Every finding on record at Troy Manor

Based on observation, interview, and record review, the facility failed to properly store food items, failed to maintain the range hood free of a buildup of grease and debris, failed to ensure staff wore beard restraints, failed to ensure one ice machine was equipped with an appropriate air gap to prevent back siphonage, and failed to ensure the kitchen floor was clean. The facility census was 104. 1. Review of the facility policy, Safe Food Handling, dated 2015, showed all food, including bulk items, should be tightly sealed with an identifying label and date. Observation on 6/1/26 at 10:49 A.M. and at 3:01 P.M. of the kitchen storage shelf above the microwave, showed the following:-The lid on a 16-ounce container of ground ginger was open to air and not sealed;-The lid on an 18-ounce container of ground white pepper was open to air and not sealed;-The lid on a clear container, labeled Salt, was open to air and not sealed;-The lid on a 16-ounce container of garlic powder was open to air and not sealed. During an interview on 6/3/26 at 2:06 P.M., the Dietary Manager said the lids on the spices should be closed or sealed. 2. Review of the facility policy, Guidelines for Cleaning Hood Filter Over Stove, dated 2015, showed the following:-The screen(s) will be cleaned monthly and interior/exterior of exhaust hood will be cleaned monthly;-Cleaning of the screen(s) is done every week;-Outside of hood is cleaned daily with a clean cloth;-Exhaust vent should be cleaned semi-annually, this can be done commercially. Observation on 6/01/26 at 10:50 A.M. of the kitchen range hood showed the following:-The range hood was equipped with seven baffle filters and protected a six-burner stove, griddle, double fryer and convection oven;-All seven baffle filters had a heavy buildup of dark-colored debris and yellow grease. The heaviest buildup was on the filters located over the griddle and double fryer;-A sticker on the range hood exterior showed the hood was professionally cleaned in May 2026. During an interview on 6/3/26 at 2:06 P.M., the Dietary Manager said the following:-A dietary aide cleaned the range hood baffle filters once or twice weekly;-A professional company cleaned the hood twice yearly. 3. Review of the facility policy, Dietary Personnel Guidelines, dated 2015, showed hairnets or bouffant disposable caps should be worn at all times and should cover the entire head of hair. Observation on 6/1/26 at 2:49 P.M. showed Dietary [NAME] R opened large cans of stewed tomatoes and poured the contents of the cans into a large steam table pan. He/She wore an orange ballcap on his/her head and a beard restraint over his/her chin that did not cover a long curled moustache, goatee and sideburns. Observation on 6/1/26 at 3:04 P.M. showed Dietary [NAME] R opened two large cans of peas and poured the contents of the cans into a large steam table pan. He/She wore an orange ballcap on his/her head and a beard restraint over his/her chin that did not cover a long curled moustache, goatee and sideburns. During an interview on 6/3/26 at 2:06 P.M., the Dietary Manager said the following:-The facility did not have a beard restaint policy;-The beard guards available for staff to use did not cover all staff's facial hair. 4. Observation on 6/2/26 at 9:58 A.M. of the staff break room ice machine, located near the entrance to the 400 Hall, showed the following:-Two plastic pipes sat directly on floor drain funnel with the ends of the pipes below the floor level. There was no air gap between the pipes and the floor drain. During an interview on 6/2/26 at 9:58 A.M., the Corporate Maintenance Representative said he was unaware the ice machine did not have an air gap. During an interview on 6/3/26 at 2:06 P.M., the Dietary Manager said she was unaware the ice machine in the staff breakroom was not equipped with an air gap. 5. Review of the facility policy, Cleaning Floors, dated 2015, showed kitchen floor maintenance will be done after each meal. Spills need to be mopped up immediately. Observation on 6/1/26 at 10:48 A.M. showed a heavy buildup of food debris and crumbs on the kitchen floor around the steam table, food preparation area and near the cooking appliances. During an interview on 6/3/26 at 2:06 P.M., the Dietary Manager said staff should sweep the floors after each meal. Staff should clean any messes made on the floor as they occur.

Based on observation, interview, and record review, the facility failed to ensure staff changed gloves and washed their hands when providing care to three residents (Residents #18, #44, and #1) in a review of 28 sampled residents. The facility failed to follow enhanced barrier precautions (EBP, infection control measures used in long term care facilities to prevent the spread of multi-drug-resistant organisms, or MDROs, by requiring staff to wear personal protective equipment, or PPE of gown and gloves during high-contact care activities) as directed when staff provided care for one resident (Resident #1) with a urinary catheter. Staff failed to place a multi-resident use glucometer on a barrier as directed by facility policy for two residents (Resident #17 and #12) and three additional residents (Resident #41, #62 and #66) when performing blood sugar finger sticks. The facility failed to clean the hub of an insulin pen as directed prior to administration for one sampled resident (Residents #17) and two additional residents (Residents #62 and #66). Staff failed to ensure one resident (Resident #19) with an upper respiratory infection properly stored breathing treatment supplies in a sanitary manner when not in use. The facility failed to follow their policy to address Legionella Control which included specific control parameters based on Center for Disease Control (CDC) and American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) standards, failed to complete a comprehensive assessment to identify areas in the facility at risk for Legionella growth and failed to complete a water flow map. The facility census was 104. Review of the undated facility policy, Gloving, showed the following: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash;-Gloves must be changed between residents and between contacts with different body sites of the same resident;-Change gloves between contacts (as defined above) with different residents or with different body sites of the same resident. 