Every finding on record at Tiffany Springs Rehabilitation & Health Care Cente

Based on interview and record review the facility failed to follow their Cardiopulmonary Resuscitation (CPR) Policy and failed to follow the documented wishes for Resident #1, when a Licensed Practical Nurse (LPN) performed CPR on the resident when the resident had a documented and physician signed Do Not Resuscitate (DNR) order. The facility census was 111. Review of the facility policy titled, Cardiopulmonary Resuscitation, dated 03/2025 showed if a resident was found unresponsive and no breathing normally, a clinical staff member will verify code status using the clinical record. If the resident is a DNR, per medical record, notify the attending provider. Review of the facility policy titled, Resident Rights, dated 12/2024 showed each resident residing in this community has the right and will be afforded the right to a dignified existence, and self determination. Each resident will have autonomy and choice, about how each resident wishes to live his/her everyday life and receipt of care.Review of Resident #1's face sheet showed:-admission date of [DATE]; -The resident was his/her own responsible party; -Diagnoses included: Chronic Obstructive Pulmonary Disease (COPD: lung disease that restricts airflow, causing coughing/wheezing/breathing difficulty), Congestive Heart Failure (CHF), pain and difficulty walking. Review of the resident's Comprehensive Care Plan dated [DATE] showed the resident was not near his/her end of life, but his/her Advance Directives will be honored. Review of the resident's Electronic Medical Record (EMR) showed an Out of Hospital Do Not Resuscitate Form signed by the resident on [DATE] and signed by the resident's primary care physician on [DATE]. Review of a nurse progress note dated [DATE] at 10:59 A.M. showed: -Upon entering the resident's room at 9:40 A.M., the resident was unresponsive in his/her wheelchair;-A sternal rub (rubbing the knuckles up and down the breast bone to obtain a pain response in an unresponsive person) was done, without any response; -Resident #1 had no pulse and no respirations; -The resident was placed on the floor at 9:42 A.M. by four staff members; -Licensed practical Nurse (LPN) A started CPR at 9:43 A.M.;-Emergency Medical Services arrived at 9:55 A.M., the resident had a heart rate of 83 beats per minute (BPM, normal range 60-100 BPM) and Blood Pressure of 146/60 Normal range 90/60- 120/80); -The resident was transported to an area hospital at 9:58 A.M During an interview on [DATE] at 12:54 P.M. LPN A said:-He/She was CPR certified; -He/She entered the resident's room at 9:40 P.M. on [DATE] to provide a skin treatment;-He/She found the resident sitting in the wheelchair, head bent down and unresponsive, without breath and without a pulse; -He/She yelled for help; -He/She performed a sternal rub without any response from the resident;-He/She checked the resident's wrist and neck for a pulse and did not feel any; -He/She, with assist of other staff, laid the resident on the floor and he/she started chest compressions; -One staff member called 911, one staff member brought the crash cart to the resident's room; -He/She completed 30 chest compressions, checked for pulses, found none and completed another 30 chest compressions where the resident was found to have a pulse; -At 9:55 A.M. the ambulance arrived to the facility and the resident was transported to the hospital at 9:58 A.M.;-He/She had one-on-one education after providing CPR to a resident with a DNR; -He/She should have checked the resident's medical record for code status prior to starting CPR; -He/She panicked and started CPR without checking the medical record; -He/She was not trying to harm the resident; -His/Her first instinct was to try to save the resident;-Code status can be found in the electronic medical record or a notebook on the crash cart. During an interview on [DATE] at 12:00 P.M. LPN B said:-Each resident's medical record should be checked to determine if the resident code status was a DNR or full code, prior to starting CPR; -There is a notebook on the crash cart with a list of residents and their code status; -The notebook is updated every night on night shift; -He/She received education from the Director of Nursing on where to find if a resident if a full code or DNR on [DATE]. During an interview on [DATE] at 12:15 P.M. Registered Nurse (RN) A said:-Code status can be found in the resident's electronic record on their name banner, and the book on the crash cart; -The book on the crash cart is updated every night, but the electronic record is the most accurate; -He/She received education on the [DATE] about checking code status before beginning CPR. During an interview on [DATE] at 1:45 P.M. the Director of Nursing said she would expect staff to check a resident's code status prior to starting CPR. Education was provided on [DATE] to check code status prior to starting CPR. During an interview on [DATE] at 11:45 A.M. the Administrator said she expected staff to check code status prior to initiating CPR. LPN A reported he/she did not check the resident's code status, panicked and began CPR.Intake 2984555

Based on observation, interview and record review the facility failed to prevent the development of an unstageable pressure injury (a severe, full-thickness wound where the base is completely covered by dead tissue) for one resident (Resident #2), of 6 sampled residents, when the facility failed to periodically check the resident's skin under a removable medical device for more than 20 days and the resident required surgery to clean the wound. The facility census was 115. Review of the facility policy titled, Skin Identification, Evaluation, and Monitoring, dated 2/2026 showed:-The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity, Communities will implement preventative measures and an individualized care plan will be formulated upon completion of findings;-A licensed nurse will evaluate the skin integrity through a physical skin evaluation upon admission, weekly and when a significant change is identified;-The nursing assistant will observe the resident's skin when assisting with activities of daily living (ADLs: tasks completed in a day to care for oneself) and report changes to the nurse;-The Licensed Nurse will initiate preventative and/or treatment intervention as indicated;-Eliminate or reduce: the source of pressure using positioning techniques, enhancement of mobility and circulation, and other sources of skin injury by evaluating the cause and providing interventions. 1. Review of Resident #2's hospital discharge paperwork dated 01/05/26 showed:-He/She was awaiting placement in post acute care facility;-He/She had a fracture of the left ankle;-His/Her skin had no lesions (abnormal change in skin caused by injury or disease). Review of the resident's Operative Report dated 12/31/25 showed:-The resident's ankle was sterilely dressed; -The resident was placed in a new splint (soft cast, made of fiberglass or plaster, the splint covers the back of the leg and calf, held in place by an elastic bandage. Padding is crucial to prevent pressure ulcers, particularly around the heel and ankle bones. The splint is usually not designed for walking and is used for non-weight-bearing protection.) Review of the resident's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 01/06/26 showed:-Brief Interview of Mental Status (BIMS) of 12 indicated minimal cognitive loss;-Partial to moderate assistance from staff for ADLs;-Risk for pressure ulcers;-Diagnoses included: Fracture of the ankle, muscle weakness, anxiety, stroke, and dementia (a disease that affects the way a person thinks and affects reasoning). Review of the resident's Comprehensive Care Plan dated 01/06/26 showed the resident had a splint on his/her left ankle and a pressure injury to right great toe. Review of the resident's admission assessment dated [DATE] showed he/she did not have impaired skin integrity. Review of the resident's Nurse Progress Notes showed the following:- The Assistant Director of Nursing (ADON) documented on 01/6/26 at 09:10 P.M. He/She had a Stage I (an area of skin damage characterized by intact, red, skin with temperature changes) to the right great toe, present on admission;-The resident had no other skin issues;-Registered Nurse (RN) A Documented on 01/10/26 at 10:22 P.M. the resident had a left ankle fracture and right great toe discoloration;-The resident had no other skin issues;-Licensed Practical Nurse (LPN) B documented on 01/12/26 at 10:51 P.M. the resident had no skin issues;-LPN A documented on 01/13/26 at 02:09 P.M. the resident had no skin issues. Review of the physician's progress note for the resident dated 01/12/26 showed:-He/She was seen for a follow up after a left ankle fracture;-The soft cast was removed and a Controlled Ankle Movement (CAM) boot (a stabilizing boot with adjustable Velcro straps) was placed on the resident;-He/She was to leave the boot on at all times except for hygiene;-He/She had a scheduled follow up appointment on 02/02/26. Review of physician's progress notes for the resident dated 02/05/26 showed:-The resident did not return in two weeks as ordered, it has been 3 1/2 weeks;-The resident reported the dressing and CAM boot placed at the last visit had not been touched since the visit three weeks ago;-The resident complained of numbness and tingling in both legs;-The resident had a medial (middle) foot/ankle ulceration approximately 3 to 6 centimeters (cm) with fibrous base and mildly erythematous (red) edges;-An order for Bactrim DS (double strength prescription antibiotic) twice daily for ten days for a wound infection;-The resident was referred to the wound clinic. Review of the resident's Physician referral document for wound clinic dated 02/05/26 showed the resident had an open area on his/her left ankle and the resident needed to be seen urgently. During an interview on 03/09/26 at 03:45 P.M the Wound Clinic RN said:-The resident was seen on 02/06/26 after a referral from the Orthopedic Surgeon, for an open wound that was caused by the CAM boot not being removed for three weeks;-The resident had a large unstageable wound on his/her left ankle/foot, that was covered in eschar (a thick, dry, black or brown layer of dead tissue (necrosis) that forms over severe wounds);-The wound measured 3.3 cm by 3.1cm by 0.1cm. Review of the resident's Physician Order Sheet (POS) dated February 2026 showed an order for wound care: Left ankle cleanse with wound cleanser, apply hydrafera blue (a prescription wound dressing) cover and secure with gauze wrap and tape, complete on day shift every 3 days for wound care, starting 02/09/26. During an interview on 02/20/26 at 04:22 P.M. the resident said:-He/She had a fall resulting in a broken ankle and hospitalization, and was sent to the facility to receive therapy;-He/She arrived to the facility on [DATE];-The CAM boot on his/her foot was never removed until the he/she returned to the physician who opened the CAM boot and found the big sore spot;-The physician scheduled wound care the very next day;-The facility staff told him/her they could not take the boot off and it was left in place for more than two weeks;-He/She had a sock on his/her foot under the boot and it was left on his/her foot for more than two weeks;-He/She reported to the facility staff his/her left ankle hurt badly, but could not tell if it was the skin or the surgery that caused the pain. During an interview on 02/20/26 at 04:37 P.M. Certified Nurse Aide (CNA) A said:-The resident complained of a lot of pain in the left foot;-He/She loosened the strap of the boot one time to assist with pain relief;-He/She did not remove the boot at any time;-He/She worked with the resident a lot, as she works that area full time. During an interview on 02/24/26 at 01:20 P.M. LPN A said:-He/She did not open or remove the boot to check the resident's skin or provide any hygiene;-If he/she completed a skin assessment and there was a wound, he/she would have documented the skin check and the wound;-He/She would follow the physician's orders and would not have opened the boot if there was an order to leave it in place. During an interview on 02/24/26 at 01:28 P.M. RN A said:-He/She never removed or opened the boot to look at the resident's skin;-The resident complained of stabbing pain in the left foot;-If the physician gave an order not to remove it then it would be left in place;-If the physician orders were to remove it then we would have done that. During an interview on 02/24/26 at 01:40 P.M. Nurse Practitioner A said:-He/She believed at the time the resident admitted to the facility, the boot was to be left on, then at a later time there was an order to remove for hygiene only;-The resident's pain was a concern from the beginning and had been addressed with medication adjustments;-She was very unhappy the surgeon found a wound under the boot on 02/12/26;-She would expect staff to open the boot and check the skin and pulses each shift. During an interview on 02/25/26 at 09:12 A.M. Unit Manager A said:- The resident had a soft cast (a thick foam and dressing wrap) when he/she was admitted to the facility;-The resident had an order to leave the soft cast in place until he/she saw the orthopedic surgeon for follow up;-The resident did not give any indication that he/she had foot pain;-The cam boot was placed on the resident on 02/12/26 at the physician's visit;-The physician ordered for the boot to be left on except for hygiene;-He/She would expect staff to check the skin under a boot for skin integrity;-He/She is unsure why skin checks were not done;-There was not an order to check the skin under the boot, but an order would not be necessary;-When the physician found the wound, the wound was unstageable;-The resident was placed on antibiotics for the wound. During an interview on 02/26/26 at 02:26 P.M. the Director of Nursing (DON) said:-When the resident was admitted he/she had on a soft cast that was not to be removed until he/she was seen by the orthopedic follow up appointment;-The resident went for an orthopedic follow up appointment on 01/12/26 and a CAM boot was placed on the resident's left foot;-The resident had an orthopedic follow up appointment on 02/05/26 where the doctor found the wound;-With the physician's order to remove for hygiene the CAM boot should have been opened and the skin checked every shift; - We did not check the resident's skin and it was wrong. During an interview on 03/09/26 at 09:00 A.M. the Orthopedic Surgeon said:-He/She expected the CAM boot to be removed for hygiene as ordered;-He/She would expect hygiene to be done at the very least daily, but preferably every 12 hours;-It was unacceptable the boot was not removed and the skin was not checked for three weeks. During an interview on 03/11/26 at 10:25 A.M. Surgeon A said:-The wound on the resident's ankle became infected, causing the hardware in his/her ankle to also become infected, resulting in the resident having to have surgery, removal of the hardware and preparing the skin for a skin graft (a surgical procedure that transplants healthy skin from a donor site to cover damaged, burned, or surgically removed skin). Review of the resident's Operative Note dated 03/05/26 showed:-He/She had a hardware infection, left ankle with full thickness ulcer to the fat layer;-Performed procedure irrigation and debridement (medical removal of dead tissue), hardware (screw) removal and surgical wound bed preparation of skin graft;-Left front, middle ankle had a large eschar with underlying wound, was noted to extend deep into the fat layer with partial tendon exposed;-A bone biopsy (small bone sample taken to test for infection, inflammation or disease) was completed. Intakes 2784865 & 2736326

Based on interview and record review, the facility failed to implement policies and procedures to ensure resident's trust fund accounts were not allowed to go into a negative balance which affected one resident (Resident #28) and when the facility failed to refund resident funds within 30 days of discharge for six residents (Residents #123, #124, #125, #126, #127, and #128). The facility census was 116. Review of facility policy Resident Trust Fund Policy, revised [DATE], showed:- Refund checks for discharged or expired residents must be completed within 5 business days of the resident discharge. Per state regulations, a completed discharge/trust fund accounting form reflecting discharge date and monies disbursed must be sent to the caseworker within 5 business days.- The Resident Fund bank account must be reconciled monthly immediately upon receipt of the bank statement. - The facility shall require all monies, either spent on behalf of the resident or withdrawn by the resident or his/her legal representative be supported by a receipt and cancelled check or signed voucher on file.- The facility shall refund the balance of the resident's personal funds when a resident is discharged . The amount shall be refunded by the end of the month following the month of discharge or by State/Federal specific guidelines. 1. Review of the facility's business office aging report (report showing outstanding invoices and balances), dated [DATE], showed the following discharged residents had money in the facility's operating account:- Resident #127, discharged [DATE], credit balance $870.42;- Resident #128, discharged [DATE], credit balance $5,683.00;- Resident #126, discharged [DATE], credit balance $2,118.00;- Resident #124, discharged [DATE], credit balance $1,077.00;- Resident #125, discharged [DATE], credit balance $40.00;- Resident #123, discharged [DATE], credit balance $399.00;Review of the facility maintained Resident Trust Fund Statements, showed:- Resident #28 had a negative trust fund balance of $1,891.89 on [DATE];- Resident #28 had a negative trust fund balance of $1,891.89 on [DATE];- Resident #28 had a negative trust fund balance of $1,891.89 on [DATE];Review of the facility maintained Quarterly Statements, dated 3rd and 4th quarters, showed:- Resident #28's trust fund account was debited for room and board for $1,891.89 on [DATE] brining the resident's account balance to negative $1,891.89.- Resident #28 deposited $1,891.89 in the resident trust fund account on [DATE] bringing his/her balance to zero. During an interview on [DATE] at 9:25 A.M., the Business Office Manager (BOM) said:- Resident #28's account went into the negative on August of 2025 because she didn't look at the account to make sure it had funds to pay for room and board. She just issued the check to the corporate account as money owed thereby causing the resident's account balance to go into the negative. In November the facility was able to fix the account balance issue by having the resident deposit funds directly into the account to bring it back to zero. The BOM said that resident accounts in the trust fund should never be negative because that indicates that resident funds are missing from the account affecting all residents.- Resident #127 had money that was owed to insurance which was resolved on [DATE] when the insurance payment posted. A refund for $870.42 is ready to be processed but she was unsure why it had been delayed.- Resident #128 had secondary insurance resolved and processed on [DATE]. His/her refund is in processing but hah not yet posted to the account. This should have been done as soon as the issue was resolved since the resident discharge on [DATE]. - Resident #126 had insurance posting that was delaying his/her refund. This was resolved according to account notes in [DATE]. $2,118.00 needs to be processed and refunded right away to the discharged resident. - Resident #124 requires an accounting adjustment which shows the resident is due $407.00 as of [DATE]. This money should have been processed already to the resident but is still outstanding. - Resident #123 discharged on [DATE] and according to an account reconciliation the resident is owed $99.00 as of [DATE] from an insurance overpayment. - Resident #125 discharged on [DATE] and it shows the resident is owed a refund of $40.00. She was not sure why the refund had not been issued. During an interview on [DATE] at 10:00 A.M., the Administrator said:- Monies owed to residents should be returned in the timeframe indicated in our facility policies.- Residents should not ever have a negative balance in the Resident Trust Account.

Based on observation, interview and record review, the facility failed to ensure residents were served food that was palatable, safe, and at an appetizing temperature during meal service. This affected 2 of 24 sampled residents (Residents #22 and #95). The facility census was 116.Request for facility policy on cooking and dining food temperatures was not provided for review.1. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/25, showed:- Resident was cognitively intact;- Diagnoses: heart failure, Parkinson's Disease, anxiety disorder, depression, and respiratory failure;During an interview on 1/20/26 at 9:27 A.M., the Resident said the food is cold and this can happen at all meal times. Some of the food is very spicy, he/she normally eats in his/her room. He/she would prefer to have his/her food be hotter than what he/she receives it2. Review of Resident #95's Quarterly MDS, dated [DATE], showed:- He/she was not screened for cognitive ability;- Diagnoses: coronary artery disease, diabetes, and seizure disorder;During an interview on 1/20/26 at 10:49 A.M., the Resident said the food is sometimes cold in the dining room. The food doesn't taste good and makes him/her disappointed, when looking forward to meals is important.During a group interview on 1/21/26 at 10:28 A.M., the Resident Council said:- 13 of 14 residents said that the food was cold at the facility;- Resident #4 said he/she could not eat the chicken yesterday because it was tough and hard;Observation on the 300 hall on 1/22/26 at 1:28 P.M., showed:- Food trays for the hall delivered in an insulated cart by dietary staff;- 1:34 P.M. (6 minutes since delivery) staff started to pass out hall food trays;- 1:50 P.M. The last hall tray is passed (12 of 12 trays) and the test tray is given to the surveyor;Observation of a lunch test tray on 1/22/26 at 1:50 P.M., showed:- Lima Beans temped at 116.0 degrees Fahrenheit;, required serving temperature is 120 degress Fahrenheit. - French Fries temped at 106.0 degrees Fahrenheit, required serving temperature is 120 degress Fahrenheit;- French Fries tasted bland and starchy. The outside texture was gritty. They were dry on the inside and were not crispy;During an interview on 1/23/26 at 8:15 A.M., the Dietary Manager (DM) said his expectation is to serve all residents food that is at a minimum of 120 degrees Fahrenheit. He expects hall trays to be delivered to residents upon delivery to the hall with minimal delay in order to preserve freshness. During an interview on 1/23/26 at 10:15 A.M., the Administrator said:- She would expect food to be served at temperatures that were in accordance with state regulations;- She would expect no more than a five minute delay in serving meals that are delivered to the hall from dietary staff;

