in the dining room. She stated R99 and R13 sat at the same table in the dining room, and the student nurse got the residents confused. The DON stated the Certified Medication Tech preceptor (CMT) 1 went over the medications with the student nurse and told her which resident needed the medications. The DON stated she was out of the building the day of the incident. The DON stated R99 became symptomatic quickly and was assessed by Registered Nurse (RN) 1. During an interview on 07/24/24 at 8:30 AM, RN1 stated she was notified within ten minutes of the incident regarding R99 receiving the wrong medications. RN1 stated she immediately assessed R99 and notified the physician. RN1 stated she checked R99's blood pressure again while waiting for a return call from the physician. RN1 stated R99's blood pressure was trending down, and she called the physician again. She stated new orders were received to send R99 to the hospital. She stated R99 was kept overnight for observation and received IV (intravenous) fluids. RN1 stated she also notified R99's son and the hospice agency. During an interview on 07/24/24 at 12:00 PM, the DON stated CMT1 was verbally counseled on the situation regarding the medication error.

Based on interview and record review, the facility staff failed follow their policy when they failed to immediately notify facility administration after one Certified Medication Technician made a sexually inappropriate comment to a resident (Resident #1). The facility census was 57. Review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, dated April 2021, showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. -The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone, including but not necessarily limited to: a. Facility staff 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated September 2022, showed: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 6/11/2023, showed: -The resident has the diagnoses of dementia with behaviors ( a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), diabetes mellitus type II (a chronic condition that affects the way the body processes blood sugar), anemia (a condition in which the blood doesn't have enough healthy red blood cells), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), psychotic disorder (a mental disorder characterized by a disconnection from reality). -The resident is alert and oriented to self. He/She rarely makes self understood and sometimes understands others. -A score of zero on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). A score of zero indicates severely impaired cognition. -The resident is totally dependent on facility staff for all activities of daily living, including bathing, dressing, and personal hygiene. Review of the facility investigation, dated 8/15/23, showed: -At 9:30 A.M. on 8/15/2023, Certified Nurses Assistant (CNA) A reported to the Director of Nursing (DON) at approximately 4:30 P.M. on 8/14/2023, CNA A was assisting Certified Medication Technician (CMT) A in changing the resident in the resident's room. As CMT A and CNA A rolled the resident to her side, he/she made a moaning sound. CMT A said to the resident Did you want to fuck me? CMT A and CNA A finished changing the resident and went on to assist other residents on the hall. At approximately 6:10 P.M., CNA A informed Licensed Practical Nurse (LPN) A, the charge nurse, of the comment CMT A made to the resident. -The DON suspended CMT A pending investigation. -When interviewed by the Administrator, CMT A said he/she did make the comment to the resident. He/She stated it was a joke of a dark variety but there was nothing behind it. During an interview on 8/16/2023 at 12:54 P.M., CNA A said: -He/She is an employee of the facility and has worked there for approximately 3 months. -At 4:30 P.M. on 8/15/2023, CNA A was assisting CMT A in changing the resident, in the resident's room. -CNA A and CMT A used the Hoyer lift to transfer the resident from the Broda chair to the bed. Then they rolled the resident to his/her side, and the resident made a moaning sound. -CMT A then bent down to look the resident in the face and said did you say fuck? Do you want to fuck me? -CNA A and CMT A completed cleaning up the resident and went on to assist other resident's on the hall. -At the end of the shift, at approximately 6:10 P.M., CNA A informed the charge nurse, LPN A, of the comment made to the resident by CMT A. LPN A instructed CNA A to inform the DON the next morning of the incident. -CNA A did not inform LPN A or the DON immediately of the comment because he/she did not think it was abuse, just a stupid comment. -He/She has received training about abuse and neglect, and when to report abuse. -He/She knows now he/she should have reported the comment immediately to the charge nurse or DON. -CNA A has not experienced any other issues with CMT A. During an interview on 8/16/2023 at 1:02 P.M., LPN A said: -He/She is an employee of the facility and has worked there for seven years. -He/She was working as the charge nurse on the resident's hall during the day shift, 6:00 A.M. to 6:30 P.M. on 8/14/2023. -CNA A informed LPN A at the end of the shift, approximately 6:15 P.M., about the comment CMT A made to the resident earlier in the shift. -LPN A told CNA A that the comment was highly inappropriate and to inform the DON the next morning. -He/She did not immediately think this was abuse and did not think it was a threat toward the resident. -LPN A has received education on abuse and neglect and when to report abuse, before and after this incident occurred. -He/She has never had an issue when working with CMT A. During an interview on 8/16/2023 at 2:15 P.M., the Administrator said: -It is his/her expectation that facility staff are able to recognize abuse toward residents and to report the allegations of abuse immediately to facility management . During an interview on 8/16/2023 at 2:50 P.M., the DON said: -It is his/her expectation that staff report incidents of abuse to the charge nurse on duty and facility management immediately. MO222960

Based on interview and record review, the facility failed to ensure staff immediately reported to the Department of Health and Senior Services (DHSS) and law enforcement any and all allegations of abuse, neglect, exploitation or mistreatment. The facility failed to immediately report an allegation of sexual abuse for one resident (Resident #1). The facility census was 50. Review of the facility's policy, Abuse and Neglect, dated 11/30/22, showed: - Ensure the Administrator reports all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Department of Health & Senior Services and to local law enforcement if a suspected crime has occurred in accordance with State law through established procedures. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 3/23/23 showed: -Diagnoses of Alzheimer's disease, glaucoma (a disease that damages the eye's optic nerve), and blindness of one eye and low vision in other eye. -Severely impaired mental status with a Brief Interview for Mental Status (BIMS) score of 5. Review of the facility's internal investigation showed: -Statement from Certified Nurse Aide (CNA) A showed: -Resident #1 came to CNA A on 4/6/23 between 12:25 A.M.