1. Review of Resident 18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility staff, dated [DATE], showed the resident was always incontinent of bowel and bladder. Observation on [DATE] at 5:00 A.M. showed the following: -Certified Nurse Assistant (CNA) T used hand sanitizer, pulled a pair of gloves from his/her pants pocket and put them on his/her hands; -The resident lay on his/her back in bed;-The resident's incontinence brief was soiled with urine; -CNA T wiped the resident's lower stomach and left and right groin with a wet washcloth;-CNA T did not change his/her gloves, rolled the resident to his/her right side, and held the resident in place with his/her left gloved hand on the resident's left hip; -CNA T rolled the soiled incontinence brief under the resident and placed a clean incontinence brief and protective pad under the resident; -The resident was incontinent of bowel; -CNA T cleaned the resident's buttocks, did not change his/her gloves and rolled the resident onto his/her left side; -CNA T steadied the resident with his/her gloved right hand on the resident's back; -CNA T cleaned the resident's buttocks, did not change gloves, pulled the resident's clean incontinence brief and protective pad under the resident, and rolled the resident onto his/her back; -CNA T did not remove his/her gloves and fastened the resident's clean incontinence brief; -CNA T pulled the resident's covers over the resident; -CNA T removed his/her gloves, did not use hand sanitizer or wash his/her hands, tied the dirty linen bag closed and left the resident's room with the bag. 2. Review of Resident #44's quarterly MDS, dated [DATE], showed the resident was always incontinent of bowel and bladder. Observation on [DATE] at 5:30 A.M. showed the following: -CNA T used hand sanitizer, pulled a pair of gloves from his/her pants pocket and put them on his/her hands; -The resident lay on his/her back in bed; -The resident's incontinence brief and protective pad under the resident were soiled with urine; -CNA T wiped the resident's lower stomach and left and right groin with a wet washcloth; -CNA T did not change his/her gloves, rolled the resident to his/her right side, and held the resident in place with his/her left gloved hand on the resident's left hip; -CNA T rolled the soiled incontinence brief under the resident and placed a clean incontinence brief and protective pad under the resident; -CNA T cleaned the resident's buttocks, did not change gloves, and rolled the resident onto his/her left side; -CNA T steadied the resident with his/her gloved right hand on the resident's back; -CNA T cleaned the resident's buttocks, did not change gloves, pulled the resident's clean incontinence brief and protective pad under the resident and rolled him/her onto his/her back; -CNA T did not remove his/her gloves and fastened the resident's clean incontinence brief; -CNA T pulled the resident's covers over the resident; -CNA T removed his/her gloves, did not use hand sanitizer or wash his/her hands, tied the dirty linen bag closed and left the resident's room with the bag. During an interview on [DATE] at 3:30 P.M., CNA T said the following: -He/She should perform hand hygiene, using a hand sanitizer or washing his/her hands with soap and water, before and after resident contact, when his/her hands were dirty, and before and after he/she changed his/her gloves; -He/She did not realize he/she forgot to use hand sanitizer or wash his/her hands before putting on gloves and after he/she provided incontinence care for Residents #18 and #44; -He/She did not realize he/she went from a dirty area to a clean area without changing his/her gloves or performing hand hygiene; -He/She usually kept gloves in his/her pants pocket because he/she could get to them quicker. During an interview on [DATE] at 3:00 P.M., the Director of Nursing (DON) said the following: -Staff should wash their hands or use hand sanitizer before and after resident care, when visibly soiled and between glove changes; -Staff should change gloves and perform hand hygiene (wash hands or use hand sanitizer) after completing personal care, and before going from a clean area to an area considered dirty (between care areas), and when visibly soiled; -Staff should not carry gloves in their uniform pockets for individual use due to potential for cross contamination and to maintain infection control practices. 3. Review of the facility policy, Enhanced Barrier Precautions to Infection Control Guidance, updated 03/2024, showed the following: -Who requires EBP: Residents with an indwelling medical device including urinary catheters, regardless of their MDRO status;-Use EBP when providing high-contact resident care activities such as transferring residents from one position to another;-Equipment: gloves and gown;-Conduct proper hand hygiene before starting care;-Gloves and donning and doffing of gown are required when conducting high-contact resident care activities that are listed above;-Residents who are on EBP should have PPE in close proximity outside the door and a trash can in resident's room for disposal prior to leaving the room. 4. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:-The resident had a urinary catheter;-Diagnosis of viral hepatitis (an inflammation of the liver caused by a viral infection). Review of the resident's care plan, last reviewed [DATE], showed the following: -The resident was on EBP related to urinary catheter; -EBP signage was posted on his/her door to notify staff; -Staff will wear appropriate personal protective equipment (PPE) when caring for the resident according to EBP guidelines. Observation on [DATE] at 1:25 P.M. showed an EBP sign and PPE supplies, including disposable gowns and gloves, on the outside of the resident's room door. Observation on [DATE] at 5:40 P.M. showed the following: -CNA T entered the resident's room; -CNA T did not perform hand hygiene, did not put on a gown, pulled a pair of gloves out of his/her pants pocket, and put them on; -CNA T assisted the resident to transfer from the bed to the wheelchair; -CNA T's uniform touched the resident's bed, bed linens, the resident's body, and the resident's urinary catheter tubing during the transfer; -After the transfer, CNA T removed his/her gloves, did not perform hand hygiene, left the resident's room, and closed the door behind him/her. During an interview on [DATE] at 3:30 P.M., CNA T said the following: -An EBP sign on a resident's door meant staff were to wear a gown and gloves when providing personal care or when touching the resident; -He/She did not wash his/her hands, use hand sanitizer, or wear a gown when he/she assisted the resident from the bed to the wheelchair because he/she did not think about it;-He/She did not realize his/her clothing came in contact with the resident's body, linens, or urinary catheter during the transfer; -He/She probably should have put on a gown before he/she assisted the resident at any time. During an interview on [DATE] at 3:00 P.M., the DON said staff should follow EBP signage when posted on a resident's door and use personal protective equipment (PPE) when indicated for infection control practices. 