Based on observation, interview and record review, the facility failed to provide services or care that adhere to accepted standards of quality when the facility failed to properly manage pain, provide medication as ordered by a physician, failed to notify physician of unavailability of pain medication, failed to obtain medication from emergency medication kit on site for one Resident (Resident #100), and failed to follow physician's orders for Residents #9, #94, #113 and failed to implement Diabetes management for Resident #9. This affected four sampled residents out of 24 sampled. The facility census was 116.Review of the facility's Medication Administration Policy dated May 2019, showed staff to administer all medications to overcome illness and to relieve and prevent symptoms as per physician order.Review of the facility policy titled Ordering Medications Policy dated May 2019, showed refill requests can be faxed, sent via Electronic Health Record system, and/or left on the pharmacy refill voicemail.Review of the facility policy titled, Pain Management Policy dated 2/2025, showed every resident has the right to the assessment and management of pain.There was no facility policy provided regarding Emergency Kit narcotics.1.Review of Resident #100's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff) dated 1/13/26, showed:-Resident was cognitively intact-He/she required partial to moderate assist with Activities of Daily Living (ADL) including toileting, dressing and grooming;-He/she was on a scheduled pain medication regimen;-He/she was dependent on staff for medication administration;-Diagnoses included heart failure, spinal stenosis, neuropathy (nerve damage causing pain or weakness) and low back pain. Review of resident's care plan dated 7/31/24, showed:-He/she was cognitively intact;-He/she was prescribed opioids (narcotic pain medication);-No care plan for staff interventions regarding monitoring pain management;-He/She had limited physical mobility and was dependent on nursing staff for mobility and transfers. Review of medication administration record on 1/23/26 showed:-The resident had an order for Hydrocodone/Acetaminophen 7.5mg/325mg by mouth four times a day for low back pain.-The facility scheduled the doses for 8 A.M. 12 P.M., 4 P.M., and 8 P.M.- The Resident missed five doses of scheduled medication and was not administered ordered medications on: 1/20/25 at 4 P.M. and 8 P.M. and 1/21/25 at 8 A.M., 12 P.M. and 4 P.M.Review of the medication administration progress notes for the month of January showed that medication was not available or reordered from pharmacy for all missed doses. There was no documentation that the provider had been notified regarding the missed doses of pain medication.Review of the medication administration record for the month of January showed that the resident had an order for Fentanyl Transdermal Patch 72 25mcg/hr. Apply one patch every 72 hours for Chronic pain. Medication was due and not administered on 1/16/26 and 1/19/26 because they were not available. There was no documentation that the physician was notified.Review of medication administration record showed that there was no additional pain medications ordered or administered while resident was out of prescribed pain medication Hydrocodone and Fentanyl.During an Interview on 1/23/26 at 1:30 P.M., the resident said the time period when the pain medications were not administered was a rough few days and he/she had an increase in pain, the facility offered Tylenol, but that did not help to decrease pain level.During an interview on 1/23/26 at 9:30 A.M., LPN C stated that when a medication is missing, they are to document in Medication Administration Record, notify physician, notify pharmacy and document notifications were made in the resident's medical record. During an interview on 1/23/26, the ADON A, said there was a posted list of medications available in the Emergency kit, however, the list is outdated. ADON A was able to pull up Resident #100 in the medication dispensing machine and confirm that Hydrocodone/Acetaminophen 7.5mg/325mg was available to pull for resident use in the Emergency kit. During an interview on 1/23/26 at 1:30 P.M., the Director of Nursing (DON) stated that it is unreasonable for a resident to miss more than one dose of scheduled pain medications and a list of what medications are in the Emergency kit is available to on all nursing units. The resident, prescriber and unit manager should be notified of medication missed if not available. She was not notified of medications not being administered from Emergency kit or not being re-ordered.2.Review of Resident #94's Comprehensive MDS assessment dated [DATE], showed:-Cognitively intact;-Required minimal assist with toileting and upper body dressing related to recent arm fracture and surgical repair;-Had scheduled and as needed pain medications frequently in the prior 5 days;-Required nursing staff to administer inhaled medications.Review of the facility's Medication Administration Policy dated May 2019, showed staff are to read each order entirely and are to know the use and side effects of each medication that is administered to each resident.Observation on 1/23/26 at 9 A.M., showed resident speaking to Certified Med Tech (CMT) B and said he/she had a runny nose and when he/she asked for a nasal spray the day prior, was given Albuterol inhaler. Resident asked CMT B if that would work CMT B replied, it might.Review of medication administration record on 1/22/26, showed that resident had orders for Acetaminophen Tablet 650mg. Give 2 tablets by mouth every 8 hours as needed for fever. There were no orders for Acetaminophen to be given for pain. There were 14 administrations of medications with associated pain scores documented and that the medication was effective for reported pain. The resident had no fevers documented.Review of medication administration record on 1/22/26, showed: Resident had an order for Oxycodone HCL 5MG every 6 hours as needed for severe pain. There were two administrations of Oxycodone with associated pain scores as two out of 10 on the pain scale. (2 being low and 10 being high pain) There were no additional orders for non-narcotic pain medication.Review of physician orders on 1/23/26, showed that resident had an order for ProAir HFA Inhalation Aerosol solution; 2 inhalations inhale orally every 6 hours as needed for Shortness of breath/wheezing. Resident had received 2 doses of this medication, there was no supporting documentation of shortness of breath or wheezing.During an interview on 1/23/26, CMT B, said the resident stated that new symptoms should be reported to nurse or provider when on unit and new orders come from them. CMT B stated that Acetaminophen should only be given for fever as the order is written. CMT B was able to verify the only other as needed medication for pain available to resident was Oxycodone HCL 5MG. CMT B said that the resident does not like the way it makes them feel.3. Review of Resident #9's admission MDS dated [DATE], showed: -Resident cognitively intact;-Required partial to moderate assist with ADL's, toileting, transfers and dressing;-Diagnoses included kidney failure, diabetes, heart failure and failure to thrive.Review of facility's Weight Assessment and Intervention Policy dated 12/24, showed a 5% weight loss in 1 month is significant and greater than 5% is severe.Review of resident's weight record on 1/21/26, showed: Order from physician to obtain a daily weight on resident on 1/4/26. Since admission, 1/2/26, there were four out of 16 weights not documented (01/03/26, 01/07/26, 01/13/26, 1/17/26). There was documented weight loss of 25.3# or 13% in 19 days. There is no documentation of provider notification of weight loss.During an interview on 1/21/26 at 10:00 A.M., the resident said that he/she had not lost that much weight. Resident also reported that facility had not been performing blood glucose monitoring until requested by resident/family.Review of Hospital Referral on 1/21/26, showed: resident had diabetes mellitus; resident had insulin orders and was administered insulin with blood glucose monitoring.Review of Hospital's discharge medication reconciliation showed that insulin was to be stopped.Review of facility records showed resident was admitted on [DATE] and blood glucose monitoring did not begin until 1/16/26 and only after requested by resident.The facility did not have a Diabetes Management, Hypoglycemia (low blood sugar) or Hyperglycemia (high blood sugar) policies.4. Review of resident #113's admission MDS dated [DATE], showed:- Cognitive impairment;- Fracture of left leg with surgical repair;- Incontinent of bowel and bladder;- Partial to moderate assist with bed mobility, transfers and toileting;-Last documented bowel movement was on 1/2/26;-Diagnoses included recent leg fracture with surgical repair, pain and non-Alzheimer's dementia.Review of resident's care plan dated 1/8/26, showed no mention of pain, incontinence, constipation, recent fracture.Review of Physician's orders for the month of January showed:-Milk of Magnesia (MOM) 400mg/5mL. Give 30mL by mouth every 23 hours as need for constipation. There was no documentation of MOM being provided to the resident.-Bisacodyl Suppository 10MG. Insert 1 suppository rectally every 23 hours as needed for constipation daily if no results from MOM. There is documentation of administration of Suppository on 1/8/26 but no documentation that MOM was administered.Review of nursing progress notes for the month of January showed that resident used their fingers and successfully removed their own fecal impaction in effort to reduce discomfort.During an Interview on 1/22/26 at 11:00 A.M., the resident said that they have had intermittent pain since surgery and when they are immobile is the only time they are pain free. He/she did not believe he/she had constipation problems.During an Interview on 1/23/26 at 1:30 P.M., DON stated that all physician orders should be followed per facility policy and that it would be an expectation for pain to be on the care plan of a resident admitted with pain as a diagnosis.

Based on interview and record review, the facility failed to notify four residents (Resident #16, #23, #75, and #106) when they were within $200.00 of the Social Security Income (SSI) limit ($6,068.80) or when the resident's account was over the SSI limit. This affected four of 24 residents sampled. Facility census was 116. Review of the facility policy, Facility Resident Trust Fund Policy, revised May 2012, showed any individual Resident Trust Account that is nearing the state specified maximum balance will require notification to the Resident/Responsible part via Form letter.1. Review of Resident #16's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 12/30/25, showed:- Resident was cognitively intact;- Diagnoses: coronary artery disease, heart failure, kidney disease, diabetes, anxiety disorder, depression, and dementia;Review of the Resident's Monthly Trust Fund Account Balance, showed:- January 2025 $6366.00, which is over the SSI income limit;- February 2025 $6918.00, which is over the SSI income limit;- March 2025 $6932.00, which is over the SSI income limit;- May 2025 $6857.00, which is over the SSI income limit;- June 2025 $6791.00, which is over the SSI income limit;- August 2025 $6725.00, which is over the SSI income limit;2. Review of Resident #23's Annual MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnoses: coronary artery disease, heart failure, GERD (acid reflux), psychotic disorder, and depression;Review of the Resident's Monthly Trust Fund Account Balance, dated 1/22/25, showed the current account balance $6,263.27, which was over the SSI limit.3. Review of Resident #75's Quarterly MDS, dated [DATE], showed:- Reside was cognitively intact;- Diagnoses: cerebral palsy, anxiety disorder, and depression;Review of Resident's Monthly Trust Fund Account Balance, dated 1/22/25, showed the current account balance was over the SSI limit, $6,114.33.4. Review of Resident #106's Quarterly MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnoses: anemia, hypertension, kidney disease, and depression;Review of the Resident's Monthly Trust Fund Account Balance, showed:- June 2025 $16,859.00, which is over the SSI limit;- August 2025 $18,027, which is over the SSI limit;During an interview on 1/6/25 at 9:30 A.M., the Business Office Manager (BOM) said:- She had discussions with the residents when they are over the SSI limit but has never sent a formal letter informing them of the requirement to spend down their money. She is working with the families and the residents to reduce the balances, but was not aware she was required to send a letter to the resident or guardian.During an interview on 1/8/25 at 10:10 A.M., the Administrator said residents should be assisted in spending down their funds if they are within $200 of the limit of their SSI income level. A letter is required to be sent to each resident notifying them of this situation.

Based on observation and interview, the facility failed to ensure the bathroom exhaust vents were free of excess dust in residents' rooms. This affected 11 rooms. The facility census was 116.Observation on 1/20/26 starting at 11:17 A.M., showed the bathroom exhaust vents covered in dirt in:- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER]. During an interview on 1/21/26 at 3:08 P.M., the Maintenance Director said they cleaned the bathroom exhaust vent twice a year. It was last done in July to August in 2025. He thought the maintenance staff may have started and then got called away to other jobs and not completed the task for all exhaust vents, that was why some of them had so much dirt on them.

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care for two sampled residents, (Resident #13 and #6). This affected two of 24 sampled residents (Resident #13, and #6). The facility census was 116. Review of the facility's Activities of Daily Living Policy dated, 09/04/25, showed this facility provides each resident with care according to the resident's care plan and the resident's ability to perform activities of daily living including bathing, dressing, grooming and toileting. 1.Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/25, showed:-Severe cognitive impairment;-Extensive assistance of two staff members for bed mobility, transfers, toileting and personal hygiene;-Incontinent of bowel and bladder;-Diagnoses included dementia and depression. Review of the resident's undated care plan showed:-ADL self-care deficit;-Incontinent of bowel and bladder;-Assistance of two staff for toileting;-Impaired skin integrity. Observation on 01/22/2026 at 8:03 P.M., showed:-Certified Nurses Aide (CNA) B and CNA D washed their hands and applied gloves;-CNA B and CNA C removed the resident's wet incontinent brief;-CNA B wiped down the left groin, used a new wipe and wiped down the right groin;-CNA B and CNA C turned the resident on his/her side;-CNA B wiped down the middle of the resident's buttocks;-CNA B did not separate and clean all the skin folds;-CNA B did not clean all areas that urine and feces had touched. During an interview on 01/22/2026 at 8:55 P.M CNA B said he/she should have separated and cleaned all areas of the skin where urine or feces has touched. During an interview on 01/22/2026 at 8:55 P.M CNA C said staff should separate and cleanse all areas of the skin where urine or feces has touched. During an interview on 01/22/2026 09:05 P.M., Licensed Practical Nurse (LPN) E said:-Staff should separate and cleanse all skin folds as well as the upper thighs and outer buttocks;-Staff should clean all areas that urine and feces had touched. During an interview on 1/22/26 at 09:10 P.M., the Director of Nursing (DON) said:-She expected staff to separate skin folds and clean all areas urine and feces have touched. During an interview on 1/23/26 at 11:43 A.M., the Administrator said:-She expected the staff to ensure residents were clean and dry;-She expected staff to separate skin folds and clean all areas urine and feces have touched. 2. Review of Resident #6's care plan, showed: Revised 8/29/25 - The resident had bladder incontinence. Assist the resident to the bathroom or offer the bedpan on a routine basis, (upon arising in the morning, before and after meals, at bedtime and as needed). Revised 10/26/25 - The resident had an Activities of Daily Living (ADL) Self Care Performance Deficit Disease Process. The resident required set up and supervision for transfers. The resident required one staff participation to use the toilet. Review of the resident's Significant Change in Status MDS, dated [DATE] showed: Cognitive skills intact. Upper extremity impaired on both sides. Lower extremity impaired on one side. Required supervision or touch assistance with transfers. Required partial to moderate assistance with toilet use. Frequently incontinent of bowel and bladder. Diagnoses included high blood pressure, Osteoporosis (abnormal loss of bone density), and bipolar disorder (a mental condition marked by alternating periods of elation and depression). Observation on 1/22/26 at 8:44 P.M., showed: CNA C used the gait bet (a special belt placed around the resident's waist to provide a handle to hold onto during a transfer) and transferred the resident from his/her electric wheelchair to his/her bed. CNA B and CNA C removed the resident's clothes and placed a gown on the resident. CNA B placed the bedpan under the resident. CNA B wiped down one side of the groin. Used a new wipe and wiped across the pubic and area and down the other side of the groin. CNA B wiped down the middle twice with a different wipe each time. CNA B did not separate and clean all the skin folds. CNA B and CNA C turned the resident on his/her side and CNA B removed the bedpan with a moderate amount of amber urine in it. CNA B wiped up one side of the inner buttocks, used a new wipe each time and wiped from front to back twice. CNA B used a new wipe and with the same area of the wipe, wiped up and down both sides of the buttocks then back and forth across the buttocks. CNA B did not clean all areas of the skin where urine had touched. During an interview on 1/22/26 at 9:19 P.M., CNA C said he/she should separate and clean all the skin folds where urine had touched. It should be one wipe, one swipe. Should not wipe back and forth across both sides of the buttocks. During an interview on 1/23/26 at 9:30 P.M., CNA B said he/she should have separated and cleaned all areas of the skin where urine had touched. He/She should have used one wipe for one swipe and not wiped back and forth across the buttocks. During an interview on 1/23/26 at 9:47 A.M., Assistant Director of Nursing (ADON) C said staff should separate and clean all areas of the skin where urine had touched, including the inner thighs. The staff should not wipe back and forth across the resident's buttocks. During an interview on 1/23/26 at 11:37 A.M., the DON said the staff should separate and clean all areas of the skin where urine had touched. Staff should not wipe back and forth across the buttocks.

Based on observation, interview, and record review, the facility failed promote each resident's right to self-determination when the facility failed to provide services to maintain good grooming and personal hygiene in accordance with resident preferences for two residents (Resident #76 and #92) out of 24 sampled residents. The facility census was 116.Review showed the facility did not provide a policy related to showers.1. Review of Resident #76's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/25, showed:- The resident was cognitively intact;- Required assistance with showering, bathing, and toileting;- Diagnoses included: seizures, diabetes, and heart failure. Review of the Resident's care plan, dated 01/09/26, showed:- The resident preferred a shower on Wednesdays and Saturdays in the evening;- Required two staff participation with bathing;- Staff were required to keep the resident's routine consistent, skin clean, dry, and well moisturized related to fragile skin.Review of the Resident's shower task sheet in the electronic medical record showed staff documented providing six showers over the past 30 days. Showers were provided on a Monday or Friday between the hours of 11:26 A.M. and 2:59 P.M. and not in accordance with the resident's plan of care. During an interview on 01/22/2026 at 7:57 P.M., the Resident said:- He/She didn't get showers that often and it had been almost two weeks since his/her last shower;- The staff tell resident's they can ask for showers, but he/she feels the showers should be scheduled so the staff won't forget to do it;- Going without showers makes him/her feel dirty and he/she does not like feeling that way;- He/She has asked staff to provide a shower and staff have said that they would do it later, but then the staff won't come back to give the shower. He/She doesn't like that.During an interview on 01/22/2026 at 8:04 P.M., the Assistant Director of Nursing (ADON) said:- It was possible that the resident was not getting enough showers because the resident liked to really wash his/her hair, really scrub, and would take a long time in the shower;- He/She had just scheduled the resident for a shower in the morning and not in the evenings.2. Review of Resident #92's Quarterly MDS, dated [DATE], showed:- The resident was cognitively intact;- Dependent on staff with transfers, bathing, and toileting;- Diagnoses included: morbid obesity, diabetes, and respiratory failure. Review of the Resident's care plan, dated 01/16/26, showed:- The resident was totally dependent on staff to provide a bath;- Staff were to provide the resident with a sponge bath when a full bath or shower could not be tolerated;- Staff were to keep the resident's skin clean, dry, and well moisturized related to decreased mobility and incontinence.During an interview on 01/20/2026 at 10:00 A.M., the Resident said:- He/She was lucky to get one bed bath, usually every other week;- He/She doesn't refuse the showers. He/she has trouble remembering things but knows when he/she has not had a shower. It upsets him/her when staff say he/she had already had a shower;Observation on 01/20/2026 at 10:00 A.M., showed the resident lying in bed, his/her hair is greasy and unkempt. A strong smell of foul body odor near the resident.During an interview on 01/22/2026 at 8:30 A.M., ADON B said the resident's shower days had been on Mondays and Thursdays and staff hadn't been able to complete his/her shower on Monday.During an interview on 01/22/2026 at 7:43 P.M., CNA A said:- The facility did not have a shower aide during the day shift; there was only one aide on the evening shift;- Staff should chart the showers in the electronic chart when completed;- Staff should notify the charge nurse if the resident refuses a shower.During an interview on 01/22/2026 at 10:42 A.M., RN A said: - The facility used to have a shower aide but not anymore, so aides on each hall have to provide showers and other duties; - The showers are assigned to the aides on each shift, and completion should be documented in the resident's electronic record;- If a resident refuses, the staff should notify the charge nurse who would try to talk to the resident, at least three times;- Sometimes the residents would sign a refusal and sometimes they would not;- Sundays were makeup days for missed showers.During an interview on 01/22/2026 at 8:34 P.M., the Resident said:- He/She thinks his/her last bed bath was about a week ago; does not like missing showers/baths;- He/She would like to get bathed more often;- He/She did not remember when he/she was last bathed and said he/she enjoys a bed bath and it makes his/her body feel good.Observation on 01/22/2026 at 8:34 P.M., showed the resident lay in bed, his/her hair greasy, with a strong foul body odor. During an interview on 01/22/2026 at 8:04 P.M., ADON B said the resident's showers are scheduled based on room number. Preferences should be given and discussed at care plan meetings. Staff should provide care as directed in the plan of care. During an interview on 01/23/26 at 11:37 A.M., the Director of Nursing (DON) said the residents should receive their showers or bed baths twice a week and should have a choice of date, and time. Staff should provide care as directed in the plan of care.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment when facility staff did not apply Personal Protective Equipment (PPE) when they provided care and treatment for one resident (Resident #13). This affected one of 24 sampled residents (Resident #13). The facility census was 116.Review of the facility's undated, Enhanced Barrier Precautions policy, showed:-Enhanced barrier precautions (EPB) are recommended for residents with any of the following: o Wounds; o Indwelling medical devices; o High contact care activities;-High contact care activities when a gown and gloves should be worn include: o Bathing/showering; o Changing bed linens; o Changing briefs; o Assisting with toileting. 1. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/25, showed:- Severe cognitive impairment;- Extensive assistance of two staff members for bed mobility, transfers, toileting and personal hygiene;- Incontinent of bowel and bladder;- The resident had a wound;- Diagnoses dementia and depression.Review of the resident's undated care plan showed:-Activities of Daily Living (ADL)s self care deficit;-Incontinent of bowel and bladder;-Assistance of two staff for toileting;-Pressure injury to coccyx;-On enhanced barrier precautions due to wound;-Staff will wear gown and gloves when performing high contact resident care.Review of the resident's Physician's Order Sheet (POS) dated January 2026, showed Enhanced Barrier Precautions with providing personal hygiene and toileting.Observation and interview on 01/22/26 at 08:08 A.M., showed:-A sign outside the resident's room that showed the resident was on enhanced barrier precautions;-An isolation cart outside the resident's room;-Certified Nurse Aide (CNA) F and CNA G entered the resident's room;-The resident had a bandage on his/her left buttock;-CNA G uncovered the resident and raised up the resident's gown;-CNA F unfastened the resident's wet brief;-CNA F and CNA G did not put on isolation gowns or gloves before they entered the resident's room and provided care to the resident;-CNA F said the resident was on EBP because he/she had a wound;-CNA F said he/she should have put on a gown and gloves on before he/she entered the resident's room;-CNA F said anytime a resident is on EPB a gown and gloves should be worn when providing peri care;-CNA G said he/she should have put on a gown and gloves on before he/she entered the resident's room;-CNA G said a gown and gloves should be worn when touching bed sheets or the gown of the resident on EPB.Observation and interview on 01/22/2026 at 8:03 P.M., showed:-A sign outside the resident's room that showed the resident was on enhanced barrier precautions;-An isolation cart outside the resident's room;-CNA B and CNA C washed their hands and applied gloves;-CNA B and CNA C removed the resident's wet incontinent brief;-The resident had bandage on his/her left buttock;-CNA B and CNA C provided peri care to the resident;-CNA B and CNA C did not put on isolation gowns before they entered the resident's room and provided care to the resident;-CNA B said the resident was on EBP because he/she had a wound;-CNA B said he/she should have put on a gown on before he/she entered the resident's room;-CNA B said anytime a resident is on EPB a gown and gloves should be worn when providing peri care;-CNA C said he/she should have put on a gown on before he/she entered the resident's room.During an interview on 1/22/26 at 09:10 P.M., the Director of Nursing (DON) said:-She expected staff to put on full Personal Protective Equipment (PPE) when they entered a room with EPB;-The resident had a wound;-A gown and gloves should have been worn when providing cares.During an interview on 12/18/25 at 01:25 P.M. the Administrator said she expected staff to follow the facility protocol when it came to infection control and PPE.