-12:30 A.M. and questioned why he/she had not been seen by the cops yet or examined because he/she was raped. CNA A inquired with Resident #1 when this had happened and by whom and Resident #1 responded 'it happened not too long ago and did not know by whom. Resident #1 also stated if he/she went to hospital now they could still find residue from the person. Resident #1 asked CNA A again why no police or nurse had come to talk to him/her or examined him/her. CNA A notified the Licensed Practical Nurse (LPN) of conversation with Resident #1 - Statement from LPN A showed: - He/she was notified by CNA A of the resident's statement at 12:25 A.M., went and completed a head to toe assessment. The resident was found calmly laying on bed under covers with breathing even and unlabored. LPN A asked Resident #1 if something had happened to him/her and he/she stated 'Someone came in and I was raped. LPN A asked Resident #1 if he/she knew whom had done this to him/her and he/she stated 'I have no idea.' LPN A asked the resident if it was dark or day light and Resident #1 stated 'it wasn't dark. O God, yes it was today.' Resident #1 was able to identify that he/she was at the facility but did not know what day or year it is. Resident #1 described the person who raped him/her as a man who did not choke him/her or hit him/her, but just had sex with him/her. LPN A requested permission to remove the resident's clothes and complete a head to toe skin assessment. Peri area was dry and intact. No bruising, swelling, redness, open areas, drainage, or discharge noted. Coccyx was dry and intact. No bruising, redness, swelling, drainage, or open areas noted. Resident #1 denied pain or discomfort. The Administrator was notified on 4/6/23 at 12:44 A.M. by LPN A; - Administrator investigation notes showed: -12:45 A.M. received call from LPN A; -12:50 A.M. to 1:20 A.M. reviewed medical record; -1:20 A.M. contacted the resident's daughter, Durable Power of Attorney (DPOA) for Health Care to Resident #1; during discussion DPOA in agreement due to the resident's diagnosis, recent delirium, current demeanor, and assessment, reported occurrence did not happen. Camera footage reviewed; -1:30 A.M. left message for primary care provider; -9:30 A.M. received call from nurse at primary care providers office; -9:39 A.M. faxed DHSS; -10:05 A.M. met with DPOA, no concerns; -11:35 A.M. met with Resident #1 completed brief trauma questionnaire; -11:42 A.M. spoke with DHSS to update; -12:29 P.M. spoke with DHSS to make sure faxes received; -12:35 P.M. reviewed reasoning and decision not to report within two hours. See 'Reporting Decision Tool: When to Report to State Agency and Law Enforcement' from [NAME] Coaching for Nursing Home Administrators. Reasoning included A. reasonably related to resident's condition the nurse's assessment with no evidence of recent sexual activity and recent delirium and agitation that is now not this event she was remembering did not invoke any agitation, fear, or anxiety and he/she went right back to sleep. B. It is not unexpected that he/she would have false memories given the recent false memory from 3/30/23. C. Reasonable cause to suspect showed nurse did not nor did the daughter. Conclusion was there was not an immediate need, the resident was safe. Called Regional office during business hours just to have it on file. - Progress notes in electronic medical record showed: - Administrator documented he/she received report at 2:11 A.M. from LPN A, reviewed Resident #1's chart, notified Resident#1's daughter. Daughter reported to administrator that there was no known history of allegations and if situation had occurred her mother would be very upset. Administrator followed up with LPN A who notified Administrator that Resident #1 had returned to sleep. Notes made by Administrator showed 'Given the account of the resident's demeanor during and after report, the resident's diagnosis and the results of the assessment completed by the nurse, the allegation does not appear to be substantiated. Will contact DHSS to report allegation and to speak to primary care provider. Review of the Missouri University ([NAME]) Reporting Decision Tool: When Do I Report to State Agency and Law Enforcement? Problem solving flowchart upon discovery of an incident/allegation dated October 2018 included the following: - The incident is suspected abuse, neglect, exploitation, or misappropriation. You need to immediately take action. This must be reported to the Abuse Hotline immediately and to Local Law Enforcement within TWO HOURS of SUSPICION. For example, (1) a resident tells you another resident hit them or sexually abused them; (2) a family member or visitor hit them or sexually abused them; or (3) a staff member hit them or sexually abused them; or that someone is taking advantage of them financially or you discover that money has been stolen or misappropriated. In addition, an injury of unknown origin that is suspicious in nature i.e., excessive or large bruising, skin tear(s), or broken bones would require immediate reporting to the State Agency (hotline) and Local Law Enforcement. Department of Health and Senior Services was notified on 4/6/23 at 9:45 A.M., nine hours after the initial allegation was made. During an interview on 4/7/23 at 12:30 P.M., the Administrator said: - She waited to report as she did not want to go through the Central Registry Unit (CRU) hotline and wanted to call the Regional office during business hours; - She used the reporting decision tool dated October 2018 titled: When do I report to state agency and law enforcement; - She reviewed facility camera footage and saw nothing; - She did not call law enforcement based on her conversation with the LPN on duty whom examined Resident #1; - She stated Resident #1's family did not want law enforcement called or Resident #1 sent to the hospital. During an interview on 4/7/23 at 1:23 P.M., Resident #1 said: - He/she feels safe in the facility and feels facility has good protection; - No one has ever come into his/her room to hurt him/her; - A man tried to rape him/her, it was dark, and it did not occur this past week but it has been longer than that; - He/she thinks rape occurred in nursing home in his/her room; - The rape was not very violent, as somebody got into bed with him/her and tried to have sex with him/her. During an interview on 4/7/23 at 3:35 P.M., the DPOA of Resident #1 said: - The facility reached out to him/her immediately about 1:30 A.M.; - He/she was not on board with sending Resident #1 to hospital; - He/she did not want law enforcement contacted. Complaint MO216595

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible, when the facility used portable electric heaters in resident use areas. The facility had one space heater plugged in and running in two separate shower rooms. Both of the heaters were placed beside a sink. There was a bottle of cleanser hanging above one of the space heaters. Review of the manufacturer's owner's manual showed: the heaters are hot when in use. To avoid burns, do not let bare skin touch hot surfaces. This heater is not intended for use the bathrooms, laundry areas, or other similar indoor locations. A heater has hot and arcing or sparking parts inside. Residents used the shower rooms unattended. Two confused and wandering residents (Resident #2 and #3) also had access to the shower rooms. The facility census was 52. The administrator was notified on 2/8/23 at 3:40 P.M. of an Immediate Jeopardy (IJ) which began on 2/8/23. The IJ was removed on 2/9/23 as confirmed by surveyor on-site. The facility did not provide a policy on use of space heaters. Review of the ProFusion manufacturer's owner's manual showed: the heaters are hot when in use. To avoid burns, do not let bare skin touch hot surfaces. Extreme caution and supervision are necessary when any heater is used near invalids and whenever the heater is left operating and unattended. This heater is not intended for use in bathrooms, laundry areas, or other similar indoor locations. A heater has hot and arcing or sparking parts inside. Do not use in areas where gasoline, paint or flammable liquids are used or stored. The output of this heater may vary and its temperature may become intense enough to burn exposed skin. Use of this heater is not recommended for persons with reduced sensitivity to heat or an inability to react to avoid burns. 