5. Review of the undated facility policy, Blood Glucose Monitoring, showed to place equipment on a clean surface (such as clean towel). Review of the undated American Health Care Association, Tips for Meeting the Cleaning and Disinfection of Blood Glucose Meter Requirements in Skilled Nursing Facilities, showed the following:-Place a barrier under the blood glucose meter (glucometer) when in a resident's room or placed on top of the medication cart to avoid the spread of microorganisms and contamination of surfaces and other equipment or supplies;-Tip: Place a clean and dry paper towel(s) under the blood glucose meter before placing it on a resident table or on top of the medication cart. 6. Review of Resident #12's Physician Orders, dated [DATE], showed the following:-The resident had a diagnosis of Type 2 diabetes mellitus (metabolic disorder);-Monitor blood glucose (measurement of the amount of glucose or sugar in the blood) three times daily. Observation on [DATE] at 4:57 A.M., showed the following:-Registered Nurse (RN) E put on gloves, entered the resident's room and sat the multi-resident use glucometer on top of the resident's blanket without a barrier;-RN E obtained the blood sample from the resident's finger, picked up the glucometer, performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer, removed the blood-filled test strip from the glucometer, and laid the glucometer on the resident's blanket on the resident's bed;-Without changing his/her gloves, RN E cleaned the resident's abdomen with an alcohol swab and administered the insulin in the resident's abdomen;-RN E took off his/her gloves, did not perform hand hygiene, placed the glucometer in a small white basket on top of the medication cart, and pushed the medication cart to the nurse's station. 7. Review of Resident #41's Physician Orders, dated [DATE], showed the following:-The resident had a diagnosis of Type 1 diabetes mellitus (metabolic disorder);-Monitor blood glucose four times daily. Observation on [DATE] at 5:35 A.M., showed the following:-RN E approached the resident at the dining room table and sat the multi-resident use glucometer on the dining room table without a barrier;-RN E put on gloves without performing hand hygiene;-RN E obtained the blood sample from the resident's finger, performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer, removed the blood-filled test strip from the glucometer, and laid the glucometer on the dining room table without a barrier;-Without changing his/her gloves, RN E charted the blood glucose results in the electronic medical record (EMR), cleaned the resident's abdomen with an alcohol swab, administered the insulin into the resident's abdomen, and placed the insulin pen in the medication cart;-RN E removed his/her gloves and without performing hand hygiene, charted the insulin administration in the EMR. During an interview on [DATE] at 5:07 A.M. and 5:42 A.M., RN E said the following:-He/She should have changed his/her gloves and performed hand hygiene after obtaining the resident's blood sample and before administering insulin to the resident and charting on the EMR; -He/She usually sat the glucometer in a small white basket to use as a barrier, but did not. 8. The facility did not provide a policy related to the cleaning of insulin pen hubs. Review of the Lantus Solostar (prefilled insulin pen containing long-acting medication to treat diabetes) manufacturer's administration guidelines, revised 11/2018, showed the following procedure to attach the needle:-Wipe the rubber seal with alcohol;-Remove the protective seal from a new needle;-Attach the needle to the pen. Review of the Humulin 70/30 Kwik pen Flex Pen (prefilled insulin pen) manufacturer's administration guidelines, revised [DATE], showed when preparing the pen, wipe the rubber seal with an alcohol swab. 9. Review of Resident #62's Physician Orders, dated [DATE], showed the following:-The resident had a diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease (happens when high blood sugar damages the kidney's filtering units, impairing their ability to remove waste.);-Blood sugar finger stick two times a day before breakfast and at bedtime;-Lantus Solostar 100 Units/mL, inject 45 units subcutaneously (under the skin) in the morning. Observation on [DATE] at 4:52 A.M., showed the following:-The glucometer set directly on top of the medication cart without a barrier;-Licensed Practical Nurse (LPN) L put a test strip into the glucometer, gathered the supplies for the ordered blood sugar finger stick and entered the resident's room;-LPN L placed the multi-resident use glucometer directly on top of the resident's abdomen which was covered with a t-shirt, without a barrier;-LPN L obtained the blood sample from the resident's finger, picked up the multi-resident use glucometer, performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer, then set the glucometer directly onto the resident's bed on top of a blanket, without a barrier;-LPN L left the resident's room with the multi-resident use glucometer and placed it directly on top of the medication cart, without a barrier;-LPN L removed the resident's Lantus insulin pen from the medication cart, removed the cap from the insulin pen, and without cleaning the hub of the insulin pen with an alcohol pad, applied the needle to the hub and administered the insulin to the resident. 10. Review of Resident #17's physician orders, dated [DATE], showed the following:-The resident had a diagnosis of Type 2 diabetes with hyperglycemia (a chronic condition characterized by insulin resistance and relative insulin deficiency, leading to persistently elevated blood glucose levels);-Blood sugar finger stick between 3:00 P.M. and 6:00 P.M.;-Lantus Solostar 100 Units/mL, inject 20 units subcutaneously between 3:00 P.M. and 6:00 P.M. Observation on [DATE] at 3:45 P.M., showed the following:-LPN L put a test strip into the glucometer, gathered the supplies for the ordered blood sugar finger stick and entered the resident's room;-LPN L obtained the blood sample from the resident's finger, performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer, then sat the glucometer directly onto the resident's bed side table without a barrier;-LPN L left the resident's room with the multi-resident use blood glucometer and placed it directly on top of the medication cart, without a barrier;-LPN L obtained the resident's Lantus insulin pen from the medication cart, removed the cap from the insulin pen, and without cleaning the hub of the insulin pen with an alcohol pad, applied the needle to the hub and administered the insulin to the resident. 11. Review of Resident #66's Physician Orders, dated [DATE], showed the following:-The resident had a diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease;-Blood sugar finger stick between 3:00 P.M. and 6:00 P.M.;-Humulin 70/30 (consists of 70% intermediate-acting insulin and 30% short-acting insulin), 100 Units/mL Kwik pen, inject 5 units subcutaneously between 3:00 P.M. and 6:00 P.M. Observation on [DATE] at 4:03 P.M., showed the following:-LPN L put a test strip into the glucometer, gathered the supplies for the ordered blood sugar finger stick and entered the resident's room;-LPN L placed the multi-resident use blood glucometer directly on the resident's bedside table without a barrier;-LPN L obtained the blood sample from the resident's finger, performed the blood sugar finger stick by placing a blood-filled test strip in the glucometer, then sat the glucometer directly onto the resident's bedside table without a barrier;-LPN L left the resident's room with the multi-resident use blood glucometer and placed it directly on top of the medication cart, without a barrier;-LPN L removed the resident's Humulin 70/30 Kwik pen from the medication cart, removed the cap from the insulin pen and without cleaning the hub of the insulin pen with an alcohol pad, applied the needle to the hub and administered the insulin to the resident. During an interview on [DATE] at 4:13 P.M., LPN L said the following:-He/She had never been instructed to use a barrier under the multi-resident use glucometer either at the medication cart or at the resident's bedside;-He/She knew the hub of the insulin pen needed cleaned with alcohol before use, but he/she did not clean it before administering insulin to Resident #17, #62 or #66. During an interview on [DATE] at 10:45 A.M., the DON said the following:-Staff should place multi-resident use glucometers on a clean surface like a bleach wipe on the medication cart or a paper towel in residents' rooms;-Staff should not set multi-resident use glucometers directly on the medication cart, on a resident's bedside table, on a resident's shirt or a resident's blanket;-When administering insulin with an insulin pen, staff should clean the hub of the insulin pen with an alcohol pad before applying the needle. 