Based on observation, interview and record review, the facility failed to implement and monitor interventions put into place for one resident with significant unplanned weight loss (Resident #97) to prevent the resident from further weight loss when staff failed to offer Super Cereal (a highly nutritious, calorie-dense food to prevent malnutrition) and a Magic Cup (a high-protein nutritional treat designed to fight malnutrition) and when the staff failed document in the resident's medical record that the prescribed diet had not been consumed. Staff additionally failed to notify the resident's physician and the Registered Dietitian (RD) when the prescribed diet had not been consumed. This affected one of 24 sampled residents. The facility census was 116. Review of the Facility's Nutrition and Unplanned Weight Loss policy dated, December 2024 showed:-The nursing staff will monitor and document the weight and dietary intake of residents;-The threshold for significant unplanned weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; 3 months - 7.5 % weight loss is significant; 6 months - 6% weight loss is significant;-The physician will review possible causes of weight loss and consider supplementation strategies to increase the intake of nutrients and calories;-This strategy may include fortification of foods and providing in between snacks and nutritional supplementation.1. Review of Resident #97's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/23/25 showed:-Moderate cognitive impairment;-Substantial assistance of staff for all Activities of Daily Living (ADLs);-Weight of 129 pounds (lbs);-No physician prescribed weight loss;-Weight loss of 5% or more;-No difficulty swallowing or chewing; dependent on staff to assist with meal set up;-Diagnoses included Parkinson's Disease, malnutrition and heart failure.Review of the resident's care plan updated on 01/05/26 showed:-Assist of one for ADLs;-Set up help from staff for eating;-At risk of impaired nutrition;-Serve diet as ordered;-Serve supplements as ordered at breakfast and lunch.Review of the resident's Physician's Order Sheet (POS) dated January 2026 showed:-Order start date: 12/13/25, regular diet and add magic cup at lunch;-Order start date: 12/13/25, fortified foods for supplement, super cereal at breakfast.Review of the resident's medical record showed:(lbs);-12/05/25 129.4 pounds (lbs);-10/07/25 133.6 lbs-09/17/25 136.0 lbs;-06/11/25 144.8 lbs;-No record of weights was found for July, August and November of 2025;-June to December 2025 showed a 15.4 pound weight loss or 10.64% in 6 months. Review of the resident's RD note dated 12/11/25 showed:-Encouragement from staff at meals;-Add super cereal with breakfast and ice cream with lunch;-Monitor intake percentages at meals for changes.Observation and interview on 01/20/26 at 01:23 P.M. showed:-Certified Nurse Aide (CNA) A served the resident his/her lunch;-No magic cup or ice cream was served to the resident;-CNA A said the kitchen provided the magic cup and he/she did not know much about it;-CNA A did not get a magic cup for the resident;-CNA A did not tell the nurse or go to the kitchen, the resident did not get a magic cup.Observation and interview on 01/21/26 at 01:17 P.M., showed:-CNA A served the resident his/her lunch;-No magic cup or ice cream was served to the resident;-The resident said he/she was hungry because he/she did not get breakfast that morning.During an interview on 01/21/26 at 08:17 P.M., CNA A said:-The staff filled out the meal tickets for the resident;-The resident told them what he/she wanted to eat;-The resident did not get a breakfast tray this morning;-He/She went to get the resident a snack before lunch;-He/She did not tell the nurse the resident did not get breakfast tray.A review of the resident's breakfast meal ticket dated 01/22/26 showed:-Sugar and coffee creamer were circled on the meal ticket;-Coffee was circled on the meal ticket;-Super Cereal was circled on the meal ticket;-Cornflakes were written on the bottom of the meal ticket.Observation on 01/22/26 at 09:20 A.M., showed:-CNA F served the resident his/her breakfast;-The resident's breakfast tray contained, a 75 ounce (oz) pre-packaged bowl of corn flakes and a pint of milk;-No Super Cereal was served to the resident.During an interview on 1/22/26 at 10:52 A.M., CNA F said:-The staff filled out the menus for the day before;-He/She does not tell the nurse or the kitchen if the resident does not eat;-He/She had never documented that the resident did not eat or did not get what they ordered.During an interview on 1/22/26 at 11:09 A.M., [NAME] A said:-Super cereal is not a bowl of cornflakes;-The resident should have been offered the super cereal;-All diet orders should be followed. During an interview on 1/22/26 at 11:12 A.M., the Dietary Manager said:-The resident had an order for Super Cereal and a magic cup for weight loss;-He did not know why the resident's breakfast ticket had super cereal circled but corn flakes written on it;-If the resident does not want or does not eat the super cereal the nurse and the RD should be notified;-He was not aware the resident had not been getting the magic cup and the super cereal. During an interview on 01/22/2026 11:22 A.M., Assistant Director of Nursing (ADON) C said:-The nurse, physician and RD should be notified if the resident does not eat;-The resident should be offered the super cereal and the magic cup;-She expected the CNAs to tell the charge nurse if the resident did not eat his/her meal or was not offered his/her ordered diet.During an interview on 1/22/26 at 08:52 P.M., the Director of Nursing (DON) said:-She expects the CNAs to tell the unit manager that the resident did not eat the super cereal, the magic cup and/or the meal;-The super cereal and magic cup must be on the tray and offered to the resident;-The physician and RD should be notified if the resident is not consuming the prescribed diet.During an interview on 1/23/26 at 11:43 A.M., the Administrator said:-She expected the resident to receive his/her diet as ordered by the physician;-The resident is a weight loss and that is why the special diet is ordered;-She expected the CNAs to tell the unit manager that the resident did not eat or did not get the super cereal and magic cup;-She expected the unit manager to tell the physician and the RD.

Based on observation, interview and record review, the facility failed to develop a baseline care plan for one resident (Resident #113), when staff did not care plan pain control. This affected one of 24 sampled residents. The facility census was 116. Review of the facility's Care Plan Policy dated 12/2024, showed: The purpose is to assess strengths, weakness and care needs for each resident that will assist the staff and resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible.1.Review of Resident #113's admission MDS., dated 1/6/26 showed:-Not cognitively intact;-Incontinent of bowel and bladder;-Partial to moderate assistance needed for toileting, toilet hygiene, dressing, transfers and mobility when in bed;-He/She reported frequent pain during the last five days;-Diagnoses included fracture of left lower leg with repair, pain due to internal orthopedic prosthetic devices and cognitive communication deficit. Review of the resident's care plan dated 1/8/26 showed:-He/She was at risk of skin breakdown related to existing pressure injury to coccyx and leg splint;-He/She was dependent on nursing staff for all personal hygiene, grooming, and transfers;-No plan of care regarding incontinence care or toileting programs with staff intervention;-No initiation of a pain management regimen with staff interventions for newly fractured leg;-He/She was dependent on facility staff to assess pain and provide pain management including pain medications. Observation on 1/20/26 at 8:13 A.M., showed the resident yelling from their private room with the door shut, saying I am in pain. The yelling continued for approximately half an hour and could be heard from common areas on the nursing unit.Observation on 01/20/26 at 09:05 A.M., showed a family member in the Resident's room asking staff for the resident to be cleaned up after incontinence.During an Interview on 1/22/26 at 11:00 A.M., the resident said he/she has had intermittent pain since surgery and to not move, was the only time he/she did not feel pain.During an interview on 1/23/26 at 2:30 P.M. the Director of Nursing and Administrator said the/she expected that pain be identified on the resident's care plan if the resident was admitted with pain as a diagnosis.

Based on interviews and record review the facility failed to honor a resident's choice for a Do Not Resuscitate (DNR) advanced directive when the facility staff performed Cardiopulmonary Resuscitation (CPR), an emergency lifesaving procedure performed when the heart stops beating, and notified EMS (Emergency Medical Services) to complete all life saving measures because the facility failed to ensure the DNR had been entered into the resident's physician orders and medical record accurately. The facility census was 108.On [DATE], the Administrator was notified of the past noncompliance incident which occurred on [DATE]. On [DATE], facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented to include:- 100% audit all current residents for proper code status orders and advance directives;- All nursing staff educated on advance directive policy including: * All residents should have an advance directive order in place; * All residents advance directive status audited by social services weekly and sent to clinical leadership; * Night nurses will print code status order listing nightly and ensure all residents have code status, comparing to census and place on the emergency supply crash cart; *If a resident is found to not have a code status in place review miscellaneous under advance directive for Do Not Resuscitate (DNR- No life saving measures), review for completion, enter code status. Notify clinical supervisor;- Education will continue with all new licensed staff prior to working their next scheduled shift;- Director of Nursing (DON) or designee will review code status audit completed by social services weekly for eight weeks to ensure consistency;- DON or designee will audit emergency crash carts three times weekly for code status audit reports being ran nightly by nurses for eight weeks;- Administrator or designee will attend clinical rounds and ensure code status reports are being reviewed two times weekly for eight weeks;- Quality Assurance and Performance Improvement (QAPI) meeting was immediately held with the medical director on [DATE];- DON or designee will audit daily staffing assignments to review that one Basic Life Support (BLS) for healthcare providers Cardiopulmonary Resuscitation (CPR- All life saving measures) certified staff member was scheduled every shift. This will occur Monday through Friday for the next 60 days to ensure consistency;- DON or designee will audit all van transports to review that one BLS for healthcare providers CPR certified staff member was present during transports for full code residents. This will occur Monday through Friday for the next 60 days;- Any deficient practice will be corrected immediately. Patterns or trends will be reported to Quality Assurance (QA) Committee for further recommendations and follow up. The non-compliance was corrected at the time of the onsite visit on [DATE].Review of the facility's Advanced Directive Policy, dated [DATE], showed:- Prior to or upon admission of a resident, the Social Services Director (SSD) or designee will inquire of the resident, and/or his/her representative, about the existence of any written advance directives;- Information about whether or not the resident has executed an advance directive shall be placed in the medical record;- The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive;- Do Not Resuscitate indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no CPR or other life-sustaining treatments or methods are to be used;- Staff will assist the resident or representative to make changes to advanced directives in accordance with state law. Changes and/or revocations will be added to the clinical record. The care plan will be updated to reflect the change.Review of the facility's Cardiopulmonary Resuscitation Policy, dated February 2025, showed:- If a resident is found unresponsive and not breathing normally, a clinical staff member will verify code status using the medical record;- If the resident is full code, per the medical record, a staff member that is certified in CPR will initiate CPR;- If the resident is DNR, per the medical record, notify the attending provider;- Discuss information on advance directives to each resident/representative upon admission and at least quarterly in care conference.1.Review of Resident #1's care plan, revised [DATE], showed:- [DATE] Code Status: DNR; - Ensure resident's wishes are honored in regard to any Advanced Care Directive;- Resident's wishes for end-of-life care will be honored; The resident was on hospice services;- The resident is dependent on staff for activities of daily living, cognitive stimulation, social interaction, and transfers. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:- Cognitive skills intact;- Dependent on staff for all cares;- Diagnoses included: lung cancer and depression.Review of the resident's medical record on [DATE] showed:- On [DATE] a DNR was signed by resident and uploaded to miscellaneous section in record;- On [DATE] at 1:03 P.M. the Physician Order Sheet showed Full Code discontinued but the DNR order or notification of code status change was not entered;- On [DATE] at 4:39 A.M. - LPN B's progress note entered on 3:35 A.M. stated: Certified Nursing Assistants (CNA's) went into change the resident. They rolled resident to change them when the resident stopped breathing. LPN B ran to see if the resident was a full code. Resident was a full code so LPN B called 911, then began CPR on the resident. CNA A called the on-call supervisor to notify them of the situation. At 3:50 A.M. LPN B also notified hospice that the resident had stopped breathing. At 4:00 A.M. the ambulance team arrived and took over CPR/intubation on the resident. At 4:08 A.M. LPN B called the family member and notified them that the resident had stopped breathing and the ambulance was here providing CPR measures to the resident. At 4:35 A.M. the ambulance team announced the time of death. At 4:54 A.M. hospice arrived and updated the police; - On [DATE] at 5:02 A.M. the Assistant Director of Nursing (ADON) arrived at the facility around 4:30 A.M. EMS called the code at 4:35 A.M. The resident made presentable for family;- On [DATE] at 7:29 A.M. LPN B documented the resident's body was released to funeral home. Family present at the bedside;- admission record showed no advance directive listed;- The electronic medical record banner with the resident's information did not indicate the resident was a DNR.During an interview on [DATE] at 11:05 A.M., LPN A said:- Nursing staff should always check a resident's code status;- There should be an order in the resident's chart, it should be notated on the banner, and the nurse could also validate the code status in the miscellaneous section of a resident's medical record;- Clinical nursing staff review code status changes;- Social Services upload the code status changes then nursing changes the orders once uploaded into the chart;- The facility had updated the policy since the incident, to ensure night shift nurses check code statuses;- Social services does a weekly audit on code statuses, and nursing staff review in clinical meetings. During an interview on [DATE] at 11:48 A.M., FNP A (Family Nurse Practitioner) said:- She was upset the incident had occurred since resident had signed the DNR on the 26th, coded over the weekend, and that the information hadn't been updated for quick access by nursing;- She was disappointed for the resident and did not want them to go through that. It had taken a lot to get the resident to sign the DNR because of anxiety, but eventually came around and signed it. During an interview on [DATE] at 12:20 P.M., LPN B said:- To identify a resident as having a DNR code status, it would usually be on the computer and was not for this resident;- Nursing staff would also print a roster with code statuses and place in folder on crash cart located in the hallway, but it was not there;- The roster that was available didn't list the resident, so staff didn't know the resident's current code status;- He/She had called hospice to check the code status and was told the hospice didn't have a record of the resident having a DNR and he/she had to perform CPR;- He/She had called 911 and began CPR;- He/She was educated that he/she should have checked the miscellaneous section to see the uploaded DNR;- He/She had taken the paper on the crash cart and printed a new one that night and the resident wasn't listed as DNR;During an interview on [DATE] at 12:26 P.M CNA A said:- A resident's Code Status should be on the computer, in the heading or on the care plan;- If a resident stopped breathing he/she would get the charge nurse right away and the charge nurse would direct from there. During an interview on [DATE] at 12:32 P.M., CNA B said:- To check a resident for DNR status we would look on the computer under the resident's name;- If a resident's not breathing he/she would go get the nurse and they would handle it from there. During an interview on [DATE] at 1:00 P.M., the DON said:- Regarding the resident's DNR not being readily found, social services had gotten the DNR order and it was given to the nurse to change from full code to DNR. Full code was removed but the nurse said he/she got interrupted and didn't finish entering it;- The procedure for updating the code status involved an email to DON, Administrator, SSD, and ADON when code status changes;- A report sheet with code statuses is printed out and put on the crash cart and the nurses can also check the miscellaneous section in a resident's record for the DNR;- The facility had training the next day to address the incident and proper procedures with all the nurses;- The code status changes will be sent via emails from SSD to clinical staff, then once DNR is entered properly we email back to the chain to verify the change;- Night nurses print out the code status report then verify the number of residents versus the number of codes statuses we have;- The nursing staff are all aware now about this procedure as well as about checking in the miscellaneous section for the uploaded DNR. During an interview on [DATE] at 1:13 P.M., SSD said:- Regarding the incident, the social services assistant had sent an email out to nursing to change the code status after we had received the signed DNR from the resident and he/she was not sure what happened after that;- The change in code status updating had been put into place to ensure it doesn't happen again and she will check to make sure the code statuses are changed when asked and that day, before leaving she will audit to make sure it had been entered correctly.During an interview on [DATE] at 9:30 A.M., the Administrator said:- She had been first made aware of the incident on [DATE]. The on call nurse had called and told her a resident had coded, they performed CPR, and after checking the resident record had noted a valid DNR had been uploaded in the computer but had not been entered into the physician orders and the code status wasn't on the record banner;- She immediately performed an audit on every resident to ensure code status had been entered and was listed properly on the banner;- She then started education with the nurses to ensure they knew where to find the code status, including checking in the miscellaneous section for the uploaded documents;- Education given with night nurses to verify code status versus the number of residents to ensure all are accounted for properly;- The plan going forward included educating all the nurses, including any possible agency nurses, on making sure DNR orders entered, checked, and they know where to locate documentation;- She would also will be monitoring and sitting in on clinical meetings;- If there is a change in code status the SSD sends an email to everyone on the clinical team to ensure the change is entered and we talk about the changes in nursing clinical meetings;- SSD does a code audit every week to ensure code statuses are entered into the records properly;- These procedures are ongoing;- The medical director had been notified and was satisfied with all we had implemented.Intake #2604470