1. Review of Resident #1's quarterly Minimum Data Set (a federally mandated assessment completed by facility staff) dated 1/21/23 showed: -Brief Interview of Mental Status (BIMS) of 13, indicating no cognitive impairment. -Limited assistance from staff for transfers, walking, dressing, toilet use, and personal hygiene. -Diagnosis of : stroke, Diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy) Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness or the inability to move and/or feel on one side of the body, making it hard to perform everyday activities like eating or dressing.) During an interview on 2/8/23 Resident #1 said: -Space heaters were used in the shower rooms because there was no heat in there. It was very uncomfortable to take a shower. The heaters have been in use for a few months, before Christmas. Observation of shower room [ROOM NUMBER] on 2/8/23 at 12:14 P.M. showed: -A ProFusion electric heater plugged in and running. -Heat set to high. -Fan set to high. -No staff were in the shower room. -The heater was sitting under the edge of the shower room sink. Observation of shower room [ROOM NUMBER] on 2/8/23 at 12:17 P.M. showed: -A ProFusion electric heater plugged in and running. -Heat set to high. -Fan set to high. -No staff in shower room. -The heater was sitting under the edge of the shower room sink, During an interview on 2/8/23 at 12:25 P.M., Certified Medication Technician (CMT) A said: - Someone came in and did construction work in the building and did not put heaters in shower rooms. - Shower aides turned on the space heaters. - There were three residents who used the bathroom in the shower rooms by themselves. - Space heaters have been used during cold snaps. During an interview on 2/8/23 at 12:30 P.M., Certified Nurse Aide (CNA) B said: - The shower rooms have not had heat since the new construction occurred a couple of months ago. - He/she was aware there were space heaters in the shower rooms. - He/She had not received any guidance on when to use the space heaters. During an interview on 2/8/23 at 2:25 P.M. CNA A said: -The space heaters have been in place since November or December, but he/she was unsure of the exact date. He/she turned the heaters on when he/she came to work to do baths at 5:30 A.M. There have been times when he/she came in at 5:30 A.M. and the heaters were on. There are residents with dementia (Resident's #2 and #3) that also wander who have access to the shower room and also used it for toileting. Review of Resident #2's quarterly MDS dated [DATE] showed: -BIMS of 5: indicating significant cognitive deficit. -Diagnosis of Alzheimer's Disease. -Walks independently. -Wanders. Review of Resident #3's quarterly MDS dated [DATE] showed: -BIMS of 3: indicating significant cognitive deficit. -Diagnosis of Alzheimer's Disease. -Walks independently. -Wanders. During an interview on 2/8/23 at 1:45 P.M. the Maintenance Director said: -He/she was unsure of the exact date that space heater use began, it was during a cold time after Christmas. -He/she notified the Administrator the heaters were in use. During an interview on 2/8/23 at 2:13 P.M., the Administrator said: -She was aware that heaters were in use as a temporary solution so pipes would not freeze. The contractor who completed the Heating Ventilation and Air Conditioning (HVAC) project did not put heating in the shower rooms, bathrooms or kitchen. The Maintenance Director notified her the heaters were in use after the first of the year. She told the Maintenance Director space heaters were not acceptable, but the HVAC contractor told her that was the only alternative. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level K Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO213181

Based on observation, interview and record review, the facility failed to keep one resident's (Resident #1) environment free from accident hazards and the resident free from injury, when facility staff failed to secure the resident in the facility van during a transport. The van driver slammed on the brakes and the resident, who was not secured, fell forward hitting his/her head resulting in multiple skin tears on both arms and legs, a fractured nose and fractured cervical spine which resulted in hospitalization . This had the potential to affect all residents who used the facility van for transportation. The facility census was 78. The administrator was notified on 5/9/19 at 3:45 P.M. of an Immediate Jeopardy (IJ) which began on 5/8/19. The IJ was removed on 5/8/19, as confirmed by surveyor onsite verification. Review of the undated facility policy for safe transportation showed: -It is the policy to protect resident health and safety when the facility is responsible for providing transportation, the agency promotes safe driving practices, with provisions for handling emergency situation; -Driving/transporting residents is an essential job function at the facility. Employees must be mindful that they are a representative of the facility while transporting residents either in personal or agency vehicles. If there are accurate complaints of employees committing driving infractions, they may be subject to disciplinary actions, including termination from employment; -All employees will follow procedures to ensure safe transportation, handling, and transfers of residents and any equipment used by residents when assisting with transportation. When the facility is responsible for transportation of the resident or their equipment, employees will utilize the following assistive techniques: Employees will provide assistance with seatbelts, as needed to ensure they are correctly fastened. When the vehicle is in motion, seatbelts are to be worn at all times by all passengers. Employees will comply with all seat belts instructions provided by the vehicle manufacturers. Employees will ensure all supplies or equipment, including wheelchairs and walkers or other mobility aides or specialized equipment used by the resident is properly secured before the vehicle is in motion. Review of the user instructions dated 8/15 for the QRT-1 series wheelchair restraints (the equipment used to secure a wheelchair to the van floor) showed: -Secure the wheelchair: place wheelchair facing forward in securement area; apply wheelchair locks or turn power off; attach tie-downs into floor anchorages and ensure they are locked in; attach the four tie-down hooks to solid frame members or weldments, near seat level; ensure all tie-downs are locked and properly tensioned; -Attach lap belt - use integrated stiffeners to feed belts through opening between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant; -Attach shoulder belt - extend shoulder belt over passenger's shoulder and across torso and fasten pin connector onto lap belt; -Ensure belts are adjusted as firmly as possible; -WARNING! - systems should only be used with forward facing wheelchairs. Review of the owners manual dated 9/14 for the Spitfire Scout scooter (scooter used by Resident #1) showed: -Under no circumstances should the scooter be used as a seat in a motor vehicle. 1. Review Resident #1's care plan for falls dated 11/1/18, showed: -At risk for falls related to decreased mobility; -Goal to have no injuries related to falls; -Assist with transfers as needed. If unsteady offer to assist. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 4/30/19, showed: -Alert and oriented with some confusion; -Independent with transfers and mobility; -Uses a wheelchair or scooter; -Limited assistance with dressing, bathing and personal hygiene; -[DIAGNOSES REDACTED]. -No history of falls; -Weight of 197 pounds. Review of the nurses' notes dated 5/8/19 at 2:28 P.M., signed by Licensed Practical Nurse (LPN) A showed: -Received call from primary care provider (PCP) who stated they would like to see the resident in the office as soon as possible. No transportation available at this time, PCP nurse stated they would speak with the PCP. Found transportation, called back to PCP and notified them that the facility would get the resident to the office as soon as possible. This nurse told the transportation aide to take the resident to the doctor's office. Review of the nurses' notes dated 5/8/19 at 3:02 P.M., signed by LPN A showed: -Received call from the transportation aide that the resident had fallen in the van and was bleeding from his/her head. The aide stated that he/she had called 911. Emergency Medical Services (EMS) arrived and picked the resident up and took him/her to the local hospital emergency department (ED). Review of the facility's internal investigation dated 5/8/19 at 3:20 P.M. showed: -Resident was injured during a transport. Driver braked the vehicle suddenly and the resident hit his/her head. The resident was not buckled in. The resident was being transported in the older van. The resident had a head injury. The ambulance was immediately called and the resident was transported to the hospital. Review of the EMS report dated 5/8/19 showed: -EMS responded to a call that an elderly person had fallen inside of a nursing home transport vehicle and was bleeding. Upon arrival, the transport van was parked on the side of the street. The driver approached the ambulance, visibly distressed, stating: He/she is not responding. Approached the passenger side of the transport van, there was no seat, just a step to enter the vehicle. The resident was laying on the ground in this area with his/her head bent forward such that his/her chin was touching his/her chest, and unable to extend backward due to being pinned against the dash under a fire extinguisher and the hand/rod used by the driver to open the passenger door. The driver stated that the resident had been sitting on a scooter that was loaded into the van just behind the first row seating. There did not appear to be any form of securing straps to secure the resident to the scooter. The resident was unresponsive, breathing slowly and impaired due to his/her positioning. The pulse oximeter displayed a heart rate of 109 and an oxygen level (SPO2) was unobtainable by the finger monitor. There was a laceration above the resident's nose that had been bleeding since the fall. There was no deformity or abnormalities to the neck, back or pelvis. The resident was put on a stretcher and taken to the local hospital. During an interview on 5/14/19 at 11:50 A.M. Emergency Services Technician (EMT) A said: -He/she responded to the 911 call on 5/8/19. Upon arriving at the seen, the van had a passenger door with no seat. The resident was on the floor in this area with his/her head pinned under the dash board by the fire extinguisher. His/her head was bent forward with his/her chin on his/her chest. The resident was non-responsive and breathing shallow. They could not get an oxygen reading from the pulse oximeter while he/she was in the van. Once he/she was on the stretcher and they were able to get an oxygen reading and the resident's pulse was stronger. He/she was told that a car pulled out in front of the van and the driver had to slam on the brakes to avoid hitting the car causing the resident to fall out of the scooter. He/she did not see a seatbelt by the scooter and he/she does not recall if the scooter was secured to the floor. Review of the ED notes dated 5/8/19 at 4:14 P.M. showed: -Resident #1 at the ED after he/she sustained force injury to his/her head and face. The resident apparently was sitting in his/her motorized wheelchair in a moving van that suddenly came to a halt. He/she was thrown forward and ended up somewhere in the front of the van next to the fire extinguisher. There was a reported loss of consciousness for several minutes. The resident has obvious signs of trauma to his/her periorbital (eye), nasal, facial region. There are lacerations present and large amounts of blood.; -The resident had numerous facial lacerations to the right corner of his/her eye, mid-forehead and nasal bridge. There were a total of 7 cm (centimeters) that had to be repaired.; -CT (computerized tomography - an x-ray that combines a series of images from different angles of the body and uses a computer to create images) of the head showed a nasal bone fracture; -CT of the neck showed fractures of C6 and C7 (the cervical spine located in the neck area). Review of the nurses' notes dated 5/8/19 at 7:24 P.M., signed by LPN A showed: -Spoke with ED nurse who stated the resident may get transferred to a hospital in the city for questionable neck fractures. During an interview on 5/9/19 at 11:00 A.M. the Administrator said: -Certified Medication Aide (CMT) A was transporting Resident #1 to a doctor's appointment; -CMT A left the facility's driveway and was on the street when a car pulled out in front of the van; -The driver had to slam on the brakes, when he/she did, the resident fell out of the scooter and hit his/her head; -The resident was taken to a local hospital for treatment; -The resident was not wearing a seatbelt; -The resident sat in his/her scooter; -The resident suffered a head injury with a neck fracture. Review of the signed statement by CMT A dated 5/8/19, showed: -I was driving the resident to an appointment, and a white minivan pulled out in front of my vehicle, so I hit the brakes and the resident fell forward and hit his/her head on the handle to open the passenger side door and busted his/her head open. The resident was not buckled in at the time, I called 911 and informed my charge nurse. I know that I was supposed to buckle him/her in. I just forgot. During a interview on 5/9/19 at 11:40 A.M. and on 5/9/19 at 2:10 P.M., CMT A said: -On 5/8/19 he/she was scheduled to pass medications at 2:00 P.M.; -He/she was told he/she had to transport the resident to a doctor's appointment immediately; -He/she had never transported the resident before; -He/she put the resident in the van in the resident's scooter using the lift of the van; -He/she put the resident's scooter in the space by the van's lift; -He/she did not turn the scooter so that the resident was forward facing; -He/she did not put a seat belt on the resident or secure the scooter to the floor of the van using the straps; -After he/she pulled out of the facility driveway, a minivan pulled out in front of him/her, he/she slammed on the brakes of the van to avoid hitting the car and the resident fell out of the side of the scooter and into the handle of the passenger door; -He/she tried to call the facility to alert his/her charge nurse, but did not get an answer, he/she then called 911; -The resident was not responding; -The resident lay in a fetal position with his/her head bent forward with his/her chin touching his/her chest; -There was blood around the resident's head; -The EMT's arrived and took the resident to the hospital. Review of the signed statement from LPN A dated 5/9/19, showed: -He/she received a call yesterday at approximately 3:00 P.M. from CMT A, he/she was frantic and stated The resident fell out of the wheelchair and hit his/her head, he/she is bleeding and not responding to me, I called 911, but I need someone here now. I informed the administrator there was an emergency with the resident. Upon arriving at the van, the ambulance was already there. The resident was scrunched up in the front of the van with bleeding coming from his/her head. He/she could not visualize the severity of his/her wound in his/her position. The resident's skin color was pallor (pale) with slight circumoral cyanosis (blue discoloration around the mouth) noted. He/she asked CMT A if he/she had the resident buckled in. The CMT replied no. The resident was taken to the local hospital via EMS. During an interview on 5/9/19 at 3:00 P.M., LPN A said: -He/she was the nurse on duty and took the telephone call from CMT A; -He/she went to the scene and saw the resident lying on his/her right side in the front of the van; -The EMT's were attempting to get the resident out of the passenger door van; -The resident was not responding and appeared to be unconscious; -The resident had a lot of blood on his/her face and he/she was blue around his/her mouth; -CMT A stated that he/she did not have a seatbelt on the resident, nor was the scooter secured. Observation on 5/9/19 at 4:00 P.M., at a local hospital showed the resident in a bed with a soft cervical collar on. The resident's right eye was bruised and swollen with sutures above the right eye, sutures in the mid forehead region and on the bridge of his/her nose. The resident's nose was swollen and bruised. Multiple skin tears with bruising were on both arms. The resident could not answer any questions. The resident moaned and stated It hurt when he/she touched his/her neck and face. During an interview on 5/9/19 at 4:00 P.M., hospital Registered Nurse (RN) A said: -The resident has not responded to any questions since he/she has been in the hospital; -The resident is receiving pain medication routinely for his/her complaints of neck and facial pain; -The resident has a fractured nose and fractures of C6 and C7. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 7