12. Review of the undated facility policy, Oxygen Equipment Cleaning Guidelines, showed the policy did not address how to store oxygen equipment when not in use. Review of the undated facility policy, Oxygen Administration, showed the policy did not address how to store oxygen equipment when not in use. Review of the National Heart, Lung and Blood Institute (NIH) guidelines, dated October, 2021, between uses nebulizer parts should be stored in a dry, clean plastic storage bag. 13. Review of Resident #19's undated face sheet showed diagnoses included acute respiratory infection (URI, a new onset infection affecting the nose, throat and sinuses), interstitial pulmonary disease (a lung disorder characterized by inflammation and scarring of the air sacs in the lungs) and chronic obstructive pulmonary disease (COPD/lung disease). Review of the resident's Physician Order Sheet (POS), dated [DATE], showed the following:-Oxygen 2 liters/minute via nasal cannula (a device used to deliver oxygen with two small tubes that fit into the nostrils) as needed for shortness of breath (original order dated [DATE]); -Ipratropium-albuterol solution for nebulization (an inhaled medication to treat symptoms of lung diseases) 0.5 mg/3 mg in 3 milliliters (ml) solution, one vial inhalation four times a day as needed (original order dated [DATE]);-Amoxicillin-clavulanate (an antibiotic) 875-125 milligrams (mg), one tablet twice a day for seven days for an acute URI (original order dated [DATE]);-Azithromycin (an antibiotic) 500 mg one tablet daily on [DATE] for an acute URI;-Azithromycin 250 mg one tablet daily from [DATE] through [DATE] for an acute URI;-Ipratropium-albuterol solution for nebulization 0.5 mg/3 mg in 3 ml solution three times a day from [DATE] to [DATE]. Review of the resident's Care Plan, revised on [DATE], showed the following:-The resident received antibiotics for respiratory infection/pulmonary edema (excess fluid in the airs sacs of the lungs);-He/She used oxygen for COPD;-The resident requested the urinal be kept uncovered on his/her bedside table/floor by the bed to enable self-use. Review of the resident's progress note, dated [DATE] at 2:16 P.M., showed the resident had a URI and pulmonary edema, per chest x-ray. The resident has a documented history of multiple risk factors. He/She was completely sedentary. He/She wished to remain in bed at all times. The resident received routine nebulizer treatments and antibiotic therapy through the 5th. Observation on [DATE] at 2:42 P.M., showed a urinal containing urine sat on the resident's mattress. A nebulizer mask lay uncovered on the resident's bed directly next to the urinal. There was no clear bag available in the room to store the nebulizer mask when not in use. Observation on [DATE] at 9:19 A.M., showed a urinal containing urine sat on the resident's mattress. A nebulizer mask lay uncovered on the resident's bed directly next to the urinal. There was no clear bag available in the room to store the nebulizer mask when not in use. Observation on [DATE] at 5:50 A.M., showed a urinal containing urine sat on the resident's mattress. A nebulizer mask lay uncovered on the resident's bed directly next to the urinal. There was no clear bag available in the room to store the nebulizer masks when not in use. Observation on [DATE] at 8:35 A.M., showed a urinal containing urine sat on the resident's mattress. A nebulizer mask lay uncovered on the resident's bed directly next to the urinal. During an interview on [DATE] at 9:45 A.M., the resident said staff had not educated him/her about storing the nebulizer mask in a bag when not in use, but it would probably be a good idea. Staff had not provided a bag to place the nebulizer mask in when he/she was not using it. During an interview on [DATE] at 3:32 P.M., Restorative Aide I said breathing treatment supplies should be stored in a clear bag and not on the mattress when not in use. During an interview on [DATE] at 12:09 P.M., Licensed Practical Nurse (LPN) A, said the following:-Nebulizer masks should be stored in a bag when not in use;-The resident's nebulizer mask should not be directly on a resident's bed and not close to the urinal;-He/She did not see a clear bag to store the mask when not in use in the resident's room. During an interview on [DATE], At 12:11 P.M., LPN H said the following: -Nebulizer supplies should be stored in a clear bag when not in use;-Nebulizer masks should never be directly on the mattress or near a urinal. During an interview on [DATE], at 12:28 P.M., the Director of Nursing (DON) said the following:-The nebulizer mask should be stored in a clear bag when not in use;-The nebulizer mask should not to be sitting on a resident's bed and she would hope it would not be sitting next to a urinal that was in use. 14. Review of the undated facility policy, Guideline to Develop a Water Management Program to Reduce Legionella Growth, showed the following: -Purpose: The purpose of this guideline is to aid the facility in creating a site-specific water management program to reduce Legionella growth in the facility;-The committee will conduct a facility risk assessment on an annual basis to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system;-Describe the building water systems using text;-The committee will write a simple description of the building water system specific to your facility;-Describe in detail the same sections used in the example as follows: -Water enters; -Cold water is distributed; -Cold water is heated; -Hot water is distributed; -Hot, cold, and tempered wastewater is discarded;-Describe the building water systems using a flow diagram;-Using the building water systems descriptions from section 2, the committee will create a flow diagram to represent water flow specific to your facility;-Identify where Legionella could grow and spread;-Using the flow diagram for your facility form section 3, the committee will identify where potentially hazardous conditions could occur. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated [DATE] and revised on [DATE], showed the following:-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical and epidemiological considerations for healthcare facilities are described in this toolkit;-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Review of the undated Centers for Disease Control and Prevention Legionella Environmental Assessment Form showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begins to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. 