Based on observation, interview and record review, the facility failed to ensure three residents (Resident #1, #2, and #5) received treatment and care in accordance with professional standards of practice when the facility failed to provide timely lab testing with results. Two residents (Resident #2 & #5) were admitted to the hospital with septic shock. The facility also failed to obtain lab testing for one resident (Resident #1) who was without his/her psychotropic medication for fourteen days when the pharmacy would not provide the medication without lab results. The facility also failed to follow physician's orders for the resident when they did not administer psychotropic medication. The sample size was six residents. The facility census was 111. A policy regarding professional standards of care was requested but not provided. Review of the laboratory services agreement, dated 8/1/24, showed: -Lab will travel to location to draw and/or collect patient specimens for duly ordered tests and will transport the specimens to one of the laboratories for testing. -Requisition procedures: -Online: all orders will be submitted via the online order porter for order entry and test results. -Written requisitions: Facility shall use laboratories pre-printed requisition form which must be properly completed by facility and delivered to the laboratory representative by hand at the time of specimen collection. -Reporting procedures: laboratory shall make test results available to facility via the online order portal. Review of facility policy, titled Test Results Notification, dated 12/2024, showed: -Results of laboratory, radiological, and diagnostic tests shall be reported to the facility. The medical practitioner shall be notified of the results. -The medical practitioner shall mark labs as reviewed in the electronic health record. -Director of Nursing or their designee will review results of laboratory, radiological, and diagnostic tests daily. -Any lab result not marked as reviewed by the medical practitioner will be called to the practitioner. Documentation of the notification will be done in the electronic health record. -All other radiological and diagnostic test results will be called to the practitioner. Documentation of the notification will be done in the electronic health record. 1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/13/24, showed: -He/She had severe cognitive impairment; -Total care of all activities of daily living; -Diagnoses included: Alzheimer's disease with late onset (a neurodegenerative disease that affected the brain and caused memory and language problems) dementia, anxiety disorder, depression, insomnia due to other mental disorder, and palliative care (a specialized approach to medical care that focuses on improving the quality of life for people with serious illness). Review of the resident's care plan, revised 12/9/24, showed: -He/She received end of life hospice services; -He/She was at risk for septicemia (a life threatening condition where bacteria or other microorganisms enter the bloodstream and spread throughout the body) and will be minimized and prevented via prompt recognition and treatment symptoms of urinary tract infection (UTI) through review date; -Monitor and document for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; -He/She was on antibiotic therapy, macrobid until 11/18/24 due to UTI; -Administer antibiotics as ordered; -He/She had communication problem due to hearing deficit and cognitive decline; -Monitor, document for physical or nonverbal indicators of discomfort or distress and follow up as needed. Review of the hospice physician's order showed: -11/12/24 at 2:01 P.M., patient showed signs of UTI - delirium, low grade fever, restless and stated he/she hurt and burns in his/her genital area, the physician ordered macrobid 100 mg twice daily for 5 days; -11/22/24 at 2:15 P.M., patient had persistent diarrhea, the physician ordered a TSH (thyroid-stimulating hormone) test (a test that measures thyroid-stimulating hormone in your blood) and C-diff (clostridioides difficile) (a test that measures a bacterium that can cause diarrhea, colitis, and other intestinal conditions). Review of the facility hospice book showed: -On 11/22/24, hand written note from nurse showed he/she provided facility new orders for C-diff and TSH; -On 11/26/24, hand written note from nurse showed he/she provided facility new order for KUB (kidney, ureter, and bladder (KUB) X-ray) to rule out obstruction; -On 12/3/24, note showed provided facility hand written orders on third party form. Review of lab requisition standing order log from 11/1/24-12/30/24, showed no orders on the requisition log for the resident. Review of the resident's progress notes, dated 12/1/24-12/30/24, showed: -On 12/3/24, Assistant Director of Nursing (ADON) wrote resident had been screaming since yesterday and yelling out and had been incontinent of urine several times; -On 12/18/24, Licensed Practical Nurse (LPN) A wrote he/she spoke to hospice nurse who stated she ordered labs to be completed in November and they were not carried out, so nurse entered lab as they had been ordered. -On 12/22/24, Certified Medication Technician (CMT) B heard resident yelling and found the resident on the floor wedged between the nightstand and side of his/her bed at 7:40 P.M.; -On 12/23/24, ADON wrote alerted of resident's swelling to face. He/She assessed resident and found resident to have significant swelling redness, warmth to right side of face and face was firm to touch. Resident was observed leaning forward in Broda chair moaning. Notified hospice and hospice nurse called charged nurse stating the facility could send the resident to hospital. Charge nurse notified him/her, and he/she contacted nurse practitioner (NP). NP ordered radiographic images (xrays) and to start resident on doxycycline (antibiotic used for bacterial infections) 100 mg twice daily for seven days. Xray orders were entered and physician rounded on resident during the xrays. -On 12/23/24, Physician wrote saw resident after being requested by nursing due to resident having a fall overnight. Facility staff think resident landed on their face first and possibly more on right side. Patient observed bent forward in Broda chair all night. Hospice was notified and instructed facility to place resident in common area. On call was notified and instructed to be sent to hospital. Resident observed yelling help repeatedly. Resident was difficult to reposition in reclining position for full physical, but face had extensive edema and right eye edematous and shut. Nurse indicated they had given resident morphine twice during morning. The xray tech came to evaluate and it took three people to hold resident in reclined position in order to obtain plain films of face. He/She reviewed three views of x-ray at patient's side, but was difficult to study due to movement. He/She saw a possible nasal bone fracture which could have contributed to resident's facial swelling. Discussed giving ativan and morphine together at resident's next dose and reposition. He/She attempted to contact hospice nurse to discuss, but could not get through so evaluated resident independently. -On 12/23/24, ADON wrote resident sent to hospital per hospice; -On 12/23/24, ADON wrote resident had UTI and the hospital was going to start resident on a round (treatment of) of IV antibiotics. He/She spoke to resident's representative and representative shared his/her concern with the amount of UTIs resident had since last hospitalization in September. He/She expressed concern that antibiotic was not doing anything for resident's UTI. -On 12/26/24, Director of Nursing (DON) wrote resident continued hospitalization , receiving IV antibiotics for UTI. Review of hospital medical record, dated 12/27/24, showed: -Resident was admitted to hospital on 12/23 with altered mental status, found to be septic (blood infection), pneumonia, MSSA bacteremia (methicillin-susceptible staphylococcus aureus) (a type of bacteria that is sensitive to antibiotic methicillin), and a UTI; -Hospital labs showed on 12/23/24 at 12:36 P.M. that his/her white blood count (WBC) was 37.21 (above a normal white blood count range is 4.5-11.0 in adults); -He/She was treated with IV antibiotics, ancef (cefazolin) (an antibiotic used to treat bacterial infections); -Anticipated discharge from the hospital was 12/31/24. During an interview on 12/29/24 at 9:16 A.M., the resident's representative said: -He/She told facility and hospice three weeks ago the resident probably had a UTI due to his/her change in mental status of being more foggy; -Hospice staff reported they ordered a test for a urinalysis (UA) three weeks before the facility put lab orders in; -The hospice case worker reported to the resident's representative the hospice orders had not been carried out by the facility. -Now Resident #2 was hospitalized with an infection in his/her blood, UTI, and pneumonia; -The hospital had to place the resident on an antibiotic and stated it was going to take three to six weeks to treat the infection in his/her blood; -The hospital stated they may have to put a PICC line (a long, flexible tube that is inserted into a vein in the arm or neck and threaded into a large vein above the heart) in Resident #2. During an interview on 12/30/24 at 3:54 A.M., Certified Nurse Aide (CNA) A said: -He/She reported to the nurse a change in condition with the resident when his/her speech became unclear and he/she had a different look in the face; -He/She usually had clear speech; -He/She noticed a change in condition on Saturday 12/21/24, the same day resident fell out of his/her bed; -He/She was now in the hospital with a UTI. During an interview on 12/29/24 at 4:01 A.M., Licensed Practical Nurse (LPN) A said: -He/She contacted the hospice nurse one day about the resident; -During a call with the hospice nurse, he/she wanted to know the results of the resident's labs; -He/She could not locate the lab orders or that the labs were ever entered into the electronic medical system; -He/She found orders written in the hospice book; -During the last two weeks the resident's yelling and restlessness had increased significantly; -The resident's family member said when the resident got like this, it was because they usually had a UTI; -A UA was completed a month ago, but they had still not received the results from the lab; -The resident was hospitalized for a UTI and was septic. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -Hospice had collected the resident's urine around 12/23/24; -The UA was ordered 12/23/24 at the same time the KUB was ordered for the resident; -The requested lab was completed before the resident went to the hospital; -The results were never received for these labs; -Hospice staff did not have access to facility electronic medical records or the laboratory results. During an interview on 12/31/24 at 2:33 P.M., the Hospice Registered Nurse (RN) Case Manager, said: -There were several lab orders that he/she had written and provided to a facility nurse and wrote in the resident's hospice binder; -He/She would ask for results and the nurse on duty would not have access to the lab system to provide the results; -He/She requested the UA on 11/12/24 and started empirically (by means of observation) treating the resident due to a low grade fever and restlessness; -He/She placed a request for TSH and second request for C-diff on 11/22/24; He/She had ordered the same testing in October, but the labs had not been done; -He/She would write new orders down on the facility form that was titled facility's third party and that form was handed to the facility charge nurse with any new orders he/she provided the facility with; -He/She made C-Diff lab request on 11/22/24; -He/She ordered TSH and C-Diff on 11/26/24; -He/She never received the results for the TSH or the C-Diff; -He/She did not have access to the facility electronic medical record system or the lab system records. 2. Review of Resident #5's Discharge MDS, dated [DATE], showed: -discharged to short-term general hospital; -Return anticipated. Review of Resident #5's entry tracking record MDS, dated [DATE], showed he/she entered from short-term general hospital stay. Review of Resident #5's Admission MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, able to make self-understood and understand others; -He/She was dependent in a wheelchair; -He/She was depending for toileting hygiene; -Diagnosis included UTI, pneumonia (an infection of the lungs), paraplegia (condition resulting in loss of muscle function and sensation in the lower half of the body), sepsis (a life-threatening medical emergency that required immediate medical care), and bacteremia (bacteria in blood stream). Review of the resident's care plan, revised 12/24/24, showed: -Monitor and document for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; -He/She had hypothyroidism; -Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as indicated; -He/She was on antibiotic therapy-sepsis until 1/29/24; -Administer medications as ordered. Review of lab requisition standing order log from 11/1/24-12/31/24, showed: -On 11/22/24, UA with urine culture was ordered, a note was made that it was not ready by the phlebotomist; -On 11/27/24, UA was picked up and signed for by phlebotomist; -On 12/4/24, UA with urine culture, signed by phlebotomist with note that it was not ready. Review of laboratory reports showed: -On 11/26/24, a UA was collected, it was reported 12/3/24 a problem with sample integrity; -On 12/5/24, a UA was collected and was reported on 12/9/24 report was 5 days after specimen collection. During an interview on 12/31/24 at 11:33 A.M., NP B said: -The resident and his/her spouse came to him/her two weeks before going to the hospital and indicated he/she had foul smelling urine; . -The resident requested a UA so they could ensure they did not have a bladder infection; -He/She developed a plan with facility staff in order to complete straight catheter specimen collection due to complexity of resident's paraplegia and their inability to retain urine during transfers via mechanical lift; -The specimen was collected and something happened with the lab where the specimen was not labeled correctly and the specimen was not processed; -A week and a half later he/she still did not have the lab results; -The resident was hospitalized [DATE]-[DATE] for UTI with sepsis. -Every time the resident had a UTI he/she would go septic and go to hospital; -He/She ended up becoming septic and was hospitalized again; -He/She was currently receiving intravenous line (IV) antibiotics in the hospital. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -The resident could turn septic really quickly; -The resident was sent to hospital before his/her UA results were received; -It can almost be too late by the time the facility collects the UA specimen and results were received from the lab; -He/She was unaware of any delay in collection for this resident's UA samples. 3. Review of Resident #1's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -Diagnoses included: Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder), overactive bladder, need for assistance with personal care, personality disorder, anxiety disorder (a mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life), depression, and bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior). Review of the resident's care plan, revised 12/18/24, showed: -He/She had depression, anxiety, bipolar, and schizoaffective disorder; -Clozapine (a medication used to treat schizophrenia) treatment had caused severe neutropenia, defined as an absolute neutrophil count (ANC) (a blood test that measures the number of neutrophils in the blood) less than 500/mm3. Severe neutropenia can lead to serious infection and death. Prior to initiating treatment, a baseline ANC must be at least 1,500/mm3 for the general population and must be at least 1,000/mm3 for patients with documented benign ethnic neutropenia (BEN). During treatment, patients must have regular ANC monitoring. Advise patients to immediately report symptoms consistent with severe neutropenia or infection (fever, weakness, lethargy, sore throat). -Because of risk of severe neutropenia, clozapine is available only through restricted program under a risk evaluation mitigation strategy called Clozapine REMS program. -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Monitor/document/report to NURSE/MD signs and symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Review of physician's orders, dated 12/30/24, showed: -Ordered 10/11/23, clozapine oral tablet 50 mg tablet, give 1 tablet by mouth daily at bedtime; -Ordered 10/12/23, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder; -Ordered 12/17/24, weekly complete blood count with differential (CBCD) lab for clozapine. Review of the resident's electronic progress notes, dated 12/1/24-12/30/24, showed: -On 12/17/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, medication was not in stock. Pharmacy was waiting on labs. The ADON was aware; -On 12/17/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on pharmacy to deliver medication, charge nurse and unit manager aware; -On 12/18/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting for lab to draw blood, then needed to fax pharmacy results. Charge nurse and unit manager notified; -On 12/18/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, medication unavailable, waiting for lab results to send to pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/19/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not in stock, pharmacy is waiting for labs. The ADON was made aware; -On 12/19/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting for lab results to fax to pharmacy; -On 12/21/24, CMT B wrote clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder. This medication was not available until the patients' labs were give to the pharmacy, the ADON was made aware; -On 12/22/24, CMT B wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, this medication was not available, labs were needed; -On 12/22/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available in stock, pharmacy needed a copy of the labs; -On 12/23/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on pharmacy to deliver, charge nurse, unit manager, and medical doctor aware; -On 12/24/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on lab results to fax to pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/24/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder. This medication was not available until labs were received, the ADON is aware of this; -On 12/25/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting for delivery from pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/25/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available until pharmacy received labs; -On 12/26/24, CMT C wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder not available; -On 12/26/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth for schizoaffective disorder, this medication is not available until labs have been received; -On 12/27/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on pharmacy to deliver, charge nurse, unit manager, and medical doctor aware; -On 12/27/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet my mouth at bedtime for schizoaffective disorder. This medication was not available, until pharmacy has new labs; -On 12/28/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on lab results, charge nurse, unit manager, and medical doctor aware; -On 12/28/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet my mouth at bedtime for schizoaffective, this medication was not available at this time, new labs were needed; -On 12/29/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on lab, charge nurse, unit manager, and medical doctor aware; -On 12/29/24, CMT B wrote clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available at that time, the pharmacy was needing updated labs; -On 12/30/24, CMT C wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, not available; -On 12/30/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available, new labs were needed. Review of the lab requisition standing order log, dated 12/1/24-12/30/24, showed: -On 12/9/24 a CBC with differential was ordered, there were no initials entered by phlebotomist that these labs were obtained; -On 12/16/24 a CBC with differential was ordered, there were no initials entered by phlebotomist that these labs were obtained; -On 12/28/24 a UA with urine culture was ordered, there were no initials entered by phlebotomist that this specimen was obtained; -On 12/30/24 a CBC with differential was entered and were initialed that had been completed by phlebotomist; Review of laboratory reports, 12/1/24-12/30/24, showed: -On 12/3/24 CMP was collected and CBC with differential, and reported to the facility nursing staff on 12/4/24; -No other lab reports were available for December. During an interview on 12/30/24 at 2:29 P.M., the resident said: -He/She was experiencing itching, burning and his/her urine looked like lemonade; -He/she and needed another lab to be done; -The nurse on duty working on Friday night (12/27) was going to take urine for his/her labs to be complete, but the facility did not have any urine specimen containers; -He/She was put on ciprofloxacin (an antibiotic used to treat infections) a month ago; -He/She did not know if the facility ever received his/her lab results; -He/She had been without his/her clonazepam for two weeks; -He/She saw his/her psychiatric doctor two weeks ago and he/she had been without the medication since then; -He/She had felt more stressed, had not been slept well, had cringed his/her teeth which made his/her jaw and forehead hurt since not having his/her psychotropic medication. During an interview on 12/30/24 at 4:01 A.M., LPN A said: -The resident was to have labs completed one time weekly for psychotropic medication clozapine; -The last lab for the resident was last completed on 12/4/24; -CMT A had reported this to him/her several times; -The lab had still not come out and drawn his/her labs; -The online laboratory system showed nothing in lab reports to be viewed or pulled up for the resident. During an interview on 12/30/24 at 2:47 P.M., the DON said: -The resident had not received his/her psychotropic medications due to the lab never made it on Friday and never collected labs on the resident; -The facility notified the lab regarding the failed pick up and the physician was made aware. During an interview on 12/31/24 at 11:02 A.M., CMT A said: -The resident had been without his/her clonazepam for approximately two weeks; -He/She notified all the nurses; -The pharmacy would only send five medications at a time; -The pharmacy wanted weekly lab draws in order for staff to provide medication; -The resident's last lab draw was on 12/3/24; -The resident had been restless during the night; -He/She had not observed any other behavior changes in the resident; -The psychiatrist was notified regarding the medication; -He/She had contacted the pharmacy every day regarding the medication; -The clonazepam was not available in the facility emergency medication storage system to provide to the resident. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -The NP changed his/her laboratory orders to monthly in November; -He/She talked with the pharmacy and pharmacy said the way the medication was ordered it required weekly laboratory results; -The NP changed the lab orders to weekly; -The labs were on requisition for labs to be obtained on 12/9 and 12/16, but were not drawn by the phlebotomist and there was no reason from the lab on why the requisition was left blank; it was not done. During an interview on 12/31/24 at 1:19 P.M., the Psychiatrist office manager said: -The resident was last seen on 12/16/24 in the office; -The facility had not notified the physician about any issues with the resident being able to obtain his/her clonazepam; -That call was the first time their office was made area aware of any issues with the resident not receiving the clonazepam. During an interview on 1/2/25, the Psychiatrist said: -He/She changed the lab order to be completed monthly during the resident's last appointment; -He/She provided a printed lab order to the resident during his/her visit on 12/16/24; -Possible results of the resident not receiving his/her medication included mood changes, manic episodes, and a risk of psychosis. 4. During an interview on 12/30/24 at 4:01 A.M., LPN A said: -The facility had a new lab, they are supposed to pick up labs 2:00-3:00 A.M. on Mondays, Wednesday, and Friday; -If labs were ordered stat (immediately), the lab was [NAME] (late); -Each unit in the facility has a soiled utility room with a fridge and laboratory staff know to come check refrigerators if there are urine samples to be picked up. on 11/21/24 inquiring why he/she had so many UA orders at the same time. -He/She contacted the nurse practitioner about not having the lab results and if he/she should recollect the UAs; -The DON and ADON contacted him/her via text message on 11/21/24 after she put in new UA orders and wanted to know why all the orders had been entered for so many residents; -He/She notified DON/ADON that residents were still experiencing symptoms and no lab results were found. During an interview on 12/30/24 at 5:48 A.M., RN A said: -There was issues with stat lab orders as the lab did not respond as they should for stat labs. During an interview on 12/31/24 at 9:40 A.M., NP A said: -There had been a delay in treatment for residents in the facility due to issues with the laboratory company; -The delay in laboratory results had especially impacted residents with UTIs having delayed treatments, and even hospitalization . During an interview on 12/30/24 at 2:47 P.M., the DON said: -She was aware of the issues with laboratory services; -The laboratory did not always show up as scheduled; -At times the laboratory phlebotomist will show up and say they only had time to do lab draws on five residents and then leave; -The laboratory company had promised a lot of items they had not been able to commit to. -The corporate facility staff had talked to their management team multiple times; -She expected stat lab orders to take six hours or less; -There were times that stat lab orders will be made and the laboratory will say that they cannot be to the facility until Monday morning; -The facility had advised the laboratory they were willing to pay stat fees and the facility could not get the laboratory to come out even with fees; -NP A had questioned where lab results were located and would contact the laboratory and try to locate specimens; -She expected urine specimens to be picked up within 24 hours; -The facility had to start adding CBC on all UA orders or the laboratory would refuse to pick up the UA; -She did not know where some specimens were, if they had been picked up or if specimens had been thrown away; -The facility was giving the laboratory 48 hours before they would attempt to call and track down results; -There were multiple issues with locating and obtaining laboratory results; -The laboratory came to pick up this afternoon, on Mondays the laboratory was supposed to be arriving between 2-3 A.M.; -There are some dates nothing is ever picked up by the lab company. During an interview on 12/30/24 at 3:14 P.M., the Administrator said: -He/She was aware there was issues with the laboratory including issues with labs being drawn, labs being picked up, and stat labs sometimes taking longer to obtain results; -He/She expected the laboratory to take what specimens were in the refrigerators every time they were in the facility; -He/She believed the lab came to the building [NAME] days a week; -He/She was unsure on expectation of how long stat laboratories should take; -He/She was not aware of any outcomes to residents as a result of not having laboratories drawn or test results back in a timely manner. During an interview on 12/31/24 at 10:31 A.M., Laboratory Account Manager said: -The facility was to order lab work and put in the lab requisition book; -The laboratory technician would go to the facility, get the lab requisition book and then proceed to draw the patient's labs; -Stat labs are put in by the facility and the laboratory customer service was alerted and dispatch out the orders to a technician; -Stat lab orders are processed at a local hospital; -The stat lab results are faxed to the facility, but the system was not perfect and sometimes the lab had to call the hospital to get results because the hospital's patients came first over our stat labs; -UAs are put on lab requisition orders and laboratory technicians pick up the specimens; -The laboratory turn around time for results is same day or the next morning