Based on interview and record review, the facility failed to ensure staff provided safe protective oversight and care intervention for one of 16 sampled residents (Resident #4) when the resident went outside on the front porch and staff responded by physically restraining and moving the resident inside resulting in the resident tipping over in his/her wheelchair and hitting his/her head on the floor. The charge nurse, who was present when the resident's wheelchair tipped over, did not assess the resident before leaving the resident in the responsibility of two nurse aides (NA), who lifted the resident off the floor before nursing assessed his/her condition. Staff failed to immediately notify the physician of the resident sustaining a head injury during the incident. The facility census was 91. 1. Review of the facility's undated policy on change in a resident's condition or status showed: - The facility shall promptly notify the resident's attending physician of changes in the resident's condition and/or status. - The nurse supervisor or designee will notify the resident's attending physician when the resident is involved in any accident that results in an injury including an injury or accident that has the potential for requiring physician intervention. - Except in medical emergencies, notifications will be made within twenty-four to forty-eight hours of a change occurring in the resident's condition or status. Review of the facility's Falls and Fall Risk, Managing policy, revised 12/07, showed the staff will identify interventions related to residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling, based on previous evaluations and current data. Review of the facility's policy on safe lifting and movement of a resident, revised 10/09, showed in order to protect the safety and well-being of residents, the facility used appropriate techniques to move residents. Resident safety will be incorporated into decisions regarding the moving of residents. Review of the facility's undated resident restraint policy showed physical restraints will not be imposed for the purpose of staff convenience. Restraints are only to be used as treatment for [REDACTED]. Review of the undated facility policy on resident rights, showed: - Residents will be free from physical restraints except when necessary to protect the resident from injury; - When a restraint must be used for resident safety, the resident's physician must write an order specifying the the duration and circumstances under which the restraints may be used. 2. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/13/15, showed: - Sometimes understood by others; - Sometimes understands others; - Severely cognitively impaired; - Required extensive assistance with transfers; - Used a wheelchair for ambulation independently; - Hearing impairment causing inability to understand others; - [DIAGNOSES REDACTED]. Review of the resident's care plan, edited on 4/15/15, showed: - He/she had cognitive loss/dementia. Staff to approach resident with clear simple instructions each time before care so the resident knew what to expect and what he/she should do. - He/she had communication impairment related to minimal hearing difficulty and inability to understand others. Staff was to face the resident when speaking to him/her and make sure to have his/her attention. Staff to ask the resident simple questions requiring yes/no answers. The resident may nod his/her head yes or no. Staff was to use short, simple to understand sentences. - He/she was able to move him/herself in his/her wheelchair. - He/she could become agitated and aggressive, verbally and physically, towards others. He/she could wander around in his/her wheelchair. Staff was to invite and encourage the resident to participate in visiting and activities. He/she enjoyed when his/her family took him/her out on the front porch. Staff was to allow him/her to express his/her feelings, concerns, needs, and wants. Staff was to remind the resident that being aggressive was not appropriate. - Staff to offer supervised porch time. He/she enjoyed having staff stop and interact with him/her. - If staff noticed him/her traveling in an unsafe area, redirect him/her quickly. Redirection was easiest by offering a new topic of interest. He/she really liked hot chocolate; offering this might help redirect him/her. Review of a facility's security camera video clip from 7/12/15, which had no audio sound, showed: - Family Member (FM) A stood in the middle of an electronic door between the facility's entrance atrium and the front lobby of the facility causing the door to remain in an open position. - The resident, in a wheelchair, self-propelled him/herself through the opening into the atrium, pressed the electronic release panel opening the front door of the facility, and moved through the door to the facility's front porch. - The receptionist and FM A observed the resident and NA B, NA C, and Licensed Practical Nurse (LPN) D responded. - LPN D observed from the lobby while NA B and NA C went to the front porch. - NA B and NA C immediately turned the resident around without facing the resident to speak to him/her in the wheelchair. They positioned the resident with his/her feet facing the door. - NA B picked up the resident's legs, holding them up and extending them out from the chair while NA C wrapped his/her arms around the resident's arms. - While the NAs held the resident's arms and legs, NA B walked backwards in a bent over position. The two moved the resident in the wheelchair through the front door tipping the wheelchair with the resident over backwards onto the atrium floor. - LPN D immediately left without assessing the resident. - FM A left the facility through the front door. - The NAs stayed at the resident's side. They waited one minute 15 seconds after he/she fell , then picked him/her up from the floor in his/her wheelchair, and pushed the resident in the wheelchair through the electronic door into the facility's lobby as LPN D returned with Registered Nurse (RN) C and RN E. Review of a Nursing Investigation Sheet for the resident, dated 7/12/15, at 5:20 P.M., showed LPN D documented: - The front door alarm sounded. - He/she, NA B, and NA C witnessed the fall.- He/she heard the front door sounding. - He/she and NA C observed the resident sitting in a wheelchair outside the front door. - NA B and NA C went to help the resident through the door. - NA C pushed the resident through the door as NA B held the resident's feet. - When pushing the wheelchair through the door. the wheelchair hit the bump in the doorway and the resident and chair tipped over backward. - He/she heard the resident's head hit the floor. - He/she could not find the station two nurse so he/she paged for him/her. - Then he/she went to the station three charge nurse for assistance. - When he/she returned, the NAs were inside the facility. - He/she educated the NAs about not moving residents until help arrived to avoid further injury. Review of the Falls Investigation for the resident, dated 7/12/15, showed: - The fall occurred at 5:45 P.M. - The resident followed a visitor and was able to go outside. - Two aides and a nurse tried to take the resident inside. - The wheelchair tipped over and the resident ended up in the floor. During an interview on 7/16/15, at 4:04 P.M., and 7/21/15, at 3:10 P.M., FM A said on 7/12/15, at supper time, he/she was leaving the facility, the resident came out in his/her wheelchair behind him/her. The resident just got out the front door to the front porch when three staff came. One of the staff said it would take all three of them to get the resident back in the facility and took off to get someone. The other staff told the resident let's go back