15. Review of the facility provided water management binder showed the following: -No specific assessment and water management plan related to Legionella;-No water flow map. Observation on [DATE] in occupied resident room [ROOM NUMBER] showed the following:-At 4:22 P.M. (after running the water at the hot water faucet for one minute), the temperature of the hot water was 93.2 degrees F (within optimal growth range for Legionella);-At 4:24 P.M., the temperature of the hot water was 100.4 degrees F (within optimal growth range for Legionella);-At 4:26 P.M., the temperature of the hot water was 106.2 degrees F (within optimal growth range for Legionella). -At 4:27 P.M. (after running the water at the hot water faucet for six minutes), the temperature of the hot water was 109.9 degrees F. Observation on [DATE] in occupied resident room [ROOM NUMBER] showed the following:-At 4:42 P.M. (after the running the water at the hot water faucet for one minute), the temperature of the hot water was 107.8 degrees F (within optimal growth range for Legionella);-At 4:43 P.M., the temperature of the hot water was 108 degrees F (within optimal growth range for Legionella);-At 4:45 P.M., the temperature of the hot water was 108.9 degrees F. During interviews on [DATE] at 2:30 P.M. and 4:55 P.M., the Corporate Maintenance Representative said the following:-He was filling in for the maintenance director who was on vacation;-He was unaware of what was specifically needed related to the Legionella plan;-The facility did not have a specific water flow map;-He had not heard of ASHRAE guidelines;-He was unaware of the temperature ranges were specifically for Legionella growth. During interviews on [DATE] at 2:30 P.M and 4:55 P.M., the Administrator said the following: -The water management team met monthly;-He, the Maintenance Director and the Director of Nursing made up the water management team;-He was unsure what resources were used for the water management team, but he felt like the assessment was completed from the CDC toolkit;-He was unaware of the ASHRAE guidelines;-He was unsure what the specific water temperatures for optimal growth of Legionella were, but that the maintenance department did weekly hot and cold-water temperature checks; During an interview on [DATE], at 12:49 P.M., the Maintenance Director said the following:-He, the Administrator and the DON were the members of the water management team;-He did not know what AHSRAE stood for or what the ASHRAE guidelines were;-The facility did not have any areas at risk for Legionella development to the best of his knowledge because they do not have cooling towers or storage tanks;-The facility did not develop a water flow diagram;-He was aware it took a long time for the water in room [ROOM NUMBER] to get warm; staff didn't really use the water in that room;-He was unsure at what temperature Legionalla grew in water; -Maintenance staff checked the hot and cold-water temperatures weekly; -He flushed the water lines on the 500 hall once every month or two since the facility did not use the 500 hall; -He did not flush the unused showers and was unsure if water was hooked up to the whirlpool tubs in the shower rooms.

Based on observation, interview, and record review, the facility failed to destroy discontinued and course completed medications within 30 days for one resident (Resident #6), in a review of 28 sampled residents, and for four additional residents (Residents #81, #16 #83 and #82). The facility census was 104. Upon request, the facility did not provide a medication destruction policy. 1. Review of Resident #81's Physician Order, dated 05/20/25, showed an order to discontinue trazodone (a medication used to treat depression and anxiety) 50 milligrams (mg), one half tablet daily at bedtime related to anxiety disorder. Observation on 06/03/26 at 11:52 A.M., showed 30 and one-half tablets of trazodone, labeled for the resident, were stored in a medication destruction cabinet located in the 300/400 hall medication storage room. Staff failed to destroy the medication within 30 days after the medication were discontinued. 2. Review of Resident #16's Physician Order, dated 06/22/25, showed an order to discontinue gabapentin (used to treat seizures and nerve pain) 600 mg, one tablet three times daily for fibromyalgia (chronic muscle pain). Observation on 06/03/26 at 11:52 A.M., showed 90 tablets of gabapentin, labeled for the resident, were stored in a medication destruction cabinet located in the 300/400 hall medication storage room. Staff failed to destroy the medications within 30 days after the medications were discontinued. 3. Review of Resident #83's Physician Order, dated 09/17/25, showed an order to discontinue mirtazapine (anti-depressant medication) 7.5 mg, one tablet daily at bedtime related to major depressive disorder. Observation on 06/03/26 at 11:52 A.M., showed 20 tablets of mirtazapine, labeled for the resident, were stored in a medication destruction cabinet located in the 300/400 hall medication storage room. Staff failed to destroy the medications within 30 days after the medications were discontinued. 4. Review of Resident #82's Physician Order, dated 12/10/25, showed an order to discontinue pantoprazole (used to treat gastroesophageal reflux disease) 40 mg, one tablet two times daily for gastroesophageal reflux disease. Observation on 06/03/26 at 11:52 A.M., showed 30 tablets of pantoprazole, labeled for the resident, were stored in a medication destruction cabinet located in the 300/400 hall medication storage room. Staff failed to destroy the medications within 30 days after the medications were discontinued. 5. Review of Resident #6's Physician Order, dated 01/29/26, showed an order to discontinue divalproex (anticonvulsant medication used to treat seizures, migraines, and manic episodes of bipolar disorder) 250 mg, three capsules daily at bedtime related to cerebellar stroke syndrome (a neurological condition caused by interrupted blood flow (ischemia) or bleeding (hemorrhage) in the cerebellum). Observation on 06/03/26 at 11:52 A.M., showed one capsule of divalproex, labeled for the resident, was stored in a medication destruction cabinet located in the 300/400 hall medication storage room. Staff failed to destroy the medications within 30 days after the medications were discontinued. 6. During an interview on 06/03/26 at 1:11 P.M., the Infection Preventionist said she usually destroyed the medications in the medication destruction cabinet located in the 300/400 hall medication storage room. She tried to destroy medications every Friday but had not always completed the task. She last destroyed medications on 05/20/26. At that time, there were no medications left in the cabinet to be destroyed. She had never been instructed on how often medication destruction needed to be completed. 7. During an interview on 06/04/26 at 10:45 A.M, the Director of Nursing (DON) said staff usually destroyed medications two times a month. Staff should destroy medications at least once a month. She was ultimately responsible for ensuring staff destroyed the medications.

Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for four residents (Residents # 96, #2, #1, and #18), in a review of 28 sampled residents. The facility census was 104. Review of the facility's undated policy, Comprehensive Care Plan, showed the following:-An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the residents' highest practicable physical, mental, and psychosocial well-being;-The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain;-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS, a federally required assessment completed by facility staff);-Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition;-The interdisciplinary care plan learn is responsible for the periodic review and updating of care plans when a significant change in the residents' condition has occurred, at least quarterly and when changes occur that impact the residents' care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 1. Review of Resident #96's undated face sheet showed the resident's diagnoses included abnormal weight loss. Review of the resident's medical record showed the following:-On 11/04/25, staff documented the resident weighed 155.2 pounds;-On 04/03/26, staff documented the resident weighed 147.2 pounds. Review of the resident's Care Plan, last revised, 04/21/26, showed the following:-Goal of maintaining current body weight of 174 to 179 pounds with a target date of 07/31/26. (Staff documented the resident's weight was 147.2 pounds on 4/3/26). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility staff, dated 05/01/26, showed the following:-Severely impaired cognition;-Weight 147 pounds;-Loss of 5% or more in the last month or loss of 10% or more in last six months. Review of the resident's medical record showed on 05/03/26, the resident weighed 139.6 pounds which was a 10% loss in six months. Review of the resident's physician order sheet, dated May 2026, showed the following:-Monitor/record weight monthly and as needed. Notify the physician of significant weight change (original order dated 05/04/18);-Small and bite size diet (original order dated 04/21/26);-Remeron 7.5 milligrams (mg) at bedtime for weight loss (original order dated 05/26/26);-Supplement VHC (nutritional supplement drink) 90 milliliters (ml) three times daily (original order dated 05/27/26). Review of the resident's care plan showed it was not updated to reflect the resident's weight loss or added interventions to address the resident's weight loss. 2. Review of Resident #2's undated continuity of care document (CCD) showed the resident had a diagnosis of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side. Review of the resident's progress note, dated 03/25/25 at 2:55 A.M., showed staff documented the resident fell in his/her room. Review of the resident's progress note, dated 03/27/25 at 6:18 P.M., showed staff documented an x-ray of the resident's left ankle revealed he/she had a fracture of the distal tibia (lower end of the shin bone) and fibula (long, slender bone located on the outer side of the lower leg, runs parallel to the tibia or shinbone) which appeared to be acute (new onset). Staff notified the resident's physician and received new orders to splint the area, non-weight-bearing (NWB) status and refer to orthopedics. May need to send the resident to the emergency room (ER) for splint and evaluation. Review of the resident's progress note, dated 03/28/25 at 1:44 P.M., showed staff documented the resident returned from the hospital. Soft splint in place to left lower extremity (LLE) from below the knee down to foot. ER diagnosis closed (no break in the skin) bimalleolar fracture (a severe, unstable ankle injury where both the medial malleolus [inside of the ankle], and the lateral malleolus [outside of the ankle] are broken. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the following:-Controlled ankle motion boot (CAM boot, an orthopedic device used to protect, stabilize, and immobilize the foot and ankle during recovery) to left lower extremity. May remove after sitting up in shower chair to shower (original order dated 04/14/25, open-ended (no stop date); -Weight bearing as tolerated, assist (at least two-person) with gait belt and per physical and occupational therapy protocol; -May use CAM boot or Springleaf (a specific type of ankle-foot brace worn on the lower leg and foot to support the ankle), continue active range of motion (AROM) and passive range of motion (PROM) to left ankle, Hoyer (mechanical lift) when needed (original order dated 05/23/25, open-ended (no stop date). Review of the resident's progress note, dated 12/26/25 at 5:06 P.M., showed staff documented the resident had an unwitnessed fall on 12/26/25 at 4:30 P.M. and complained of extreme pain to the left arm/elbow/shoulder region and left hip. The resident transferred to the hospital. Review of the resident's progress note, dated 12/31/25 at 7:59 P.M., showed staff documented the resident was being transferred by two staff when the resident became weak in the legs and began to slump. The resident's family member requested Hoyer (mechanical lift) transfers from then on. Due to family request, the facility would utilize a Hoyer lift for all transfers moving forward. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility staff, dated 03/06/26, showed the following:-Cognitively intact; -Impairment of one upper and one lower extremity;-Substantial to maximal assistance for toileting and bathing; -Dependent on staff for transfers; -At risk for falls; -One fall since prior assessment. Review of the resident's Care Plan, last reviewed 03/26/26, showed the following:-Activities of daily living (ADLs) status/rehabilitation potential: the resident had a mild deficit in ADLs and mobility at this time;-Assist the resident in putting his/her right lower extremity brace on to improve/increase his/her mobility and lessen pain/discomfort (the brace was ordered for the left lower extremity); -The resident was at risk for falling related to history of falls, history of stroke, poor mobility, type 2 diabetes mellitus (metabolic disease), use of psychotropics (medications used to treat mental disorders) and cardiac medications; -The resident fell on [DATE], 09/10/25, 09/14/25, and 12/20/25;(The resident's care plan did not show the resident's additional history of falls on 03/25/25, 06/25/25, and 12/26/25, need for two-person transfers with a mechanical lift and continued use of a CAM boot to the left lower extremity when up. During an interview on 06/02/26 at 2:45 P.M., Resident #2 said the following: -He/She had a fall about two weeks after his/her admission to the facility and broke his/her ankle in two places; -He/She wore a CAM boot on his/her the left lower leg when he/she was not in bed. 3. Review of Resident #1's undated continuity of care document (CCD) showed the resident had a diagnosis of chronic viral hepatitis C (persistent, long-lasting liver inflammation cause by the hepatitis C virus, primarily spread through contact with infected blood). Review of the resident's Physician Order Sheet (POS), dated May 2026, showed the following: -C-reactive protein (CRP, a blood test that measures the level of C-reactive protein in the blood, and if elevated can detect inflammation anywhere in the body) and erythrocyte sedimentation rate (ESR, a blood test that detects and measures the amount of inflammation in the body) every three months on the 9th of January, April, August, and November (original order dated 08/03/21, ) for diagnosis of viral hepatitis. Review of the resident's care plan showed facility staff failed to include the resident had a history of chronic viral hepatitis C, or the goals and interventions related to the diagnosis. 4. Review of Resident #18's undated continuity of care document (CCD showed the resident had diagnoses of cerebral vascular accident (CVA, a stroke) and seizures. Review of the resident's Physician Order Sheet (POS), dated March 2026, showed the following:-Eliquis (apixaban, a blood thinner) 5 milligrams (mg) twice daily (original order dated 03/13/25); -Keppra (used to treat seizures) 100 mg twice daily (original order dated 03/06/25); -Keppra level (a lab to check levels of the medication in the blood) every second Tuesday (original order date 10/12/23). Review of the resident's care plan, last reviewed 04/20/26, showed facility staff failed to document the resident had a seizure disorder, received seizure medication, or the goals and interventions for a history of seizures or use of a seizure and a blood thinning medications. 5. During interviews on 06/04/26 at 12:28 P.M. and 06/11/26 at 2:01 P.M., the Director of Nursing (DON) said the following: -She expected nurses to update residents' care plans so they were up-to-date and resident specific to show a full picture of how to care for the resident;-Any nurse could update the care plan;-The facility did not currently have a care plan coordinator;-The facility had been without a care plan coordinator since 05/29/26;-Part of the reason the care plans were not up-to-date was the prior care plan coordinator was not completing them properly. During interviews on 06/04/26 at 4:40 P.M. and 06/15/26, at 1:12 P.M., the Administrator said the following:-The facility currently did not have a care plan coordinator;-The prior care plan coordinator had not completed the care plans or updated them properly;-He expected all residents' care plans to be up to date and resident specific.