Based on observation, interview and record review, the facility failed to provide necessary laboratory services for residents when they did not ensure residents needs were met with timely collection and reporting of laboratory results. This occurred when the facility failed to obtain lab testing for one resident (Resident #1) who was without his/her psychotropic medication for fourteen days when the pharmacy would not provide the medication without lab results. The facility also failed to ensure urine cultures for residents with potential urinary tract infections (UTI) were collected by the laboratory company, tested , and results received by the facility so the physician's could properly treat infections Residents #1, #2, #3, #4, #5, and #6 for signs and symptoms of UTI. The facility additionally failed to provide timely lab testing with results for two residents (Resident #2 & #5). The facility also failed to ensure sufficient laboratory testing supplies were available for staff, when the facility had no urine specimen containers in the building. The facility census was 111. Review of facility policy, Test Results, dated 12/2017, showed: -Results of laboratory, radiological, and diagnostic tests shall be reported to the facility. -The Medical practitioner shall be notified of the results. -The Director of Nursing Services, or nurse receiving the test results, shall be responsible for notifying the medical practitioner of such test results. Review of facility policy, Test Results Notification, dated 12/2024, showed: -Results of laboratory, radiological, and diagnostic tests shall be reported to the facility. The medical practitioner shall be notified of the results. -The medical practitioner shall mark labs as reviewed in the electronic health record. -Director of Nursing or their designee will review results of laboratory, radiological, and diagnostic tests daily -Any lab result not marked as reviewed by the medical practitioner will be called to the practitioner. Documentation of the notification will be done in the electronic health record. -All other radiological and diagnostic test results will be called to the practitioner. Documentation of the notification will be done in the electronic health record. Review of laboratory services agreement, dated 8/1/24, showed: -Lab will travel to location to draw and/or collect patient specimens for duly ordered tests and will transport the specimens to one of laboratories for testing. -Requisition procedures: -Online: all orders will be submitted via the online order porter for order entry and test results. -Written requisitions: Facility shall use laboratories pre-printed requisition form which must be properly completed by facility and delivered to the laboratory representative by hand at the time of specimen collection. -Reporting procedures: laboratory shall make test results available to facility via the online order portal. -The lab agreement did not mention responsibility of lab supplies. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/27/24, showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -Diagnoses included: Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder), overactive bladder, need for assistance with personal care, personality disorder, anxiety disorder (a mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life), depression, bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior). Review of care plan, revised 12/18/24, showed: -He/She was on an antibiotic therapy for a UTI until 12/1/24; -He/She had depression, anxiety, bipolar, and schizoaffective disorder; -Clozapine (a medication used to treat schizophrenia) treatment had caused severe neutropenia, defined as an absolute neutrophil count (ANC) (a blood test that measures the number of neutrophils in the blood) less than 500/mm3. Severe neutropenia can lead to serious infection and death. Prior to initiating treatment, a baseline ANC must be at least 1,500/mm3 for the general population and must be at least 1,000/mm3 for patients with documented benign ethnic neutropenia (BEN). During treatment, patients must have regular ANC monitoring. Advise patients to immediately report symptoms consistent with severe neutropenia or infection (fever, weakness, lethargy, sore throat). -Because of risk of severe neutropenia, clozapine is available only through restricted program under a risk evaluation mitigation strategy called Clozapine REMS program. -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Monitor/document/report to NURSE/MD signs and symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Review of physician's orders, dated 12/30/24, showed: -Ordered 3/5/24, UA with complaints and symptoms of dysuria; -Ordered 3/8/24, UA with complaints and symptoms of cloudy urine or dysuria; -Ordered 5/28/24, Obtain UA with complaints and signs of burning, increase in urinary frequency; -Ordered 12/17/24, weekly complete blood count with differential (CBCD) lab for clozapine. An interview on 12/30/24 at 2:29 P.M., the Resident said: -He/She was experiencing itching, burning and needed another lab to be done; -The nurse working on Friday night was going to take urine for his/her labs to be completed but the facility did not have any urine specimen containers; -He/She was put on ciprofloxacin (an antibiotic used to treat infections) a month ago; -He/She did not know if facility ever received his/her lab results; -He/She had been without his/her clozapine for two weeks; -He/She had felt more stressed, had not been slept well, had cringed his/her teeth which made his/her jaw and forehead hurt since not having his/her psychotropic medication. Review of the resident's electronic progress notes, dated 12/1/24-12/30/24, showed: -On 12/17/24, Certified Medication Technician (CMT) B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, medication was not in stock. Pharmacy was waiting on labs. The assistant director of nursing (ADON) was aware; -On 12/17/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on pharmacy to deliver medication, charge nurse and unit manager aware; -On 12/18/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting for lab to draw blood, then needed to fax pharmacy results. Charge nurse and unit manager notified; -On 12/18/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, medication unavailable, waiting for lab results to send to pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/19/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not in stock, pharmacy is waiting for labs. The ADON was made aware; -On 12/19/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting for lab results to fax to pharmacy; -On 12/21/24, CMT B wrote clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder. This medication was not available until the patients' labs were give to the pharmacy, the ADON was made aware; -On 12/22/24, CMT B wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, this medication was not available, labs were needed; -On 12/22/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available in stock, pharmacy needed a copy of the labs; -On 12/23/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on pharmacy to deliver, charge nurse, unit manager, and medical doctor aware; -On 12/24/24, CMT A wrote, clozapine oral tablet 25mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on lab results to fax to pharmacy .charge nurse, unit manager, and medical doctor aware; -On 12/24/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder. This medication was not available until labs were received, the ADON is aware of this; -On 12/25/24, CMT A wrote, clozapine oral tablet 25mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting for delivery from pharmacy, charge nurse, unit manager, and medical doctor aware; -On 12/25/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available until pharmacy received labs; -On 12/26/24, CMT C wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder not available; -On 12/26/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth for schizoaffective disorder, this medication is not available until labs have been received; -On 12/27/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on pharmacy to deliver, charge nurse, unit manager, and medical doctor aware; -On 12/27/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet my mouth at bedtime for schizoaffective disorder. This medication was not available, until pharmacy has new labs; -On 12/28/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, waiting on lab results, charge nurse, unit manager, and medical doctor aware; -On 12/28/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet my mouth at bedtime for schizoaffective, this medication was not available at this time, new labs were needed; -On 12/29/24, CMT A wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, still waiting on lab, charge nurse, unit manager, and medical doctor aware; -On 12/29/24, CMT B wrote clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available at that time, the pharmacy was needing updated labs; -On 12/30/24, CMT C wrote, clozapine oral tablet 25 mg, give 1 tablet by mouth one time a day for schizoaffective disorder, not available; -On 12/30/24, CMT B wrote, clozapine oral tablet 50 mg, give 1 tablet by mouth at bedtime for schizoaffective disorder, this medication was not available, new labs were needed. Review of the lab requisition standing order log, dated 12/1/24-12/30/24, showed: -On 12/3/24, Thyroid Stimulating Hormone- 3 Ultra (TSH 3-UL, a thyroid test), lipid profile with calculated (a blood test that measures the levels of various fats in the blood stream) low-density lipoprotein (LDL) (a type of cholesterol found in the blood), comprehensive metabolic panel (CMP, a routine blood test that measured 14 substances in the blood that provide information about a person's overall health), glycohemoglobin A1C (glyco-HGBA1C, a blood test that shows average blood sugar), and CBC with differential (a lab test that measures the number and types of various cells in the blood including red blood cells, white blood cells, and platelets) was ordered, the phlebotomist initialed as completed; -On 12/9/24 a CBC with differential was ordered, there were no initials entered by phlebotomist that these labs were obtained; -On 12/16/24 a CBC with differential was ordered, there were no initials entered by phlebotomist that these labs were obtained; -On 12/28/24 a UA with urine culture was ordered, there were no initials entered by phlebotomist that this specimen was obtained; -On 12/30/24 a CBC with differential was entered and were initialed that had been completed by phlebotomist. Review of laboratory reports, 12/1/24-12/30/24, showed: -On 12/3/24 CMP was collected, and reported to the facility nursing staff on 12/4/24; -No other lab reports were available for December. During an interview on 12/30/24 at 4:01 A.M., Licensed Practical Nurse (LPN) A said: -He/She collected a urinalysis for the resident on 11/21/24 because he/she was contacted by DON and unit manager on the same date inquiring why he/she had so many urinalysis orders for residents to put in system; -The Resident still had complaints today that he/she had burning pain when urinating; -The Resident told me he/she still needed a urinalysis; -The Resident was to have labs completed one time weekly for psychotropic medication clozapine; -The last lab for the Resident was last completed on 12/4/24; -CMT A had reported this to him/her several times; -The online laboratory system showed nothing in labs reports to be viewed for the resident; -LPN B reported he/she had tried to collect a urine specimen over the weekend on 12/27/24 but there were no urine specimen containers available. During an interview on 12/30/24 at 2:47 P.M., Director of Nursing (DON) said: -Resident had not received his/her psychotropic medications due to the lab never made it on Friday and never collected labs on resident; -The facility notified the lab regarding the failed pick up and the physician was made aware. During an interview on 12/31/24 at 11:02 A.M., CMT A said: -Resident had been without his/her clozapine for approximately two weeks; -He/She notified all the nurses; -The pharmacy would only send five medications at a time; -The pharmacy wanted weekly lab draws in order for staff to provide medication; -Resident's last lab draw was on 12/3/24; -Resident had been restless during the night. During an interview on 12/31/24 at 12:36 P.M., the Assistant Director of Nursing (ADON) said: -The nurse practitioner changed her laboratory orders to monthly in November; -He/She talked with the pharmacy and pharmacy said the way the medication was ordered it required a weekly laboratory results; -The nurse practitioner changed the lab orders to weekly; -The labs were to be obtained on 12/9 and 12/16 but were not drawn by the phlebotomist and there was no reason from lab on why it was not done. During an interview on 12/31/24 at 1:19 P.M., Psychiatrist office manager said: -He/She was last seen on 12/16/24 in the office; -This was the first time their office was made area aware of any issues with resident not receiving the clonazepam. During an interview on 1/2/25, the Psychiatrist said: -He/She did change the lab order to be completed monthly during resident's last appointment; -He/She provided a printed lab order to the resident during his/her visit on 12/16/24; -He/She expected mood changes, manic episodes, and a risk of psychosis if resident did not receive his/her clonazepam. 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -Total care of all activities of daily living; -Diagnoses included: Alzheimer's disease with late onset (a neurodegenerative disease that affected the brain and caused memory and language problems) dementia, anxiety disorder, depression, and palliative care (a specialized approach to medical care that focuses on improving the quality of life for people with serious illness) Review of care plan, revised 12/9/24, showed: -He/She received end of life hospice services; -He/She was at risk for septicemia (a life threatening condition where bacteria or other microorganisms enter the bloodstream and spread throughout the body) and will be minimized and prevented via prompt recognition and treatment symptoms of UTI through review date; -Monitor and document for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of hospice physician's order showed: -11/12/24 at 2:01 P.M., resident was showing signs of UTI-delirium, low grade fever, restless and stated he/she hurt and burns in his/her genital area, physician ordered macrobid 100mg BID x 5 days. During an interview on 12/29/24 at 9:16 A.M., resident's representative said: -He/She told facility and hospice three weeks ago that resident probably had a urinary tract infection due to her change in her mental status of being more foggy; -It took three weeks to send the resident to the hospital; -Hospice staff reported that they ordered a test for a urinalysis; -Hospice told resident representative that the urinalysis was never completed when they followed up with the facility; -The hospital placed the resident on an antibiotic for three to six weeks to treat the infection in his/her blood; -The hospice case worker reported to the resident's representative that the hospice orders had not been carried out by the facility. Review of the resident's progress notes, dated 12/1/24-12/30/24, showed: -On 12/3/24, ADON wrote resident had been screaming since yesterday and yelling out and had been incontinent of urine several times; -On 12/18/24, LPN A wrote he/she spoke to hospice nurse who stated she ordered labs to be completed in November and they were not carried out, so nurse entered lab as they had been ordered; -On 12/23/24, ADON wrote resident sent to hospital per hospice; -On 12/23/24, ADON wrote resident had UTI and the hospital was going to start resident on IV antibiotics. -On 12/26/24, DON wrote resident continued hospitalization , receiving IV antibiotics for UTI. Review of lab requisition standing order log from 11/1/24-12/30/24, showed: -No orders on requisition log for resident. Review of hospital medical record, dated 12/27/24, showed: -Resident was admitted to hospital on 12/23 with altered mental status, sepsis (blood infection) with pneumonia, MSSA bacteremia (methicillin-susceptible staphylococcus aureus) (a type of bacteria that is sensitive to antibiotic methicillin); -Hospital labs showed on 12/23/24 at 12:36 P.M. that his/her white blood count (WBC) was 37.21 (above a normal white blood count range is 4.5-11.0 in adults); -He/She was treated with IV antibiotics, ancef (cefazolin) (an antibiotic used to treat bacterial infections). During an interview on 12/30/24 at 3:54 A.M., Certified Nurse Aide (CNA) A said: -He/She reported to nurse a change in condition with resident when his/her speech became unclear and had a different look in the face; -He/She noticed change in condition on Saturday, the same day resident fell out of his/her bed. During an interview on 12/29/24 at 4:01 A.M., LPN A said: -During a call with the hospice nurse he/she wanted to know the results of resident's labs; -He/She could not locate that lab orders were ever entered into electronic medical system; -He/She found orders written in the hospice book; -During last two weeks resident's yelling and restlessness had increased significant; -The resident's family member said when resident got like this it was usually a urinary tract infection; -A urinalysis was completed a month ago but still had not received the results from the lab; -Resident is hospitalized for a urinary tract infection and sepsis. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -Hospice had collected residents urine around 12/23/24; -The urinalysis was ordered at same time the KUB (kidney, ureter, and bladder on 12/23/24) (a medical imaging test that used xrays to visualize organs in urinary system) was ordered for resident; -The requested lab was completed before the resident went to the hospital; -The results were never received for these labs; -Hospice staff does not have access to facility electronic medical records or the laboratory results. During an interview on 12/31/24 at 2:33 P.M., Hospice RN Case Manager, said: -There were several lab orders that he/she wrote and provided to facility nurse and wrote in the resident's hospice binder; -He/She would ask for results and the nurse on duty would not have access to the lab system; -He/She requested the UA on 11/12/24 and started empirically (by means of observation) treating resident due to low grade fever and restlessness; -He/She placed a request for TSH (a thyroid-stimulating hormone) (a blood test that can measures thyroid hormone levels) and second request for c.dff (clostridium difficile) (a test to detect the presence of C.diff bacteria and its toxins) on 11/22/24; -He/She had ordered the same testing in October but the labs had not been done; -He/She would write orders down on piece of paper and hand to the nurse via facility's third party form; -He/She made c.diff lab request on 11/22/24; -He/She ordered TSH and C.diff on 11/26/24; -He/She never obtained the results for the TSH or the C.diff; -He/She did not have access to the facility electronic medical record system or the lab system records. 3. Review of Resident #3's, Annual MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She required partial to moderate assistance with toileting; -Diagnoses included: Respiratory failure (a condition in which lungs were unable to effective exchange gases), and muscle weakness. Review of care plan, revised 12/16/24, showed: -He/She required a one person assist with personal hygiene; -Staff to monitor his/her lab work including potassium, sodium, blood urea nitrogen, and creatinine. During an interview on 12/30/24 at 2:32 P.M., the resident said: -He/She had a UTI and kept telling the aides and nurses about it; -It was upsetting that the nursing home staff did nothing about his/her concerns; -He/She had been experiencing cloudy urine; -Spoke with nurse practitioner who was unaware of her symptoms or concerns; -The nurse practitioner said would have staff obtain a UA; -He/She never received any test results from his/her provided specimens; -He/She received a shot of ceftriaxone for the infection. Review of electronic medical record's provider progress notes, dated 12/1/24-12/30/24, showed: -On 12/5/24, Nurse Practitioner (NP) A wrote, resident having urinary tract symptoms. A urinalysis was ordered on 12/5 for dysuria (discomfort with urination), results were pending; -On 12/11/24, NP A followed up at patient request due to on going urinary tract symptoms and strong foul urine smell. UA had been ordered 12/5, but no results were available. A UA was reordered. Started resident on AZO for symptoms and would follow up after UA and culture results. If symptoms were worse would consider empiric (treatment based on observations of symptoms) treatment but at time resident appeared stable; -On 12/27/24, NP A followed up on UTI including cloudy urine, bladder pressure, no burning. He/She would order Rocephin to empirically (by means of observation) as he/she had symptoms for prolonged period and still did not have urinalysis results. Will follow up on symptoms and UA results when they were available. Review of lab requisition standing order log, dated 12/1/24-12/30/24, showed: -On 12/5/24, basic metabolic panel including glomerular filtration rate (GFR), urinalysis (UA) (a laboratory test that examines a urine sample to detect various substances and conditions) with culture, was completed and signed by phlebotomist; -On 12/11/24, a UA with urine culture was ordered, there was no phlebotomist initials of completion; -On 12/28/24, a UA with urine culture was ordered, there was no phlebotomist initials of completion. Review of laboratory reports showed: -On 11/20/24, specimen was collected, it was reported on 12/10/24 as problem with sample integrity; -On 12/5/24, specimen was collected for Basic Metabolic panel including GFR (BMP), it was reported on 12/6/24. A urine specimen was not included in the results; -There was no laboratory reports found for the resident on 12/11/24 or 12/28/24. During an interview on 12/30/24 at 4:01 A.M., LPN A said: -Resident is having complaints of his/her urine burning pain; -He/She obtained UA on 11/21/24 for resident; -A UA on 12/10 was ordered but there were no results in lab system; -A stat UA was ordered on 12/14, but there were no lab results; -There was an order in the system to obtain a UA again on 12/27, but there were no specimen containers in facility to obtain orders; -Resident asked for another UA that morning on 12/30/24, because he/she was still experiencing burning while urinating; -He/She gave resident a medication shot, ceftriaxone also known as Rocephin (an antibiotic to treat infections), in his/her right hip on 12/27/24 for a UTI but there were still no UA results available from the laboratory; -The physician was treating resident without lab results for the UTI; -LPN B told LPN A on 12/29/24 that he/she could not do another UA on resident because the facility did not have urine specimen collection containers. During an interview on 12/31/24 at 9:40 A.M., NP A said: -He/She had ordered urinalysis on the resident three times and it had disappeared; -He/She had to empirically (by means of observation or experience) treat resident because he/she had been sick for a month and had to do something for resident. During an interview on 12/31/24 at 12:36 P.M., the ADON said: -There had been a delay in the collection of resident's UA due to collection error; Resident had accident thrown toilet paper in his/her collection hat; -He/She would not have expected it to take the facility three weeks to collect a urinalysis on the resident. 4. Review of Resident #4, Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She required partial to moderate assistance with toileting hygiene; -Diagnoses included: Dementia (a condition causing cognitive impairment and difficulty with daily tasks), and diabetes (a condition resulting from too much sugar in the blood). Review of care plan, revised 8/5/24, showed: -Monitor for signs and symptoms of UTI: pain, burning, bladder infection, loss of bladder tone, deepening of urine color, increased pulse, temperature, and foul smelling urine; -Resident will maintain lab values within acceptable parameters per medical doctor through review date; -Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as indicated; -He/She was currently on antibiotic therapy for UTI until 12/4/24; -He/She will be free from any discomfort or adverse side effects of antibiotic therapy through the review date; -Administer medications as ordered. Review of physician's orders, dated 12/30/24, showed: -Ordered 9/24/24, check UA with complaints and symptoms related to burning with urination; -Ordered 12/19/24, saccharomyces boulardii capsule 250mg, give 1 capsule by mouth twice a day probiotic chronic interstitial cystitis (also known as bladder pain syndrome) for 30 days; -Ordered 12/19/24, cranberry tablet 300mg, give 1 tablet by mouth twice a day for chronic infection for 30 days; -Ordered 12/22/24, schedule patient with urology for interstitial cystitis bladder pain. During an interview on 12/30/24 at 2:03 P.M., the Resident said: -He/She had pain from UTI; -He/She had several recent urine specimens collected; -He/She had chronic UTI's, -It currently burned and felt like hell before, during, and after urination; -He/She felt that at times nothing was being done to treat him/her; -He/She had not heard of any results regarding urinalysis. Review of electronic medical record's progress notes, dated 12/1/24-12/30/24, showed: -On 11/14/24, Physician's assistant wrote a UA had been done, and that resident reported always have a UTI and burning with urination. Recommended to check to see if resident had a UA and results and whether he/she had been placed on antibiotics; -On 12/6/24, LPN C wrote resident continued on antibiotics for urinary tract infection; -On 12/10/24, Physician's assistant wrote resident continued with burning with urination and still having urinary tract symptoms. UA is pending and waiting on results. Recommended adding AZO 2 tabs for urinary symptoms; -On 12/20/24, Nurse Practitioner A wrote resident had severe pain with urination. Had been on AZO recently, but reports little relief with that. Recommended a urology follow up. Previous labs in November showed he/she had a positive UA. Will send repeat blood work and UA prior to urology visit. Review of lab requisition standing order log, dated 11/1/24-12/30/24, showed: -On 11/11/24, a UA with culture if indicate, nurse collection, no initials that specimen was collected by lab. Review of laboratory reports showed: -On 11/21/24, a UA was collected, on 11/27/24 was reported that specimen was too old. During an interview on 12/30/24 at 4:01 A.M., LPN A said: -He/She collected urinalysis on 11/21/24 for resident and it was not reported until 11/25/24; -It took the lab several days to provide lab results on the urine specimen; -Resident complained regarding having burning pain when he/she urinated; -A UA was also obtained on 11/11/24, and was sent out on 11/11/24, but the order was put in on 11/8/24; -No report is available or found in the system for the UA specimen that was sent out on 11/11/24. During an interview on 12/31/24 at 12:36 P.M., ADON said: -There had been a delay in sample urinalysis collection for this resident due to collection of UA in a collection hat and not a specimen cup. 5. Review of Resident #5's Admission MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, able to make self-understood and understand others; -He/She was dependent in a wheelchair; -He/She was dependent for toileting hygiene; -Diagnosis included urinary tract infection (an infection in any part of the urinary system), pneumonia (an infection of the lungs), paraplegia (condition resulting in loss of muscle function and sensation in the lower half of the body), sepsis (a life-threatening medical emergency that required immediate medical care), bacteremia (bacteria in blood stream). Review of Resident #5's entry tracking record MDS, dated [DATE], showed: -He/She entered from short-term general hospital stay. Review of Resident #5' Discharge MDS, dated [DATE], showed: -discharged to short-term general hospital; -Return anticipated of resident. Review of care plan, revised 12/24/24, showed: -Monitor and document for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; -He/She had hypothyroidism; -Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as indicated. -He/She was on antibiotic therapy-sepsis until 1/29/24; -Administer medications as ordered. Review of lab requisition standing order log from 11/1/24-12/31/24, showed: -On 11/22/24, UA with urine culture was ordered, a note was made that it was not ready by the phlebotomist; -On 12/4/24, UA with urine culture, signed by phlebotomist