in and the resident said no. The resident was not physically combative. One of the staff picked up the resident's legs, tilting them up. The other staff person stood at the back of the wheelchair. The staff at the back of the wheelchair did not keep control, the wheelchair tipped backward, and the resident hit his/her head on the floor. During an interview on 7/15/15, at 2:34 P.M., NA B said: - He/she began working at the facility on 6/2/15. He/she had no prior NA experience. When he/she began work at the facility, he/she watched movies, received training on falls, and for three days, he/ she watched staff provide care to residents on the hall resident resided on. - On 7/12/15, at 5:30 P.M., he/she heard someone yell. - He/she responded, met NA C and LPN D at the front doors, and saw the resident going outside. - He/she and NA C went outside to get the resident who was in a wheelchair. - He/she told NA C to pull the wheelchair backwards into the facility in case the resident did not want to come and planted his/her feet to stop them. - NA C said No, let's get (him/her) in and turned the resident around. - He/she cupped his/her hands around the resident's feet lifting them as he/she walked backwards while NA C had his/her hands around the resident's right and left forearms pushing the resident in from behind. - When they got the resident in the atrium, the wheelchair tipped over backwards. - The resident was not physically combative at the time. - He/she did not know why the wheelchair tipped over. - The resident remained in the tipped over wheelchair with the wheelchair back to the ground and the resident's head, neck, and shoulders on the atrium floor. - The resident said God Damnit, was trying to get up and the NAs told him/her not to. - They put the resident's arms on his/her legs and waited for the nurses to come. - It seemed like it took awhile for the nurses to arrive; they did not know what to do, and decided they needed to get the resident out of the doorway. - They were on each side of the resident supporting his/her neck with their hands because they thought his/her neck might have been hurt. - They lifted the resident up from the floor in the wheelchair and rolled the resident into the lobby when the nurses arrived. - After the incident, he/she was instructed that if a resident fell not to get them up until a nurse completed an assessment. No one had ever told him/her that before. - He/she did not know how to respond to the resident if he/she became combative. During an interview on 7/15/15, at 3:08 P.M., NA C said: - Neither he/she nor NA B were certified nurse aides. - He/she began working at the facility two months ago. - On 7/12/15, at 5:30 P.M., he/she and LPN D responded to an alarm they heard at the front door of the facility. - He/she met NA B at the front doors and saw the resident had gone outside. - He/she grabbed the resident's wheelchair handles and turned the resident around. - He/she told the resident that they were going to go back inside. - The resident seemed confused. He/she knew the resident to be combative if staff attempted to make him/her go somewhere he/she did not want to go. - He/she had not received any training on how to respond to the resident if he/she became combative. - He/she reached around the resident and held onto his/her wrists on both sides to prevent the resident from being combative and NA B grabbed the resident's feet and pulled them up in the air while walking backward. - They then pushed the resident into the atrium. - He/she let go of the resident's hands to grab the handles on the back of the wheelchair and the resident tipped over backwards. - The resident did not do anything with his/her hands when he/she let go of them. - The resident remained completely in the wheelchair when he/she went backwards onto the floor, hitting his/her head on the floor rug. - After the resident's head hit the floor, he/she dropped to the floor, and when the resident's head bounced off the floor, he/she put his/her hand under the resident head. - He/she and NA B noticed two skin tears on the resident's left arm that were bleeding badly. - LPN D told them he/she was going to get some help. - They waited for a couple of minutes, then he/she told NA B to grab the left handle of the wheelchair and he/she grabbed the right handle. - He/she was still holding the back of the resident head. - He/she told NA B to help him/her get the resident in the wheelchair back up to the right position. - After they got the resident up, the nurses arrived to help. - He/she noticed a knot at the back middle bottom of the resident's head that was as round as a tennis ball and was puffy, extending out one-fourth inch. - The resident had a quarter sized bruise on his/her right shoulder blade. - RN C told him/her that he/she should not have picked the resident up. - RN C said if the resident had an injury, picking him/her up could have made the injury worse. - He/she did not know they should wait for a nurse to assess the resident when a fall occurred. During an interview on 7/15/15, at 3:58 P.M., RN C, who worked as the RN on duty at the time of the incident, said: - On 7/12/15, LPN D told him/her the resident fell at the front door. - He/she, LPN D, and RN E went to the front door. - When they got there, the two NAs had already picked the resident up in his/her wheelchair from the floor and brought him/her into the building. - He/she and LPN D told the NAs they should not have picked the resident up. - He/she felt the NAs should have known to wait for the nurse to assess. - The NAs did not know how the resident was injured. - The resident could have broken his/her neck, collar-bone, or hip and by picking the resident up, they could have made the injury worse. - When they assessed the resident, he/she had cuts on his/her arm, and from the middle back of his/her head to the base of the resident's skull to behind the resident's ear was a purple colored bump three to four centimeters (cm) puffed out and four to five centimeters in width. He/she had an abrasion to his/her right shoulder blade. - LPN D should not have left the resident during the incident. - LPN D should have stayed to assess the resident at the time of the fall and should have had someone else notify him/her of the incident. During an interview on 7/20/15, at 9:58 A.M., LPN D said: - On 7/12/15, He she worked as a charge nurse. - He/she responded to an alarm and found the resident to be right outside the front door of the facility. - The resident was just sitting there settled and was calm. - He/she told the NAs they needed to try to get the resident back in the facility because the resident was very hard to redirect and would grab at things. - NA B and NA C brought the resident back in the facility. - The resident was being hard to redirect and planting his/her feet. - NA B lifted the resident's feet to prevent the resident from doing this. - He/she saw the wheelchair starting to tip over and knew the resident was going to fall out of the chair. - He/she left to get help. - He/she did not think he/she told the staff he/she was leaving to get help. - He she went to the 200 hall and paged RN E, then went to the 300 hall and told RN C that the resident tipped over in the wheelchair. - When he/she returned the NAs said the resident hit his/her head during the incident. - The NA's brought the resident back into the facility a little too fast. - He/she was not sure if the NAs lifted the resident's legs too high. - He/she should have probably told the NAs to bring the resident in backwards. - If they brought him/her in backwards, they would not have had to lift his/her feet and this would have slowed the momentum. It would have been safer to bring the resident in backwards. He/she did not direct the NAs on how to bring the resident back into the facility. - He/she probably made a mistake and should not have left the scene. He/she did not know what caused the resident's wheelchair to tip. - He/she was sure that the resident was going to fall over backwards by the momentum of the wheelchair. - He/she did