Based on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents #19, #3 and #2), who required staff's assistance to perform activities of daily living (ADLs), in a review of 28 sampled residents, the necessary care and services to maintain good personal hygiene. The facility census was 104. Review of the facility's undated policy for ADLs from the Nursing Guidelines Manual showed the guidelines did not direct staff when to assist residents with ADLs such as bathing, shaving, oral hygiene and basic grooming. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 04/11/26, showed the following:-Dependent on staff for showers/bathing;-Required partial/moderate staff assistance for personal hygiene. Review of the resident's Care Plan, revised on 06/01/26, showed the following:-The resident had a self-care deficit in dressing, grooming, bathing and hygiene. He/She often refused showers;-Goal: He/She will have his/her ADL needs met as evidenced by clean/neat appearance;-The resident required assistance from one staff with dressing, grooming, shaving, and combing hair;-The resident required assistance from one staff with showers or bed bath. Observation on 06/01/26 at 2:42 P.M., showed the resident lay awake in bed in a hospital gown. His/Her hair was unkempt and had a slight oily appearance. The resident had whiskers, approximately 1/4 inch long, on his/her face. During an interview on 06/01/26 at 2:42 P.M., the resident said he/she preferred a shower but would take a bed bath. His/Her shower days were on the day shift on Monday and Thursday. He/She was scheduled for a shower that day but had not yet received the shower. He/She preferred to be clean shaven. Sometimes he/she refused a shower, but he/she had not refused in quite some time. Review of the resident's electronic health record (EHR) point of care history and facility provided bath sheets showed staff did not give the resident a bath/shower or shave the resident on his/her scheduled bath day, Monday, 06/01/26. During an interview on 06/09/26 at 11:08 A.M., Certified Nursing Assistant (CNA) N said he/she was assigned to the resident's unit on 06/01/26 and did not give the resident a shower or bed bath. He/She thought CNA M gave the resident a shower. During an interview on 06/09/26 at 11:21 A.M., CNA M said the following:-He/She worked on the resident's unit on 06/01/26;-He/She was unable to give the resident a bed bath or a shower because he/she did not have enough time;-There was not a scheduled shower aide on 06/01/26;-It was very difficult to give the residents showers when there wasn't a shower aide working because of the level of care the residents required;-The resident preferred a shower over a bed bath. If he/she had time, he/she gave the resident a shower; -Staff should give the residents baths as scheduled and shave the residents if they wanted. Observation on 06/02/26 at 9:19 A.M., showed the resident lay awake in bed watching television. His/Her hair appeared uncombed and had a slight oily appearance. The resident had whiskers, approximately 1/4 inch long, on his/her face. The resident had a brown substance underneath his/her fingernails. During an interview on 06/02/26 at 9:19 A.M., the resident said staff did not give him/her a shower or bed bath the day before on his/her scheduled shower day, and he/she did not know why. Observation on 06/03/26 at 5:50 A.M., showed the resident lay awake in bed. The resident's hair was uncombed, unkempt and had an oily appearance. The resident had a full face of whiskers, approximately 1/4 to 1/2 inches long. The resident had a light brown substance under his/her fingernails. During an interview on 06/03/26 at 5:50 A.M., the resident said staff had not given him/her a bed bath or shower or shaved him/her, and he/she would like a shower. Observation on 06/04/26 at 8:35 A.M, showed the resident lay awake in bed watching television. The resident's hair was combed and looked cleaner. The resident still had approximately 1/2 inches of full facial whiskers. During an interview on 06/04/26 at 8:35 A.M., the resident said staff finally gave him/her a bed bath yesterday evening but did not shave him/her. He/She would have preferred a shower, but a bed bath was better than nothing. 2. Review of Resident #3's Care Plan, last reviewed 05/11/26, showed the following:-The resident required assistance from one staff for bathing and personal hygiene;-Keep clean and dry as possible. Review of the resident's Skin Monitoring and CNA Shower Sheet Review for May 2026 showed staff documented the following:-The resident's scheduled shower days were Tuesdays and Saturdays;-Staff gave the resident a shower and washed the resident's hair on 05/19/26;-Staff gave the resident a shower, washed the resident's hair, and shaved the resident on 05/26/26 (seven days since his/her last documented shower);-Staff gave the resident a shower and trimmed his/her fingernails on 05/31/26. No documentation staff shaved the resident. Observation on 06/01/26 at 04:00 P.M. showed the following:-The resident lay awake in his/her bed on his/her back and wore a hospital gown;-The hospital gown had two small, orange-colored stains on the upper chest area;-The resident had facial hair, approximately 1/4 inch in length, covering his/her cheeks, chin, and neck;-The resident's hair appeared greasy and unkempt;-The resident had dark debris under his/her fingernails. Observations on 06/02/26 at 1:30 P.M. and 5:00 P.M. showed the following:-The resident lay in bed and wore a hospital gown;-The hospital gown had two small, orange-colored stains on the upper chest area;-The resident had facial hair covering his/her cheeks, chin and neck;-The resident's hair appeared greasy and unkempt;-The resident had dark debris under his/her fingernails. Observation on 06/03/26 at 5:45 A.M. showed the following:-The resident lay in bed and wore a hospital gown;-The hospital gown had two small, orange-colored stains on the upper chest area;-The resident had facial hair covering his/her cheeks, chin and neck;-The resident's hair appeared greasy and unkempt;-The resident had dark debris under his/her fingernails. Observation on 06/03/26 at 6:47 A.M. showed the following:-The resident lay in bed and wore a hospital gown;-The hospital gown had two small, orange-colored stains on the upper chest area;-The resident's hair appeared greasy and unkempt;-The resident's lips were dry and scaly;-The resident had facial hair covering his/her cheeks, chin and neck;-The resident had dark debris under his/her fingernails. During an interview on 06/03/26 at 1:00 P.M., the resident's family member said the following:-The resident's personal care was inconsistent. Sometimes the resident looked clean, and other times he/she looked like he/she needed to be cleaned; -He/She did not think staff provided showers routinely for the resident because the resident's hair and clothes looked dirty at times. During an interview on 06/04/26 at 3:30 P.M., CNA T said the following:-Resident #3 sometimes refused personal care;-If the resident refused personal care, he/she tried to wash the resident while in bed, but did not attempt to wash the resident's hair, shave him/her, or trim his/her fingernails because those tasks were too difficult without the resident being in the shower room;-Sometimes staff did not provide personal care and showers for the residents as scheduled or needed because there were not always enough staff. 