Based on observations, staff interviews, and record review, the facility failed to ensure safe food handling practices, food was labeled, dated, and sealed in cold storage, and the kitchen was kept in a clean and sanitary manner. These failures had the potential to increase the prevalence and spread of foodborne illness and infection among all 116 facility residents. The facility census was 116. Findings include: Review of the facility's undated policy titled, Hand Washing & Glove Usage, revealed Employees would wash their hands before and after handling foods. Gloves were to be used whenever direct food contact was needed. Hands were to have been washed before putting them on and after removing gloves. Review of the facility's undated policy titled, Cleaning Schedule, revealed items to have been cleaned after each use included cutting boards, worktables, and counters; items to have been cleaned daily included stove top, grill, kitchen floors, microwave oven, steam table, food carts, and the exterior of large appliances; items to have been cleaned weekly included drawers, shelves, ovens, and cupboards; items to have been cleaned monthly included refrigerators, freezers, ingredient bins, food containers, and walls. Review of the facility's undated policy titled, Kitchen Sanitation, revealed the food service manager would monitor food safety and sanitation, develop a cleaning schedule for the department and was responsible for its completion, and provide written cleaning instructions for each area and piece of equipment. Observation on 10/01/24 at 9:12 AM revealed Cook1 was preparing breakfast plates. He was wearing gloves and had been handling utensils that other staff had touched. He also retrieved cartons of mixed eggs from the sandwich/salad refrigerator. He was wearing the same gloves and then retrieved six slices of bread from a bag on the counter by the toaster. He placed the bread in the toaster and when it was toasted, he took it out and placed it in a container on the steam table. He completed this task two times with the same pair of gloves during the observation. He had touched other surfaces that included the bag of bread, a knife from the counter to cut the bread in half, the handle of the warming oven, and a spatula that other staff had also touched. Continued observations on 10/01/24 between 9:20 AM and 10:00 AM of the kitchen revealed: -The two compartment vegetable prep sink had romaine lettuce in water on the left side of the sink and the right side of the sink had the parts of a dirty blender used to puree food. There was previously pureed food on those parts. -The standing mixer did not have a cover over it. Part of that cover was tucked under the mixer and the rest was hanging off the counter beside it. There was dried food on the splash guard. -The covers of the three bulk food tubs that contained flour, sugar, breadcrumbs had food debris on them and were greasy to the touch. The outside of those tubs was also greasy to touch and had black marks on the outside of them. -The walk-in refrigerator floor had food debris and pieces of cardboard from boxes. -There was a cardboard box on the bottom shelf that had two large cylindrical packages of hamburger. One of them had been opened and was loosely covered with plastic wrap. There was no date on the open hamburger large cylindrical package of when it had been opened. -Another cardboard box was open and had an open package of pre-cooked [NAME] Dean sausage crumbles. There was no date on the sausage as to when it had been opened. -The walk-in freezer had ice on the floor under the condenser. There was ice hanging from the compressor. The floor also had food debris and pieces of paper and cardboard on it. -The floor throughout the kitchen had a greasy film, the grout was stained black in some places, there was a combination of grease and food debris that had been pushed up against the baseboards behind all the appliances and stainless-steel shelving units. -The warming oven, oven/stove combination, and the two convection ovens had a large amount of burned and baked-on food inside and had a greasy film on the outside of them. -Stainless steel shelves under the griddle, steam table, baking station, by the two-compartment vegetable refrigerator had food debris and a greasy-dust film on them. -The sandwich/salad refrigerator doors had dried food particles and were greasy to the touch. Inside of refrigerator had a moderate amount of food debris on the bottom shelf. Observation of Cook1 on 10/01/24 at 12:30 PM revealed he plated food for the noon meal and used the same gloved hands (from handling the used fryer handles and spatula) to take a grilled cheese sandwich off the griddle with a spatula and holding the top of the sandwich, picked up a hamburger on a bun made by Cook2 and placed it on a plate with chicken nuggets and French fries. He then used his gloved hands to put the chicken nuggets and French fries on a different plate. Observation of Cook3 on 10/01/24 at 12:45 PM revealed she was preparing hamburger and other sandwiches on the cutting board area of the sandwich/salad table. With her gloved hands reached into the refrigerator underneath that table to retrieve raw hamburgers to put on the griddle, took chicken nuggets and French fries and put them in the fryer. Put together hamburgers with buns and condiments. She took a plastic container from the clean dish rack and put ground chicken in it. She then opened two packages of mayonnaise and added it to the ground chicken. She combined the chicken and mayonnaise and used the same gloved hands to mix it together. Observation and interview of Cook2 on 10/01/24 at 1:00 PM revealed with gloved hands she was labeling the individual containers on the sandwich/salad table, went to the dish rack, and retrieved a large metal mixing bowl, stopped back at the sandwich/salad table and took four hard boiled eggs out and went to the counter near the two-compartment vegetable sink. She took boiled macaroni from a different container and placed it in the mixing bowl, chopped the eggs, and added those to the bowl. She mixed those ingredients with her gloved hands. She stated she was not aware she should not have used her gloved hands to mix the macaroni salad ingredients together. She did not remember if she had received any food safety education. During an interview on 10/02/24 at 1:00 PM, Cook3 revealed it was a usual practice to use her gloved hands to handle food. She was not aware she should have used utensils or used new uncontaminated gloves before she touched each food. She could not remember if she had received any education on safe food handling practices when she had been hired. She knew she had not received any recently. During an interview on 10/02/24 at 1:30 PM the Dietary Manager (DM) revealed he was aware the kitchen was not kept in a sanitary manner. He stated he was aware the cooks' used gloves, but thought they used utensils and not their gloved hands to handle food. He stated he had just been hired as the DM in May 2024 and the kitchen looked better now than before. He stated he was in the process of making up new cleaning sheets. He stated the condenser for the walk-in freezer required maintenance to fix the leak, resulting in ice build-up.

Based on observations, record review, interviews, and policy review, the facility failed to ensure residents who received a pureed diet of 116 total residents were served foods prepared in a pureed form to meet their needs. This failure had the potential to cause choking, aspiration [inhalation of food into the lungs], malnutrition, weight loss, or dissatisfaction with meals. The facility census was 116. Findings include: Review of the facility's policy titled, Therapeutic Diets, dated January 2017, revealed Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered 'therapeutic' diets. Review of the facility's Order Listing Report, dated 10/04/24 and provided on paper, revealed five residents received a pureed diet. Review of the facility's Diet Extensions - Friday Week 4 menu, provided by the facility, revealed residents who received pureed foods were to receive pureed sausage links during breakfast on 10/04/24. During observation of the tray line in the kitchen on 10/04/24 beginning at 8:06 AM, revealed Cook1 served residents with a puree diet a scoop of pureed breakfast sausage. The sausage was dry and crumbly, appearing more of a ground texture, and did not hold its shape when scooped. Evaluation of a test tray in the 300 Hall with the Dietary Manager (DM) on 10/04/24 at 9:35 AM revealed the pureed sausage had a ground texture rather than a puree texture. It was dry, crumbly, and required chewing to be swallowed. The DM stated the pureed sausage looked more like ground or mechanical soft texture and needed to be smoother. The DM stated Cook1 made the pureed sausage, and it had not been prepared correctly; it should be more of a mashed potato consistency. During an interview on 10/04/24 at 9:45 AM, Cook1 stated he followed the recipe by blending the prepared breakfast sausage links and pork base. Cook1 stated he did not blend the sausage long enough to create the desired smooth texture. Review of the facility's recipe for P/PU4 [Pureed] Sausage Links, dated 10/01/24 and provided by the facility, revealed sausage links, pork base, and thickener were to be blended to puree. The instructions documented, Blend until a smooth mashed potato consistency is reached .mixture should be thick enough to hold its shape.

32513 Based on observation, interview, and record review, the facility failed to ensure pain medication and timely interventions were provided for three of three residents (Residents (R) 107, R82, and R4) reviewed for pain management of 27 sample residents. This failure placed residents at risk of harm when pain was not assessed, monitored, with timely interventions provided. The facility census was 116. Findings include: 1. Review of R107's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed R107 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the splenic flexure (the bend where the transverse colon and the descending colon meet in the upper left portion of the abdomen), liver cirrhosis, and deep vein thrombosis (DVT). Review of R107's admission Minimum Data Set (MDS) located under the MDS tab of the EMR revealed R107 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact and had frequent pain rated at a nine on a zero to 10 on the pain scale during the observation period. Review of the Pain Care Plan, dated [DATE] and located in the Care Plan tab of the EMR, revealed [R107] is at risk for pain d/t [due to] decline and acute embolism and Thrombosis (blood clots). Interventions included the following: Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Dated [DATE]. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Dated [DATE]. Monitor/document for side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician. Dated [DATE]. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM [range of motion], withdrawal, or resistance to care. Dated [DATE]. Review of the Treatment Administration Record (TAR), dated [DATE] and located under the Orders tab of the EMR, revealed the following Pain Scale record q [every] shift. ,d+[DATE]: No pain; ,d+[DATE]: Mild pain; ,d+[DATE]: Moderate pain; ,d+[DATE]: Severe pain; ,d+[DATE]: Very severe pain; 10: Worst possible pain. Start date on the order was [DATE]. Review of the Physician Orders located under the Orders tab of the EMR, revealed Norco (an opioid pain medication) ,d+[DATE]mg [milligram] Give 1 tablet by mouth every 4 hours as needed for pain x 14 days. Start Date: [DATE] and Discontinue Date: [DATE]. Review of a Nursing Progress Note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed Patient reported to writer that she hasn't peed since yesterday. She reports lower abdominal pain that she rates ,d+[DATE] . Review of an SBAR [Situation, Background, Assessment, and Recommendation], dated [DATE] and located under the Assessments tab of the EMR, indicating that R107 had a change in condition which included abdominal pain, +3 pitting edema (swelling that causes an indentation when pressed that rebound in 60 seconds or less) and difficulty urinating. Review of the Physician Orders located under the Orders tab of the EMR, revealed on [DATE], the opioid pain medication was discontinued, and Tramadol (a non-opioid pain medication) 50 mgs [milligrams] Give 1 tablet every 6 hours as needed for pain. Review of the TAR pain scale, on [DATE] and under the Orders tab of the EMR, revealed R107 had a documented pain level of 10 on the day shift. There was no documentation that R107 had received Norco or Tramadol that day. Review of the Nursing Progress Note located under the Progress Notes tab of the EMR, revealed on [DATE], Resident reports no urine this day, c/o [complaint of] abdominal pain . Review of the TAR, dated [DATE] and located under the Orders tab of the EMR, revealed R107 had a pain level completed [DATE] with a level of nine out of 10 and was administered Tramadol. During an interview on [DATE] at 11:33 AM, R107 was awake, alert but was guarded. R107 was asked about her pain. She stated, It's all over, but mostly in my lower abdomen. She was asked if she could rate her pain level now. R107 stated, It's an 11 (on a ,d+[DATE] pain scale). R107 further stated that she wanted to go into hospice care as she was aware that her pain would be better managed. R107 was asked if she had spoken to the nurses regarding her pain. She stated, Oh, yes, I tell them all the time. R107 was asked if she had spoken to the provider regarding her pain. She stated, I believe I have but, I know that I have spoken to the nurses about it. During an interview on [DATE] at 1:17 PM, the Director of Nursing (DON) stated, If she was having that much pain, the pain medication should have been scheduled, we don't have to wait for her to ask for it. I agree that she has declined. During an interview on [DATE] at 9:23 AM, Nurse Practitioner (NP) 1 stated, [R107] has clear cognitive deficits even with the pain medication sometimes she would tell me she wasn't in pain. I had her on Norco first but with her liver issues, I switched her to Tramadol. NP1 was asked why he continued with as needed pain medication instead of scheduling it routinely. NP1 stated, I never questioned her ability to ask for pain medication, I only schedule it when the resident cannot ask for the medication. The staff did not tell me that she was having continued pain. During an interview on [DATE] at 12:45 PM, the Medical Director was asked if she was aware the facility did not have a policy and procedure for pain management. She stated, No, I was not aware. 2. Review of R82's undated Face Sheet located under the Profile tab of the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic combined systolic (congestive) and diastolic (congestive) heart failure with a pacemaker and implantable cardioverter defibrillator (ICD), and type two diabetes mellitus with autonomic neuropathy, Review of the quarterly MDS with an ARD of [DATE] and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Review of the Care Plan located under the Care Plan tab of the EMR, revealed a focus area for pain, initiated [DATE] with updates for [DATE]. Care plan interventions revealed that as needed analgesics (Norco) would be available, and that the resident would be assessed for the effectiveness for pain relief. The care plan further revealed that complaints of pain and request for pain meds would be reported to the nurse and interventions for pain relief would be implemented. On-going monitoring of these interventions each shift and as needed would be assessed for the effectiveness of pain relief. Review of the Orders tab of the EMR, revealed pain scale monitoring order every shift and at night with a date of [DATE] as an active order. It also revealed an order for Norco oral tablets with an active date of [DATE]. Review of the Medication Administration Record (MAR), [DATE] and located under the Orders tab of the EMR, revealed that the resident received one acetaminophen tablet on [DATE] with a pain level of four out of 10 on the pain scale. Review of the Progress Notes tab of the EMR, revealed a note entered on [DATE] at 13:09 PM (1:09 PM) that staff went in to do R82's weekly weight and R82 refused to do his weight check stating, No my feet are hurting, and I have been waiting for a pain pill since this morning. Reported to charge nurse, he has to have a new script. Additional progress notes revealed that on [DATE] at 7:04 PM, R82 had refused two meals. On [DATE] at 4:14 PM, R82 had finally received a Norco tablet for pain. Observation on [DATE] at 8:45 AM revealed R82 was in his room in bed, alert and oriented and cognitively intact. He reported that he had been in pain since [DATE] and the facility took five days to provide him with effective pain management relief. He said they had been making excuses that my pain pill medication had expired, and a new script was needed. He revealed a pain of ,d+[DATE] as his current pain level during this observation. During an interview on [DATE] at 9:04 AM, Assistant Director of Nursing (ADON) 3 revealed R82 told her about his pain on [DATE] after the resident had received a dose that day. She stated that the resident also told her that he had been asking for pain med since [DATE] with no follow up. ADON3 also confirmed that she did not find any follow up documented on R82's response to pain med given. During an interview on [DATE] at 9:16 AM, Licensed Practical Nurse (LPN) 3 revealed that R82 complained of pain yesterday with a pain scale of eight out of 10 and was given a dose of his hydrocodone. She stated she was not aware if his pain affected his abilities and stated he got out of bed when he wanted to. During an interview on [DATE] at 9:45 AM, R82 revealed and confirmed that his pain this morning was about a seven and that he did finally get two doses of pain med yesterday. He also revealed that no one had done any follow-up about his pain management. During an interview on [DATE] at 9:59 AM, the DON revealed that she did speak to the resident on Monday [DATE] about his pain and told him that his prescription for hydrocodone had expired and a hard copy was needed. She stated she was aware that the resident did get a dose on Tuesday and said he was ok with getting an as needed (PRN) Ibuprofen for pain until his pain medication came. The DON further revealed that the facility had no pain management policy or protocol, but the expectation was that when pain med was given, there should have been a follow-up documented about the resident's response to the pain med given. She also revealed that the pharmacy Cube-X system would not dispense a narcotic without a hard script and not sure why it took more than a day to get that done. She further revealed that the R82's regular physician was not the in-house physician, but the in-house physician could provide pain medication if the primary physician was not available. The DON stated there was no evidence was documented that the nursing staff attempted to contact the physician. During an interview on [DATE] at 10:44 AM, Restorative Aide (RA) 1 revealed that the resident did report to her that his legs were in pain and refused to have his weight done. RA1 also revealed that she reported this to the nurse and documented this in the progress notes. During an interview on [DATE] at 9:42 AM, Nurse Practitioner (NP) revealed that the facility should have contacted him for this resident's pain management and the resident should not have been left without effective pain medication for Norco. He stated the facility could have just called him. 3. Review of R4's Census tab of the EMR revealed she had been admitted to the facility on [DATE]. Review of R4's Medical Diagnosis tab of the EMR revealed her diagnoses included rheumatoid arthritis, chronic pain syndrome, and anxiety. Review of R4's quarterly MDS with an ARD of [DATE] and located under the MDS tab of the EMR revealed a BIMS score of 10 out of 15 which indicated the resident was moderately cognitively impaired. R4 did not exhibit any mood or behavioral symptoms. R4 received scheduled pain medications but did not receive as-needed pain medication or non-pharmacological approaches for pain management. She had pain almost constantly which occasionally interfered with daily activities. R4 rated her pain at a two out of ten. Review of R4's Care Plan dated [DATE], revised on [DATE] and located under the Care Plan tab of the EMR, revealed she had chronic pain syndrome with polymyalgia rheumatica (a chronic inflammatory disorder that causes pain and stiffness in the neck, shoulders, and hips). Interventions included: 1. Apply analgesics as ordered. Assess for effectiveness and for side effects of medications: Lidocaine patch to left and right shoulders topically daily--on in the AM [morning] and off at HS [bedtime] 2. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. 3. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. 4. Monitor/ record/ report to Nurse any s/sx [signs or symptoms] of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). 5. Administer appropriate pain medication as per orders. Give ,d+[DATE] hour before treatments or care. 6. Evaluate the effectiveness of pain interventions Q [every] shift. Review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. During an observation and interview on [DATE] at 3:31 PM, R4 was in her room and revealed she had pain on a daily basis, and it got worse when she did not get her pain medication. She stated she was supposed to get her pain medication every four hours but during the night, it was either late or she did not receive it all. She stated when she did not get her pain medication as scheduled, she did not want to do anything. Review of R4's Physician's Orders, located under the Orders tab of the EMR, revealed she had order for Norco (hydrocodone/acetaminophen (APAP) - an opioid pain medication) 7.5 milligrams (mg)/325 mg every four hours. This was changed on [DATE] to 5 milligrams (mg)/325 mg every four hours for pain. The schedule for her medication was 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Review of R4's [DATE] and [DATE] MAR located under the Orders tab of the EMR and her Progress Notes in the Progress Notes tab of the EMR revealed: -On [DATE] at 5:19 AM, R4 did not receive her hydrocodone/APAP 7.5 mg/325 mg as the medication was not available. Order to be changed. -[DATE] at 10:11 PM, medication had not been given by the day nurse. -[DATE] at 12:18 PM Medication not available. Her hydrocodone/APAP order was changed on -[DATE]. -[DATE] at 9:36 PM, R4 did not receive her hydrocodone/APAP 5 mg/325 mg with no reason given, was not marked as not given. -[DATE] at 6:57 PM Too late, HS [hour of sleep] due shortly after. -[DATE] at 8:00 AM Speaking with physician. -[DATE] at 11:43 PM, [DATE] at 5:29 AM, [DATE] at 5:52 AM, 11:43 AM and at 12:36 AM Waiting on pharmacy to deliver. -[DATE] at 4:00 AM, dose marked as not given due to sleeping and no documentation the medication had been given on [DATE] for 12:00 PM dose. During an interview on [DATE] at 1:05 PM, R4's Physician stated she could not recall if she was notified of missed doses and pharmacy requests for Norco. The Physician stated the NP may have more information. During an interview on [DATE] at 1:19 PM, the DON stated narcotic medications required a written prescription to be pulled from Cubex. She stated the nursing staff were to notify the physician of any unavailable medication, and the physician should send the prescription to the pharmacy and/or authorize use of the Cubex. The DON stated R4's physician group was not as responsive to prescription requests and the facility was at the mercy of that group. During an interview on [DATE] at 1:28 PM, the Infection Preventionist/Assistant Director of Nursing ADON (IP/ADON) 3 stated the MAR, and Orders-Administration Notes indicated the Norco, Ativan, and lidocaine were not administered as ordered. She stated the staff had not reported the unavailability of the medication to her and she was not aware of the missed doses of pain medication. The IP/ADON3 stated the nurses should have contacted the pharmacy to obtain the necessary medication or contact the physician to get a prescription to pull the medication from the Cubex (emergency medication kit). The IP/ADON3 stated nurses were expected to notify the physician of any missed doses of medications; however, there was insufficient documentation to determine if notifications were made in the above instances. During an interview on [DATE] at 1:56 PM, the NP stated the expectation was that staff would notify him of any missing medications so he could write a prescription for a dose from Cubex. The NP stated he had not been notified of R4's missed doses of pain medications. He stated he was unaware R4 went several days without receiving her scheduled Norco and stated, that is unacceptable. The NP stated he would have gone to any extent to get the pain medications R4 needed, up to sending her to the hospital for pain medication, but he was unaware of the situation. The NP stated there should never be an instance where a medication was not given, as it was available in the Cubex, and the process should have been followed to ensure the emergency dose was given. The NP stated pain management for R4 was a delicate balance and she typically wanted more than what she received. MO242918 51678

Based on interview and record review, the facility failed to ensure a resident who had a negative Preadmission Screening and Resident Review (PASARR) Level I and then later had a significant change in status with a new serious mental illness diagnosis was accurately and timely referred for a PASARR Level II for one of two residents (Resident (R) 29) reviewed for PASARRs out of 27 sample residents. This failure placed the residents at risk of qualifying for specialized services but not receiving the services due to the inaccuracy of the PASARR Level I. The facility census was 116. Findings include: During an interview on 10/03/24 at 2:00 PM, the Administrator revealed the facility had no policy on PASARR. Review of R29's Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included acute heart failure. On 07/12/21, the resident was placed on a psychiatric hold and sent to a psychiatric facility, returning on 07/29/21 with a diagnosis of major depressive disorder with severe psychotic symptoms. Review of R29's EMR under the Progress note tab revealed that R29 had been receiving psychiatric services since returning to the facility in August 2021. Review of R29's Preadmission Screening and Resident Review summary, provided by the facility, revealed on 04/01/21, the facility initiated a PASARR Level I. Following R29's return on 07/29/21, a new Level I Screen was not done. During an interview on 10/04/24 at 2:45 PM, the Social Services Designee (SSD) stated that R29 should have had a new Level I PASARR Screening and then Level II Screening initiated when she was readmitted to the facility on [DATE] and that she had initiated the process on 10/03/24 when they were made aware of the mistake. The SSD stated, I screen all residents that are admitted if the PASARR screening was not done in the hospital. She also stated, this should not have fallen through the cracks. During an interview on 10/04/24 at 3:15 PM, the Director of Nurses (DON) stated, After reviewing [R29's] records, she should have been treated as a new admission, when she returned to the facility following a psychiatric hospital stay. The DON also stated, We have initiated the process to screen [R29] yesterday 10/03/24, we are all new here and reviewing all charts and making corrections.