not know how bad the injury from the fall was going to be and thought he/she needed to leave to get back-up or reinforcements. The biggest risk was that the resident would hit his/her head and that is what happened. - As the supervisor/charge nurse, it was his/her responsibility to stay and monitor to see if the resident was safe and did not have any major injuries. He/she should have completed a quick assessment on the resident before he/she left. He/she could have sent someone else to get help or had the receptionist page for help. - No one had trained, redirected, or talked to him/her about not staying with the resident to intervene, direct care, monitor, and assess. -The NAs should have been trained prior to the incident to not pick a resident up off the floor in order to prevent further injury. Review of the progress note, dated 7/12/15, at 6:32 P.M., showed RN E documented the resident had two open areas on his/her left arm and a scratch on his/her right upper shoulder. RN E did not mention a head injury in the note. During an interview on 7/20/15, at 10:30 A.M., RN E said: - On 7/12/15, at 5:30 P.M., he/she was paged, saw two nurses running, and was told the resident fell in the door. - When he/she got to the door, he/she asked the NAs why they picked the resident up off the floor and told them they should not have. The resident had blood all over his/her arm. - LPN D was supposed to stay at the scene to take care of the situation and direct action for the incident. By leaving, the LPN put the resident at risk. The LPN should have directed the NAs to leave the resident on the floor due to potential injury. - The NAs picking the resident up off the floor could have lead to a severe injury for the resident. - After the incident, staff took the resident to his/her nurses' station where they treated the open areas on the resident's skin. He/she did not see anything on the resident's head (joint) at the time. He/she completed a head assessment and did not observe any injuries. He/she should have documented that he/she assessed the resident's whole body at the time. - After treating the resident, he/she sat down and the resident's family member called. He/she informed the family member about the incident. He/she asked the family member if he/she wanted the resident sent to the emergency room and the family member said no. The family member said he/she was going to check the resident and go from there. - He/she did not call the physician. He/she faxed the physician. It was shift change and he/she informed the oncoming nurse of the incident. - He/she had not received any facility training for nurses since the incident. Review of the progress notes, dated 7/12/15, written at 8:38 P.M., showed staff documented the following: - The resident fell on the previous shift with previous nurse. Staff expected the resident's family to arrive at the facility to evaluate if he/she would like for the resident to be sent to the hospital emergency room (ER) for evaluation. - The resident's family arrived at 6:40 P.M. and after inspecting the resident, decided to have the resident evaluated at the hospital. - At 6:45 P.M., staff notified the resident's physician of the resident's fall that occurred at 5:40 P.M. on the previous shift. - The resident had a slight raised area to the posterior cranium and slight redness in color to the affected site. - The resident had a scrape to his/her right shoulder and two open [MEDICAL CONDITION] on his/her left wrist with blood drainage. - The resident currently took aspirin 81 milligrams (mg) daily. - The resident's family said the resident had a history of [REDACTED]. Review of the Hospital A records, dated 7/12/15, showed: - Facility resident tipped over backward in wheelchair. - Chief complaint injury to the head. - Abrasions present on the left upper extremity and left wrist. Lethargic and disoriented to person, place, and time. Resident slow to respond and responds to pain only. Eyes open to voice. Incoherent speech. - Staff Radiologist report included indication of a head injury, altered mental status. CT (CAT scans, are special X-ray tests that produce cross-sectional images of the body using X-rays and a computer) of the brain performed. Impression is acute right subdural hematoma (a collection of blood in the space between the outer layer and middle layers of the covering of the brain. It is most often caused by torn, bleeding veins on the inside of the dura (membrane covering) as a result of a blow to the head.) measuring 8.2 millimeters maximal thickness with minimal mass effect on the right cerebral cortical sulci (groove in the surface of the brain.). No midline shift is seen. - Course of care in agreement with family is for observation tonight with the plan to return to the facility tomorrow. There are no beds available at the hospital. Hospital B agrees to accept resident in transfer. - Resident sent to Hospital B for admit. Review of the progress notes showed on 7/12/15, at 11:00 P.M., the resident was being transferred from one hospital to another for admit for a brain bleed. Review of Hospital B records, showed: - 7/12/15, Family does not want any surgical intervention. They are likely going to convert to hospice care in the morning but want the resident watched overnight before making the ultimate decision. Physician informed family that this could be a life-altering or a life-ending event. The resident is having increased slurring of speech. - 7/13/15, discharge condition included right-sided parietal and temporal subdural hematoma with 8 mm midline shift. discharge condition is poor. Resident to be transported back to facility for hospice care. Review of the progress notes showed on 7/13/15, the resident was admitted to the hospital with [REDACTED]. During an interview on 7/21/15, at 7:10 A.M., the assistant administrator (AADM) said in response to the 7/12/15, resident incident investigation findings: - He felt the only new intervention needed was anti-tippers (a form of wheelchair stabilizer that prevent the chair from flipping over backwards under certain circumstances) to be placed on the back of the resident's wheelchair to prevent the resident from tipping backwards. - They educated nursing staff when a resident falls not to move the resident prior to a nursing assessment. During an interview on 7/22/15, at 2:20 P.M., the administrator (ADM) and AADM said: - The resident's vital signs were in normal range after the incident. Staff probably would not have sent the resident to the hospital unless the family member said to. - It is the facility's normal practice to fax the resident's physician unless an incident happens on Sunday. - When an issue occurred on Sunday, staff faxed the resident's physician on Monday since there was no one in the physician's office on Sunday. Staff usually did not call a resident's physician for any issue; they just faxed. The nurse determined if a resident should be sent out to the hospital or not. - When the resident fell , the receptionist should have paged for help. - LPN D should not have left the scene of a potential fall especially with two NAs. - After meeting with the resident's family on 7/21/15, they believed the staff may have been able to step back from the resident in this situation and staff needed an inservice on how to deal with behaviors. During an interview on 7/22/15, at 3:15 P.M., the AADM and assistant director of nursing (ADON) said: - Staff should not remove any resident until a licensed nurse assesses the resident head to toe. - Certified nurse aides/NAs should not move a resident after a fall in case the resident had a neck injury. - Staff should send the resident out if abnormal findings occur including head injury. - After sending out the resident, staff should call the resident's physician or on-call physician. - Staff should call a resident's physician if the resident had any swelling on the head even if the resident's vitals were stable. - Staff should call the resident's physician or on-call physician no matter what day or time the incident occurred. MO 8

Based on interviews and record review, the facility failed to follow physician's orders for one of five sampled residents (Resident #1). The resident had an order for [REDACTED]. The facility census was 103. 1. Review of Resident #1's physician order dated 1/10/13 showed an order for [REDACTED]. Review of the resident's physician orders dated 7/15/13 showed an order for [REDACTED]. Review of the physician's order dated 8/19/13 showed an order for [REDACTED]. Review of the resident's medical record showed he/she had a PT/INR drawn on 8/19/13. The result was the PT was 28.5 seconds (normal values are 11.9 seconds up to 14.3 seconds) and the INR was 2.8. The copy of the laboratory report showed the facility faxed the report to the physician on 8/19/13. The faxed laboratory report and documentation in the medical record did not show the facility received a response from the physician. Review of the resident's physician progress notes [REDACTED]. The physician noted the resident was doing very well. He/she also wrote the resident got his/her [MEDICATION NAME]'s monthly and more frequently as needed and that it had been done recently. Review of Resident #1's Minimum Data Set (MDS), a federally-mandated resident assessment completed by facility staff, dated 9/23/13 showed the following: - Independent with all activities of daily living. - Ambulated independently with a walker. - Received anticoagulant medication (medications taken to thin the blood). Review of the resident's record showed the facility did laboratory tests on 9/11/13, 10/9/13, and 11/13/13 but tests did not include a PT/INR. Review of the resident's nurses notes dated 12/15/13 at 9:34 A.M., showed the nurse documented the resident did not feel well today. The resident complained of slight dizziness. His/her blood sugar was 89 mg/dl. The resident was weak and unsteady. Vital signs were: blood pressure 90/48, pulse 57, respirations 18 and temperature 97.3. The nurse documented he/she would fax the doctor and continue to observe. Review of a fax sent to the resident's physician dated 12/15/13 showed the resident complained of being dizzy and weak. The resident's blood sugar was normal but he/she was very sleepy. The blood pressure was 90/48 (normal range is 110/70-120/80), pulse 57, respirations 18, and temperature 97.3 degrees Fahrenheit. The nurse practitioner responded on 12/16/13 to please obtain a full set of vitals today and fax the results. Review of the resident's nurses notes dated 12/16/13 at 7:11 A.M., showed the nurse documented the resident's blood sugar this A.M. was 74. He/she was weak and dizzy. The nurse documented he/she gave the resident juice and peanut butter and crackers and rechecked his/her blood sugar. The blood sugar was 104 mg/dl. The resident still complained of dizziness and weakness. The aides helped the resident get and up and to breakfast. Will continue to observe. Review of a fax sent to the resident's physician dated 12/16/13 showed the resident continued to complain of dizziness and some pain in right upper quadrant of abdomen in the area of old right [PROCEDURE]. Blood pressure 140/82, pulse 54, respirations 18, and temperature 98.6. The resident stated he/she had this every so often. The nurse practitioner replied on 12/16/13 to continue to monitor and report any changes. The nurse practitioner also asked when the resident had a bowel movement and to make sure he/she was eating his/her bedtime snack. During an interview on 12/30/13 at 10:00 A.M., Certified Nurse Aide (CNA) A said Resident #1 was usually independent with all of his/her cares but since she returned from the hospital, he/she needed more help. CNA A said he/she saw a bloody tissue in the resident's trash can the morning the resident went out to the hospital. The CNA said the nurse knew about the tissue. During an interview on 12/30/13 at 10:10 A.M. Licensed Practical Nurse (LPN) A said he/she sent the resident out to the hospital on [DATE]. The resident had increased weakness. The resident normally was independent with all his/her cares and walked independently with a walker. What triggered his/her awareness there was a problem was when the resident needed help getting dressed that morning. Apparently over the weekend, he/she had a few nose bleeds. Someone told him/her this in report but he/she was not sure who told him/her this. During report on 12/17/13, an aide came up and said he/she needed help to dress the resident. LPN A said he/she went and checked on the resident. The resident's blood pressure was lower than normal and his/her blood sugar was within normal limits. The resident was alert and oriented but would dose off between questions. The LPN said he/she asked the resident about the nose bleeds and the resident said he/she had them before but it had been awhile. The resident denied picking his/her nose. The LPN said at that point the nose bleed was not the his/her main concerns, it was the other abnormal things that concerned him/her. He/she received an order to send the resident to the emergency room . Review of the resident's physician order dated 12/17/13 showed an order given at 6:15 A.M. to send the resident to the emergency room for evaluation related to low blood pressure, dizziness, increased weakness, nose bleeds or if the resident refuses to go to the emergency room , increase fluids and collect laboratory specimens stat that included PT and call the office with results. Review of the resident's nurses notes dated 12/17/13 showed the resident was transferred to the emergency room for low blood pressure, increased weakness and dizziness, low blood sugar, pale skin, sluggish skin turgor rebound, skin cool and tacky but not cold and clammy, intermittent nose bleeds, slow and slightly slurred responses, lethargic but arousable. Vital signs: blood pressure 70/40, pulse 51, respirations 20 with long deep nose breathing and slightly labored, temperature 97.2 degrees. Blood sugar was 89 milligram/deciliter (normal blood sugar is 70-110 mg/dl). Called the emergency room to notify the resident's physician. The resident's physician returned call with orders to send the resident to the emergency room for evaluation and if the resident refused to obtain laboratory tests and call the physician's office with the laboratory results. The nurse gave the resident his/her options and the resident chose to go the emergency room . Review of the resident's hospital records dated 12/17/13 showed the resident arrived by ambulance. The nursing home sent the resident to the hospital because of dizziness when the resident stood up, apparently for several days. The nursing home personnel were concerned because the resident's blood sugar was only in the 70's and he/she has apparently had a couple of nose bleeds. No noted blood in the resident's bowel movements. The resident has had weakness and difficulty walking. Laboratory tests obtained at the hospital included PT/INR. The PT was 68.6 seconds (critically high) and INR 9.5 (critically high). The resident's red blood cell count was 2.71 (normal is 4.00 to 5.00), hemoglobin (the part of the blood that carries oxygen; low values indicate [MEDICAL CONDITION]) level was 6.5 grams/deciliter (normal values are 12-15 g/dl) and hematocrit (volume percentage of red blood cells in blood) was 24.4% (normal values 36-45%). Review of the resident's nurses notes dated 12/17/13 showed the resident was admitted to the hospital with [REDACTED]. During an interview on 1/2/14 at 4:00 P.M., the resident's physician said he/she expected staff to follow his/her physician order for [REDACTED]. During an interview on 12/30/13 at 9:40 A.M., the resident said he/she felt better. He/she did not know how he/she lost so much blood. During an interview on 12/30/13 at 2:30 P.M., the facility administrator and director of nursing said they expected staff to follow up on any faxes they sent to the physician when they did not get a response from the physician. If the nurse goes off duty before they hear back from the physician, they should pass it on in report, so the next shift could follow up on the fax response. MO