Based on record review and interviews, the facility failed to ensure the physician was notified when pain medications were unavailable to be administered per physician's order for one of three residents (Resident (R) 4) reviewed for pain of 27 sample residents. This failure had the potential to contribute to uncontrolled pain and fall risk. The facility census was 116. Findings include: Review of R4's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including: polymyalgia rheumatica (a chronic inflammatory disorder that causes pain and stiffness in the neck, shoulders, and hips); chronic pain syndrome; rheumatoid arthritis; dementia; depression, and anxiety. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. R4 did not exhibit any mood or behavioral symptoms. R4 received scheduled pain medications but did not receive as-needed pain medication or non-pharmacological approaches for pain management. She had pain almost constantly which occasionally interfered with daily activities. R4 rated her pain at a two out of ten. Review of R4's August 2024 Medication Administration Record (MAR) revealed an order for Norco (an opioid pain medication comprised of hydrocodone/acetaminophen), 7.5/325 mg (milligrams) every four hours for chronic pain, which was discontinued on 08/09/24, and a new order for Norco 5/325 mg every four hours that originated on 08/09/24. The MAR and associated Orders-Administration Notes, located in the Progress Notes tab of the EMR, documented the Norco was not administered on: -08/08/24 at 8:00 AM for a reason of Other: No corresponding note was documented. -08/0/24 at 12:00 PM: Medication not available. Speaking with physician. -08/08/24 at 4:00 PM: Medication not available. Order to be changed. Review of R4's August 2024 MAR also included an order for a lidocaine (pain medicine) patch, 5%, to be applied at 8:00 AM and removed at 8:00 PM, which originated on 07/03/24. The MAR and associated Orders-Administration Notes, documented the lidocaine patch was not administered on: -08/15/24: Pt [patient] did not have any patches on today, she said she had the pain cream. -08/16/24: Patch not available (back oreder [sic]). -08/17/24: No patches (back order). -08/18/24: This medication is on back order. Review of R4's September 2024 MAR revealed the order for Norco 5/325 mg every four hours. The MAR and associated Orders-Administration Notes, documented the Norco was not administered on: -09/18/24, 12:00 PM: No reason code or corresponding note was documented. -09/18/24, 4:00 PM: for a reason of Other: No corresponding note was documented. -09/26/24, 8:00 PM: Waiting on pharmacy to deliver. -09/27/24, 12:00 AM: Waiting on pharmacy to deliver. -09/27/24, 4:00 AM: Waiting on pharmacy for delivery. -09/28/24, 12:00 AM: Not available needs script. -09/28/24, 4:00 AM: Not available. -09/28/24, 12:00 PM: Medication unavailable, pharmacy needs a new script. Provider/oncall [sic] notified. Review of R4's September 2024 MAR also included the order for a lidocaine patch, 5%, to be applied at 8:00 AM and removed at 8:00 PM, which originated on 07/03/24. The MAR and associated Orders-Administration Notes, documented the lidocaine patch was not administered on: -09/27/24: No patches. During an interview on 10/04/24 at 1:05 PM, R4's Physician stated she could not recall if she was notified of missed doses and pharmacy requests for Norco or lidocaine. The Physician stated the Nurse Practitioner (NP) may have more information. During an interview on 10/04/24 at 1:19 PM, the Director of Nursing (DON) stated the nursing staff were to notify the physician of any unavailable medication or missed doses, and the physician should send the prescription to the pharmacy and/or authorize use of the emergency supply. During an interview on 10/04/24 at 1:28 PM, the Infection Preventionist/Assistant Director of Nursing ADON (IP/ADON) 3 stated the MAR, and Orders-Administration Notes indicated the Norco and lidocaine patch were not administered as ordered. She stated the staff had not reported the unavailability of the medication to her and she was not aware of the resident's several missed doses of pain medication. The IP/ADON3 stated nurses were expected to notify the physician of any missed doses of medications and document the follow-up; however, there was insufficient documentation to determine if notifications were made in the above instances. During an interview on 10/04/24 at 1:56 PM, the NP stated the expectation was that staff would notify him of any missing medications so he could write a prescription for an emergency dose and communicate with the pharmacy. The NP stated he had not been notified of R4's continued missed doses of medications and stated he was unaware R4 went several days without receiving her scheduled Norco and stated, that is unacceptable. The NP stated he would have gone to any extent to get the pain medications R4 needed, up to sending her to the hospital for pain medication, but he was unaware of the situation. The NP stated he was not notified of missed lidocaine doses. The NP stated there should never be an instance where medication was not given, as it was available in the emergency kit and the process should be followed to ensure the emergency dose was given.

Based on interview and record review, the facility failed to perform life saving measures to include Cardio-pulmonary resuscitation (CPR) for one sampled resident (Resident #1) when staff found the full code resident without a pulse or respirations. Additionally, the facility failed to ensure the staff knew safety protocols and emergency procedures when Licensed Practical Nurse (LPN) A did not know where to locate the crash cart (a cart that contains emergency equipment). The facility census was 117. The administrator was notified on [DATE] at 4:51 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's Emergency Procedures/Cardio-Pulmonary Resuscitation Policy, revised, February 2022, showed: -Any unnecessary interruptions in chest compressions decreases the effectiveness of CPR; -If a resident is found unresponsive and not breathing normally, a licensed staff member will verify the code status using the medical record and if the resident is a full code per the medical record a staff member that is certified in CPR will initiate CPR; -Begin CPR if the victim is unresponsive and not breathing normally without assessing the victim's pulse; -Start chest compressions rather than opening the airway and delivering rescue breaths. Review of the facility's undated, Duties of the Licensed Practical Nurse, showed: -The LPN is responsible for ensuring the delivery of efficient and effective nursing care and achieving positive clinical outcomes in accordance with accepted standards of practice; -The LPN is responsible for resident care and direction of nursing care during assigned shift including staff assignments, mentoring and educating nursing personnel; -The principal responsibilities of the LPN are to ensure the physician orders are followed as prescribed, evaluates the effectiveness of care interventions, identifies problems and develops alternative interventions. Review of the facility's undated orientation plan for agency staff showed: -Nurses will be orientated to safety protocols, emergency procedures; -Nurses will be orientated to identification of code status, advanced directives and code status competency. Review of LPN A's Personnel filed showed: -No record of orientation to safety protocols, emergency procedures; -No record of orientation to identification of code status, advanced directives and code status competency. 1. Review of the Resident #1's Significant Change Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated [DATE], showed: -Moderate cognitive impairment; -Dependent on staff for Activities of Daily Living (ADLs); -Occasionally incontinent; -Diagnosis included cancer, high blood pressure, and arthritis. Review of the resident's care plan, dated [DATE], showed: -The resident had an ADL self-care performance deficit; -The resident was dependent on one staff for ADLs; -The resident had an advanced care directive; -The resident was not at or approaching end of life at this time; -The resident was a full code status (a medical directive that indicates if a person's heart stops beating or they stop breathing, life saving measures will be provided); -The resident's wishes will be honored. Review of the resident's medical record showed: -admitted [DATE]; -Full Code (CPR should be started) start date, [DATE]. Review of the resident's progress note, dated [DATE], showed: -The Director of Nursing (DON) said LPN A called him/her at 7:54 P.M., and said the resident had passed unexpectedly. The DON asked LPN A if the resident was a full code. LPN A said he/she thought the resident was on Hospice so she/he was a DNR. The DON told LPN A he/she would be right there. When the DON arrived on the resident's hall, CNA A and CNA B, told the DON the resident was a full code and they needed to start CPR and compressions right away. The DON entered the resident's room to assess him/her. The resident had no response to verbal or tactile stimuli, no respirations, no movement or pulse. The resident had a large amount of vomit covering his/her left side. The DON looked at the resident's medical record and verified he/she was a full code status. The DON told LPN A, CNA A, and CNA B to start compressions and the DON grabbed the crash cart. CNA A and CNA B were doing chest compressions and the DON was preparing the suction machine on the crash cart. The DON gave two breaths with the Ambu Bag (bag valve mask used to provide oxygenation and ventilation to a resident who is not breathing) and started suctioning out the airway of the resident. One milliliter of dark brown liquid matter was suctioned out of the resident's airway. CNA A and CNA B continued compressions while the DON and LPN A used the Ambu bag until EMS arrived and took over. Review of the facility's investigation, dated [DATE], showed: -On [DATE] LPN A entered the resident's room with CNA B and found the resident unresponsive; -LPN A assessed for vitals, but they were absent; -LPN A called the DON and checked the code status at 7:54 P.M.; -LPN A reported the resident was a full code, but had already passed; -The DON was in the facility and immediately came to the resident's hall; -The DON checked the resident who was breathless and pulseless; -The DON checked the code status of the resident while calling the regional nurse; -The DON then called 911 and initiated CPR at 8:00 P.M.; -EMS arrived and took over CPR; -EMS called time of death at 8:30 P.M. During an interview on [DATE] at 11:10 A.M., CNA B said: -He/She works for an agency that contracts with the facility and has been working at the facility for seven months. -On [DATE] he/she was across the hall from the resident's room in the bathroom and he/she heard the resident yelling and he/she went to check on the resident. He/She told LPN A the resident was yelling and might be in pain; -Between 7:45 P.M. and 7:50 P.M. he/she was standing at the back the nurses station and LPN A came out of the resident's room and said, the resident was not looking very good. -He/She and LPN A entered the resident's room; -The resident was in bed and looked pale and did not respond to touch or verbal stimulation; -He/She touched the resident on his/her arm and shoulder and called his/her name and the resident did not answer; -LPN A put the pulse oximeter (small clip-like device use to check a person's oxygen and pulse) on the resident, but LPN A did not have a stethoscope (medical instrument used to check the action of the heart and/or breathing) or any other instruments to take vitals or assess the resident; -The pulse oximeter had numbers on it; -LPN A checked the pulses in both of the resident's wrists; -LPN A left the resident's room and called the DON and asked him/her what the resident's code status was; -LPN A left the resident's room and did not initiate CPR and did not instruct CNA B to start CPR; -CNA A came down the hall to the resident's room; -CNA A told CNA B the resident is a full code and CPR should be started immediately; -CNA B told LPN A while he/she was on the phone with the DON the resident is a full code and CPR should be started; -LPN A told CNA B there was no use to start CPR the resident was already gone; -The DON came down the hall approximately six or seven minutes later and talked to LPN A and LPN A told the DON the resident was a full code; -The DON obtained the crash cart and instructed CNA B and CNA A to start chest compressions; -The DON used the Ambu bag to give rescue breaths; -The DON had to instruct LPN A on how to use the Ambu bag while trying to suction the resident's airway; -EMS arrived and took over life saving measures; -He/She told LPN A the resident was a full code multiple times and CPR should be started now; -LPN A kept telling the him/her the resident was deceased and it would not do any good; -CPR should be started immediately on a resident who is a full code. During an interview on [DATE], at 11:44 A.M., CNA A said: -Around 7:30 P.M. on [DATE] he/she went into the resident's room because he/she was yelling; -The resident had spit up some dark fluid and he/she told LPN A; -Approximately 25 to 30 minutes later CNA B was upset and told him/her the resident had passed away and he/she told LPN A the resident was a full code and CPR needed to be started and LPN A said it would not do any good, the resident was gone; -He/She questioned LPN A about not doing CPR on a full code resident and LPN A said it would not do any good, the resident was gone; -He/She told LPN A again the resident was a full code and CPR needed to be started and continued until EMS arrives; -LPN A told CNA A the resident had already passed, so it would not do any good; -The DON arrived on the hall and told CNA B and CNA A to start CPR and the DON grabbed the crash cart; -LPN A was the charge nurse and he/she followed LPN A's direction; -CPR should be started immediately on a resident who is a full code. During an interview on [DATE], at 8:38 A.M., LPN A said: -He/She is an agency nurse; -He/She had been at this facility three times; -He/She is CPR certified; -He/She had received no orientation from the facility on CPR or code status; -He/she did not know where the crash cart was located in the facility; -The facility had a problem with how to determine what a resident's code status is; -He/She has had trouble in the past at this facility determining residents' code status. Sometimes the code status in the chart will be for the resident who was previously in that room and not for the current resident; -Around 7:50 P.M., on [DATE] he/she checked on the resident, came out and told CNA B the resident did not look good and he/she needed help to reposition the resident; -LPN A and CNA B entered the resident's room and found the resident with eyes open and fixed, mouth open, and no respirations; -He/She said he/she felt for radial (wrist) pulses and pedal pulses (pulses in the foot) bilaterally and they were absent; -The resident's body was luke warm; -He/She could not remember if he/she checked for an apical (heart) pulse or checked for a carotid (neck) pulse; -He/She could not remember if he/she had a stethoscope with him/her; -He/She said the resident showed no signs of life; -He/She did not start CPR at that time, because he/she did not know the code status of the resident: -He/She went to the nurses desk and looked at the resident's medical record and found the resident was a full code and he/she did not start CPR or instruct CNA A and CNA B to start CPR; -He/She said he/she did not start CPR on the resident immediately after finding no signs of life because he/she was not clear on the code status of the resident; -He/She called the DON and within 7 to 10 minutes the DON arrived on the hall and started CPR. During an interview on [DATE] at 10:32 A.M., the DON said: -He/She was at the facility on [DATE] in his/her office when LPN A called him/her and said there had been an unexpected death at the facility and the resident was deceased ; -He/She arrived on the 100 hall approximately 5 minutes after receiving LPN A's call; -LPN A told him/her the resident was on Hospice and was a DNR code status and then LPN A told him/her the resident was actually a full code; -He/She grabbed the crash cart and instructed CNA A and CNA B to start chest compressions on the resident; -He/She had to show LPN A how to use the Ambu bag during the code; -He/She expected LPN A to know how to use the Ambu bag and how to give life saving measures; -He/She expected LPN A to know how to determine the resident's code status without a delay in care; -CNA A and CNA B told him/her they were very upset because they told LPN A the resident was a full code and CPR needed to be started immediately and LPN A said repeatedly it won't do any good, the resident is already gone; -The code status is easily accessible in the resident's chart; -LPN A would have easy access to the code status easily at the computer at the nurses station that is next to the resident's room or on a lap top on the medication and treatment carts; -He/She expected LPN A to start CPR immediately or instruct CNA A and CNA B to start it; -He/She expected LPN A to know how to determine the resident's code status without delay in care and take control of the situation and instruct the CNA's to do chest compressions. -CPR should have been started immediately on the resident. Observation and interview on [DATE] at 10:32 A.M., showed: -LPN C said he/she worked for an agency and he/she picks up shifts on this hall; -LPN C said he/she was CPR certified; -LPN C said CPR should be started immediately on a resident who is a full code. During an interview on [DATE] at 10:44 A.M., LPN B said: -He/She is an employee of the facility; -He/She is CPR certified; -CPR should be started immediately a resident who is a full code. During an interview on [DATE] at 11:47 A.M., the Medical Director said: -He/She expects CPR to be started immediately on residents that are a full code; -He/She expects staff to know the code status of the residents; -He/She expects licensed staff to be orientated to safety protocols and emergency procedures of the facility; -He/She expected LPN A to perform CPR in the resident soon as the resident was found not breathing and no pulse. During an interview on [DATE] at 3:12 P.M. the Administrator said: -He/She expects all nursing staff to know where to find the code status of a resident; -He/She expects CPR to be performed immediately on residents who are a full code status when the resident is found with no signs of life; -He/She expects the nurses to know how to perform CPR and know how to direct staff in the event CPR is administered; -He/She expects licensed staff to be orientated to safety protocols and emergency procedures of the facility; -LPN A should have started CPR first before calling the DON; -He/She expected LPN A to initiate CPR immediately and direct CNA A and CNA B after the resident was found with no signs of life. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO# 237591 MO# 237642

Based on observation, record review, and interview, the facility failed to keep two residents (Residents #1 and #2) free from physical abuse. Certified Nurse Aide (CNA) A entered Resident #1's room and began yanking the resident's sweater off of him/her. CNA A grabbed the resident by the shoulders and forcefully threw him/her on the bed. The resident was crying out ouch, stop it, do not do that. CNA A forcefully removed the resident's pants as the resident was attempting to hold on to his/her pants. CNA A grabbed the resident's arm, wrist and hand and slapped the resident's arm. Resident #2 described CNA A and said he/she had been rough using the mechanical lift to put him/her in bed on several occasions and had roughly removed his/her incontinent brief. This affected two of seven sampled residents. The facility census was 111. The administrator was notified on 2/10/23 at 3:53 P.M., of an Immediate Jeopardy (IJ) which began on 2/9/23. The IJ was removed on 2/11/23 as confirmed by surveyor on-site. Review of the abuse and neglect policy, dated October 2022, showed: - Abuse was defined as: The willful infliction of injury resulting in physical harm and pain. - Physical abuse was defined as: Hitting and slapping a resident. - Each resident has the right to be free from abuse. - Residents must not be subjected to physical abuse by facility staff and staff from other agencies. Review of CNA A's time card showed he/she clocked in for duty on: - 2/9/23 at 3:00 P.M. and clocked out at 10:00 P.M. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 2/10/23, showed: - He/she had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. - Diagnoses included: Parkinson's disease (a disease of the nervous system that causes tremors, muscle stiffness and slow movements) and dementia with Lewy Bodies, (progressive brain disease that affects the memory, thinking, and reasoning that can cause mood disturbances). - He/she was dependent on one staff to transfer, get dressed, and use the toilet. - He/she was incontinent of bowel and bladder. - He/she had verbal and physical behaviors. Review of the resident's undated Dementia with Lewy Bodies Care plan showed: - Staff were to identify themselves and explain cares that were provided to the resident. - The staff were to stop cares when the resident was agitated and return to complete cares at a later time. Review of the resident's undated behavior care plan showed: - He/she kicked and hit staff when cares were provided. - The staff were to ensure the resident was safe, leave the resident when he/she was combative and return later to complete the resident's cares. Observation of video footage, dated 2/9/22 at 9:05 P.M., showed: - CNA A in the resident's room with the resident sitting in his/her wheelchair. CNA A did not close the door. - CNA A was standing to the side of the resident's wheelchair, the resident was leaning forward with his/her right elbow hanging off of the arm of the wheelchair almost touching the large wheel. - CNA A grabbed the resident's right elbow forcing him/her to sit up straight as CNA A yanked the resident's sweater off of his/her right arm. The resident held his/her arm stiffly. CNA A yanked the sweater from the resident's right arm and began unbuttoning his/her shirt. - CNA A could be heard saying to the resident he/she was a professional. The resident said Don't do it that way, it's not professional. - CNA A had a phone call on his/her personal cellular phone, and placed his/her phone on speaker phone. - CNA A pulled the resident's wheelchair to the right side of his/her bed, did not lock the wheels and the wheelchair rolled backwards with the resident in it. - CNA A used his/her left hand, placed it on the resident's upper back and pulled him/her to the side of the bed while the resident was in his/her wheelchair. CNA A was heard saying come on and the resident's name. - CNA A stood in front of the resident, placed his/her right hand under the resident's left armpit from the front of the resident's body and his/her left hand under the resident's right armpit from the back side of his/her body. CNA A lifted the resident by his/her shoulders, turned the resident and forcefully threw the resident on the bed. The resident's body bounced on the bed. The resident could be heard saying Ow during the transfer. - CNA A grabbed the resident's right shoulder and left knee and pushed the resident onto his/her side. The resident was heard saying Ow, ow again. - CNA A grabbed the resident's pants. The resident grabbed his/her pants waist band and said Don't do it, ow, ow, ow. CNA A continued to jerk on the resident's pants and picked the resident's hips off of the bed with his/her pants. - CNA A forced the resident to his/her back. The resident's head bounced on the pillow. CNA A forcefully pulled at the resident's pants so hard both of the resident's hips were picked up several inches off of the bed. The resident continued to hold on to his/her pants waist band with one hand. The resident said Ow again. CNA A continued to talk on the speaker phone and did not explain to the resident what he/she was doing. - CNA A pushed the resident's hands away from his/her pants and jerked them off of the resident. - CNA A was heard talking to someone on his/her speaker phone. - CNA A exited the resident's room leaving the resident uncovered in only a shirt and brief. - The resident curled into the fetal position on his/her right side and could be heard softly crying. The resident's fists were curled into tight fists. - CNA A returned to the resident's room a few seconds later with an incontinent brief. - CNA A was heard talking to someone on speaker phone. - CNA A opened the side of the resident's incontinent brief, the resident used his/her left hand to grab the incontinent brief, and CNA A moved the resident's hand from the brief shoving the resident's hand from his/her hip to his/her waist. - CNA A then forced the resident to his/her back, and opened the other side of the resident's incontinent brief. The resident grabbed the front of the incontinent brief and pulled it tight to his/her body, the resident was heard saying stop it and the resident was screaming. - CNA A pulled the resident's hand away from the incontinent brief and pulled the incontinent brief from between the resident's legs and rolled the resident to his/her side at the same time. The resident grabbed at CNA A's hand. CNA A slapped the resident's hand and jerked his/her arm. The resident screamed out and said Ow! and the resident rolled back to his/her back. - CNA A rolled the resident to his/her side and pushed half of the resident's face into a long pillow that was along the side of his/her bed. - CNA A jerked the soiled brief from under the resident and threw it on the floor. - CNA A shoved the clean incontinent brief under the resident while he/she was on his/her side. The resident's foot wiggled, then the video footage stopped. - CNA A continued to talk on the phone while he/she provided cares to the resident. During an interview and observation on 2/10/23 at 1:33 P.M., the resident's Family Member (FM) A said: - He/she witnessed CNA A on the video camera as he/she was providing cares to the resident. - He/she attempted to call the facility and no one answered the phone. - He/she sent the video to the regional nurse who was a recent Director of Nursing (DON) on 2/9/23 at 9:20 P.M. - The resident reported left arm pain and back pain, but was not able to describe his/her pain. Review of the resident's record showed the following: - 2/10/23: The resident complained of shoulder pain. - 2/10/23: Skin assessment showed no bruises or open areas. - 2/10/23: X-ray of the left shoulder report showed no evidence of a fracture or shoulder dislocation. During an interview on 2/10/23 at 10:23 A.M., the Administrator said: - The regional nurse forwarded a video FM A had recorded on 2/9/23 at 9:34 P.M. He called the facility at 9:40 P.M. and instructed the charge nurse to walk CNA A out of the facility due to an allegation of abuse. - He viewed the video and initiated an investigation. - He considered the allegation as abuse. During an interview on 2/15/23 at 10:12 A.M., CNA A said: - He/she had been rough when he/she changed Resident #1's incontinent brief. - The resident had fecal matter in his/her brief. He/She reached for the area of the brief that had fecal material on it with his/her hand. - He/she grabbed and yanked his/her hand away from the resident and the reaction was rough. - He/she did not slap the resident's hand or jerk the resident's arm. - He/she was unaware there was a video camera in the resident's room. - He/she was sent home at approximately 10:00 P.M. on 2/9/23. - He/she was told he/she was caught on camera being rough with a resident. - He/she was told he/she was not allowed to work at the facility anymore because he/she was rough with Resident #1. - He/she had received abuse and neglect training, but was unable to recall when. - He/she was not rough with any other residents. During an interview on 2/10/23 at 1:14 P.M., Certified Medication Technician (CMT) A said: - He/she heard the nurse tell CNA A at approximately 9:45 P.M. on 2/9/23 he/she had to leave the facility because of an allegation of roughness with Resident #1. - He/she heard CNA A say he/she was really rough with Resident #1 when he/she put the resident in bed because the resident was being difficult and he/she did not know the camera was in the room. During an interview on 2/15/23 at 12:04 P.M., the Administrator said: - He expected CNA A to provide cares to Resident #1 in a safe and respectful manner. - He/expected CNA A to ask for help from one of his/her peers when he/she became angry with Resident #1. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: - He/she had a BIMS score of 12, indicating minimal cognitive impairment. - Diagnoses included: Stroke and dementia. - He/she required the assistance of two staff and the mechanical lift to transfer. - He/she required the assistance of two staff to reposition while in bed and one staff to get dressed. - The resident was incontinent of bowel and bladder. Review of the resident's undated Activities of Daily Living (ADLs) showed: - The resident required two staff and the mechanical lift for transfers. - He/she was unable to move his/her left arm due to a stroke. - He/she required one to two staff for bed mobility. During an interview on 2/10/23 at 10:46 A.M., the resident said: - A staff member described as CNA A was rough when he/she used the mechanical lift to help him/her into bed. - The same staff member was rough when he/she changed the resident's soiled incontinence brief. - This incident happened during the evening the day prior. During an interview on 2/10/23 at 12:08 P.M., CNA B said: - He/she was in the resident's room at approximately 8:55 P.M. on 2/9/23 with CNA A and CNA C to assist the resident to bed with the mechanical lift. - The resident said he/she did not want CNA A in his/her room, but did not say why. - CNA A left the resident's room and did not say anything. - CNA B did not report this statement to the charge nurse. - He/she never saw CNA A be rough with the resident. 3. During an interview on 2/10/23 at 4:08 P.M., Licensed Practical Nurse (LPN) A said: - He/she was the Unit Manager for the hall Resident #1 lived on. - He/she viewed the video that showed CNA A abuse Resident #1. - He/she was sickened by the treatment CNA A gave to Resident #1. - He/she expected CNA A to treat the resident's with dignity and respect. -Was not aware of any complaints from Resident #2 regarding rough treatment by staff. During an interview on 2/15/23 at 11:30 A.M., the DON said: - She, the Unit Managers, and the Social Services Director interviewed each resident that was able to answer questions on 2/10/23. - She identified Resident #2 had reported that a CNA that fit the description of CNA A was rough with his/her cares during the evening shift recently. - Resident #2 did not have any bruises or abrasions. - She expected CNA A to provide cares to Resident's #1 and #2 with kindness and professionalism. - She expected CNA A to ensure the resident was safe and step away when Resident #1 was resistive to cares. - She expected CNA A to ask for help from one of his/her peers when Resident #1 was resistive to cares. During an interview on 2/15/23 at 4:44 P.M. the Primary Care Provider (PCP) said: - She expected all of the facility staff to always treat the resident's with dignity and respect. - She expected CNA A to treat his/her assigned residents with dignity and respect. 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 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 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. MO213839 MO213840

Based on record review and interviews, the facility staff failed to maintain a safe environment for one resident (Resident #1) out of three sampled residents when Resident #1 was identified as a high fall risk and fell two times on 11/8/22 fracturing his/her right arm. The facility nurse found the resident on the floor, and told the Certified Nurse Aid (CNA) to pick the resident up from the floor. The nurse failed to assess the resident for injuries before and after the transfer from the floor to the bed. The resident had a second fall immediately after nurse left the resident's room. CNA B found the resident and picked him/her up before a nurse assessed the resident. CNA B failed to alert the nurse to that fall. On 11/14/22 the resident was in his/her room alone with the door closed. The resident fell to the floor, crawled on the floor and picked him/herself up off of the floor and pivoted into the bed. The facility census was 105. The facility did not provide a policy regarding fall prevention or a resident safety policy. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment that is completed by the facility staff) dated 10/21/22 showed: - The resident's diagnoses included: Parkinson 's disease, (a disease of the nervous system that often causes tremors, muscular stiffness, and slow unsteady body movements) and neuro cognitive disorder with Lewy Bodies, (changes in the brain that can affect thinking and movement). - The resident had a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive deficit. - He/she required standby assistance of staff to go to the toilet, transfer and walk. - He/she required the assistance on one staff to get dressed. - He/she had frequent falls. Review of the resident's record showed: - He/she had a fall risk assessment score of 35 on 11/8/22 and 11/14/22, indicating the resident was at high risk for falls. - His/her fall care plan dated 4/23/22 showed the resident was identified at risk for falls due to his/her diagnoses of Parkinson's disease, cognitive loss and incontinent episodes. Ensure the resident was wearing appropriate foot wear and call light was in reach. - 1 on 1 activities while he/she was in COVID isolation. - The staff were to provide hourly visual checks to assure the resident's safety and offer assistance. - 11/8/22 6:00 P.M. Licensed Practical Nurse (LPN) A documented on a nurses note, the resident's family called the facility and reported the resident had fallen twice. The family said that the falls were seen once they reviewed video footage. The falls were reported to happen between 4:50 P.M. and 6:00 P.M. LPN A found the resident lying in his/her bed and visibly crying. The resident reported pain and LPN A administered pain medication to the resident. LPN A assessed the resident was guarding his/her right arm and swelling, and obtained an order from the physician to order an X-ray. - X-ray results dated 11/8/22 showed the resident had a right lower arm fracture. Observation of the video surveillance dated 11/8/22 and 11/14/22 showed: - 11/8/22 4:36 P.M. The resident's door was closed. The resident was in his/her room standing next to his/her bed, bent at the waist and smoothing his/her blanket. The resident then fell to his/her right side, landed on the floor. The resident fall was heard, the resident was moaning. - 4:48 P.M. The resident was still lying on his/her right side on the floor. LPN B knocked on the resident's door, the resident verbalized come in. LPN B holding a medication cup entered the resident's room, saw the resident lying on the floor. CNA A was walking by the resident's door as he/she pushed another resident in his/her wheel chair. LPN B stopped CNA A and instructed him/her to pick the resident up off of the floor. CNA A stepped behind the resident and stood the resident to a half standing position and pivoted the resident from the floor to the end of the bed by placing the resident's legs over the foot of the bed. LPN B remained in the room with the resident, was heard asking the resident if he/she was ok had fallen and if he/she was ok. The resident answered by saying he/she was tired. LPN B administered the resident's medication to him/her and exited the resident's room at 4:51 P.M. leaving the resident's door open. The resident was still sitting with his/her legs over the foot of the bed and leaned forward. The resident stood just as LPN B was out of the view of the camera of the resident's door. The resident fell to the floor a second time and landed on his/her right side with his/her right arm under the resident's right hip and hand behind the resident. The resident's head hit so hard on the floor his/her head recoiled. - 5:10 P.M. The resident was still on the floor attempting to sit up, and leaned to the right side. The resident was sitting half upright with his/her head leaning against his/her television stand. - 5:18 P.M. CNA B entered the resident's room, closed the resident's door and stepped behind the resident. CNA B grasped the resident under his/her arms as he/she stood behind the resident and stood the resident to his/her feet. The resident was unable to straighten his/her legs. The resident was heard telling CNA B that he/she was not able to walk. CNA B scoots the resident to his/her bed and sat him/her with his/her legs hanging over the foot of the bed. - 11/14/22 4:04 P.M. The resident was standing in his/her room with the door closed. The resident had his/her hands on the arms of a straight- back chair and pushed it next to his/her bed. The resident was wearing a splint to his/her right hand and forearm. The resident took a step sideways, lost his/her balance and fell to the floor hitting his/her head on the nearby walker. The resident landed on his/her right side. - 4:05 P.M. The resident pushed him/herself up to his hands and knees and crawled on the floor to the side of his/her bed. - 4:07 P.M. He/she struggled to stand on his her feet, used the straight-back chair and the bed frame and pulled him/herself up, bent at the waist, pivoted his/her hips and sat on the side of the bed. During an interview on 11/16/22 at 11:28 A.M. LPN B said: - He/she passed medications during the evening portion of his/her shift on 11/8/22. - He/she found the resident lying on the floor and instructed CNA A to pick the resident up off of the floor. - He/she quickly looked the resident over, but did not perform a head to toe assessment. - He/she was aware that he/she should have performed a head to toe assessment before the resident was assisted from the floor. - He/she was unaware of the second fall the resident had. During an interview on 11/16/22 at 10:56 A.M. CNA B said: - He/she found the resident lying on the floor in front of his/her television stand. - He/she picked the resident up off of the floor and placed him/her on the end of the bed. - He/she thought the resident was in pain. - He/she told the nurse and a couple of CNA's the resident had fallen. - The resident had frequent falls and the CNA's often picked him/her up off of the floor. During an interview on 11/16/22 at 1:34 P.M. LPN A said: - He/she was the charge nurse for the resident on 11/8/22. - He/she was not notified that the resident had either fall until 6:00 P.M. when the family reported the falls to him/her. - He/she immediately assessed the resident for injuries and found the resident lying in his/her bed, crying. - The resident did not want to move his/her right arm and LPN A saw swelling to that extremity. - LPN A obtained an order to X-ray the resident's right arm. The X-ray showed the resident had a broken right arm. - LPN B did not tell him/her of the resident's first fall until the family reported the falls to LPN A. - He/she expected LPN B to report the fall to him/her s that that he/she could have assessed the resident sooner and addressed the resident's pain sooner. - He/she expected CNA B to report Resident #1's fall immediately to him/her. - CNA B should not have picked the resident off of the floor after he/she fell before the nurse assessed the resident. - He/she expected resident falls to be reported to the charge nurse immediately. During an interview on 11/16/22 at 12:18 P.M. the Director of Nursing (DON) said: - He/she expected LPN B to perform an head to toe assessment after he/she found the resident lying on the floor and before the resident was moved. - He/she expected CNA B to notify the charge nurse immediately when he/she found the resident on the floor and before the resident was moved. During an interview on 11/16/22 at 12:43 P.M. the Administrator said: - He expected LPN B to provide the proper assessment when he/she found the resident lying on the floor. - The resident should not have been moved before the assessments were completed. - He expected CNA B to notify the charge nurse immediately when he/she found the resident on the floor. - CNA B should not have moved the resident before the charge nurse assessed him/her. MO209947

Based on observation, interview and record review, the facility failed to provide supervision and protective oversight for one sampled resident (Resident #1), who was assessed as needing a staff member present while he/she was in the whirlpool. Staff left the resident in the whirlpool tub unsupervised for approximately one hour. The facility census was 87. 1. Review of Resident #1's care plan for care/Activities of Daily Living (ADL's) Preferences, dated 2/27/18, showed: -Staff will honor my preferences while caring for me; -Prefer a shower two times per week or whirlpool bath. When doing a whirlpool bath, the staff must stay with the resident. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/4/18, showed: -Alert and oriented and able to answer questions; -Required supervision and oversight and physical assistance of one staff member for personal hygiene, transfers and bathing; -[DIAGNOSES REDACTED]. Review of the resident's undated care plan for signs and symptoms related to [MEDICAL CONDITION] showed: -At risk for falls; -Monitor for falls. Review of the resident's undated kardex (a guide used by the Certified Nurse Aides (CNA) to provide care) showed: -Falling star program, at risk for falls; monitor for risk of falls; -The resident is able to participate in bathing with staff assist of one; -The resident is able to transfer with assist of one staff member. Review of the resident's undated care plan for falls showed: -The resident is at risk for falls related to cerebellar ataxia (lack of muscle control), cardiac status, [MEDICAL CONDITION] drug use and weakness; -The resident will be free of falls; -Utilize the falling star program, keep the resident's call light within reach. Review of a grievance report form, dated 1/1/19, showed: -Grievance was filed by a family member; -Incident occurred on 12/31/18; -The resident was left in the whirlpool for an hour and a half; -Action taken - spoke with family member on 1/3/19 regarding the incident. CNA's educated regarding the importance of staying with the resident during the whirlpool. Review of the nurses' note dated as a late entry for 1/3/19 at 8:33 P.M., signed by the Director of Nursing (DON) showed: -Spoke with the resident and the family member regarding the whirlpool tub assistance on 12/31/18. Informed both that assistance would be provided during the whirlpool. During an interview on 1/10/19 at 10:00 A.M., the resident said: -He/She was at risk for falls due to his/her [MEDICAL CONDITION]; -He/She preferred to take a whirlpool bath; -The CNA's were supposed to stay with him/her while he/she took a whirlpool due to his/her risk for falling; -On 12/31/18 around 8:00 P.M., a CNA took him/her to have a whirlpool. There were only two CNA's on the 300 hall on 12/31/18. Another CNA came into the bathing room and asked the CNA that was staying with him/her, for help with another resident. The CNA left the bathing room. The CNA did not give him/her the call light. He/She waited for about 15 minutes and began to become anxious as the CNA had not returned. He/She leaned over in the whirlpool and was able to grab the call light. He/She had trouble reaching the call light. He/She pressed the call light button. He/She waited for another 15 or 20 minutes and no one came. He/She began to yell Nurse, nurse. No one came into the bathing room. He/She then began to scream, Someone, please help me. After an hour or an hour and a half, a CNA came into the room and said, Oh, we forgot the lady in the whirlpool. This CNA and a nurse assisted him/her out of the whirlpool and took him/her to his/her room; -The water in the whirlpool was cold by the time the staff helped him/her out of the whirlpool; -He/She called his/her family member and reported the incident to the family member. During an interview on 1/10/19 at 11:45 A.M., the DON said: -She received a grievance form on 1/3/19 indicating that the resident was left alone in the whirlpool; -The resident said he/she was left for an hour and half; -She talked with the two CNA's on the 300 hall on 12/31/18 and they admitted that the resident was left in the whirlpool for 45 minutes to an hour; -They went into the bathing room after they heard the resident screaming for help; -She educated the CNA's not to leave the resident alone in the whirlpool; -The call light activated a light outside the door when the light was turned on; -There was a board at the nurses' station that sounded when a call light was turned on. Observation on 1/10/19 from 10:00 A.M. to 4:00 P.M., showed: -A board at the nurses' station that indicated a call light was on; -A faint sound could be heard when the call light was on; -The sound could not be heard when 10 feet away from the nurses' station. During an interview on 1/10/19 at 3:00 P.M. CNA A said: -There was only two CNA's for the 300 hall on 12/31/18 after 7:00 P.M.; -There were 40 residents to take care of; -He/She took the resident into the bathing room and put him/her in the whirlpool around 8:00 P.M.; -Around 8:10 P.M. CNA B came into the bathing room and asked for his/her help with another resident; -He/She left the resident in the whirlpool and assisted CNA B; -He/She and CNA B assisted another resident on the other side of 300 hall then began to put other residents to bed and change other residents; -He/She did not remember how long he/she was gone from the bathing room; -He/She was not aware that the resident was a fall risk; -He/She was not aware the resident needed to be supervised in the whirlpool. During an interview on 1/10/19 at 3:10 P.M., CNA B said: -He/She and CNA A were the only CNA's on the 300 hall on 12/31/18 after 7:00 P.M.; -There were 40 residents to take care of; -He/She went into the bathing room around 8:10 P.M. to ask CNA A for help with another resident; -He/She and CNA A assisted another resident, then began putting other residents to bed on the other end of the 300 hall; -When he/she went around the corner by the nurses' station, he/she heard the resident screaming from the bathing room; -He/She went into the bathing room and with a nurse's assistance, got the resident out of the whirlpool; -He/She did not remember if the call light was on. During an interview on 1/10/18 at 4:30 P.M., the DON said: -The staff were supposed to stay with the resident when the resident took a whirlpool bath. During an interview on 1/11/18 at 2:30 P.M. Family Member A said: -He/She received a telephone call from the resident on 12/31/18 at 10:30 P.M.; -The resident was very upset and crying. He/She said he/she had been left in the whirlpool for an hour and a half; -He/She stayed on the telephone for an hour and calmed the resident; -He/She talked with a staff member on 12/31/18 who confirmed the resident had been left in the whirlpool for an extended amount of time; -He/She talked with the DON on 1/3/19 who also confirmed that the resident had been left in the whirlpool; -He/She said the resident should not be left in the whirlpool alone due to his/her [MEDICAL CONDITION] and the risk for falls. During an interview on 1/24/19 at 1:25 P.M., the DON said: - Each resident had a call light and when the resident pressed his/her call light, the call went directly to the CNA assigned to the resident's facility phone; - If a CNA did not answer a resident's call light within a certain time frame, he/she was uncertain the exact time frame, the resident's call light rolled over to the charge nurse's phone; - Also a dome light outside the resident's room would light up; - The call light also showed up on a panel at the nurse's station. During an interview on 1/24/19 at 1:35 P.M. the resident said: - He/She took whirlpool baths. The whirlpool baths made him/her feel better; - He/She did not want to left alone in the whirlpool; - He/She was horrified that someone might leave him/her unattended in a whirlpool again; - He/She had nightmares since staff left him/her in the whirlpool; - He/She always made staff promise to stay with him/her when he/she took a whirlpool bath; - He/She took a whirlpool twice a week; - He/She would not climb into the whirlpool unless staff promised not to leave him/her unattended in the whirlpool; - When he/she got out of the whirlpool on 12/31/18, he/she was very cold and his/her hands were like prunes. Observation on 1/24/19 at 2:00 P.M. of the bathing room on the 300 hall showed: -A whirlpool tub with a call light cord at the foot of the tub; -The whirlpool tub was approximately four feet tall, three feet wide, and six feet long; -The head of the tub with a ledge to sit on positioned on one side and the call light on the wall by the foot of the tub; -The call light did not reach the ledge where a resident sat; -The bathing room was approximately 20 feet from the nurses' station; -A light attached above the bathing room door that lit up when activated, but with no sound to alert staff that the call light was activated. During an interview on 1/24/19 at 3:15 P.M., Licensed Practical Nurse (LPN) A said: - He/She worked the night staff left the resident in the whirlpool; - The night of the occurrence was the first night he/she worked in the facility; - One CNA left the resident in the whirlpool; - He/She called the resident's daughter after the incident. During an interview on 1/24/19 at 3:25 P.M., the facility Corporate Nurse Consultant (CNC) said: - Staff should not leave a resident alone in the whirlpool; - If a resident preferred to be left alone in the whirlpool, staff must assess the resident first to ensure staff could safely leave a resident alone in the whirlpool; - Staff had not assessed the resident for safety to be left alone in the whirlpool. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility showed they educated staff who were on duty 12/31/18 and who provided care to Resident #1. They were educated to supervise the resident during a whirlpool bath. If the resident prefers to bathe alone, an assessment will be done to determine if the preference can be safely honored. The cords for the call lights in both whirlpool bath tubs were extended. The facility will educate all nursing staff that residents may not be left unsupervised in a shower, bath or whirlpool. Staff will be educated to carry phones at all times. All staff will be educated prior to returning to work on the unit. The call light system will be serviced to ensure the call light message goes to the phones consistently. In the interim, if a resident is using the whirlpool, staff will be present and another staff member will be checking to see if any additional assistance is needed. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 1