3. Review of Resident #2's Care Plan, last reviewed 03/27/26, showed the following:-The resident had a mild deficit in ADLs;-Allow sufficient time to complete grooming/personal hygiene. Review of the resident's Skin Monitoring and CNA Shower Sheet Review for May 2026 showed the following:-The resident's scheduled shower days were Tuesdays and Fridays;-The resident received a shower and personal care (fingernails trimmed, hair washed, shaved) on 05/22/26;-No documentation staff gave the resident a shower or provided personal care for the resident after 05/22/26. During an interview on 06/02/26 at 02:45 P.M., the resident said the following:-He/She was to receive a shower two times each week, on Tuesdays and Fridays, but he/she did not regularly receive his/her showers;-He/She had facial hair and usually shaved himself/herself with staff assistance after a shower;-He/She was self-conscious and embarrassed to be seen if his/her face was not shaven;-He/She did not ask staff for help, because he/she felt guilty because the staff were busy helping other residents. Observation on 06/02/26 at 02:45 P.M. showed the following:-The resident lay awake in his/her bed and wore a hospital gown;-The resident's hair was unkempt and had an oily appearance;-The resident had facial hair on his/her chin. Observation on 06/03/26 at 06:50 A.M. showed the following:-The resident sat in his/her wheelchair;-His/Her hair appeared unkempt and had an oily appearance;-He/She had facial hair on his/her chin. 4. During an interview on 06/04/26 at 2:10 P.M., Certified Medication Technician (CMT) O said the following:-He/She assisted staff to provide personal care to the residents when needed;-There was no designated shower aide, so sometimes staff did not give the residents their showers as scheduled if there were not enough staff to assist on the hall. During an interview on 06/04/26 at 12:28 P.M., the Director of Nursing (DON) said the following:-The residents were scheduled to receive a minimum of two baths a week;-If there was enough staff, a shower aide was assigned to give showers. Unfortunately, the facility had to pull the shower aide to work on the floor if there were call-ins;-The shower aide was pulled from showers to work the floor more than she would like;-Staff should provide nail care, wash residents' hair and shave the residents during their shower or bed bath;-If staff did not give a resident a shower on their scheduled shower day, staff were to give the resident a shower on Sunday (the make-up day for showers).

Based on interview and record review, the facility failed to provide a written notice to four residents (Resident #10, #12, #53 and #70), in a review of 28 sampled residents, and to one additional resident (Resident #103) or their representatives related to transfer that included the reason for transfer, the date of transfer, location being transferred to, the resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman (a trained advocate, often a volunteer, who works to protect the rights and improve the quality of life for residents in long-term care facilities, such as nursing homes and assisted living facilities), the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocate for residents with mental illness. The facility also failed to communicate transfers/discharges to the Ombudsman. Additionally, the facility failed to provide a written bed-hold notice to the resident or their representative upon transfer that specified the duration of the bed-hold policy (if any), reserve bed payment policy, or policy regarding bed-hold periods. The facility census was 104. A transfer/discharge policy was requested and was not provided by the facility. Review of the undated facility policy, Bed Hold Guidelines, showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave;-Medicare does not pay for any type of bed hold. If the resident is discharged to the hospital, or goes out of the facility for over-night leave of absence, the bed may be held by paying the current room rate for bed being reserved;-Private pay residents discharged to the hospital or going on over-night leave of absence may reserve their bed by paying the current rate for the bed being reserved;-If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs on weekend or holiday;-If the resident or resident representative does not choose to hold the bed, the bed will be released and any personal belongings must be picked up within three days;-Bed holds are strictly VOLUNTARY. If the bed is not held and is not available when the resident wants to be re-admitted , the resident's name will be placed on a waiting list for the next available bed. 1. During an interview on 05/28/26, at 4:33 P.M., the representative from the Long-Term Care Ombudsman program said their office had not received transfer or discharge notices from the facility for numerous months. 2. Review of Resident #10's face sheet showed a family member was listed as the resident's responsible party. Review of the resident's progress note, dated 01/29/26 at 2:22 A.M., showed the following: -At 1:00 A.M., the resident had an unwitnessed fall in his/her room;-The resident wanted to go to the hospital;-At 1:30 A.M., the ambulance arrived and took the resident to the hospital. Review of the resident's progress note, dated 01/29/26 at 7:25 A.M., showed the following:-The hospital contacted the facility;-The resident had a fractured clavicle/collar bone;-The resident was ready to be picked up from the hospital. Review of the resident's medical record showed no documentation the facility provided a written notice of transfer or a written bed hold notice to the resident or resident's representative when the resident was transferred to the hospital on [DATE]. During an interview on 06/04/26 at 12:56 P.M., the resident's responsible party/representative said he/she did not receive transfer notice or a bed hold notice when his/her family member was sent to the hospital. 3. Review of Resident #12's undated face sheet showed the resident was his/her own responsible party. Review of the resident's progress notes, dated 01/03/26 at 12:03 P.M., showed the following:-The nurse called the physician to discuss the resident's late-night fall on 01/02/26;-The nurse called and requested the resident be sent to the hospital for evaluation. Review of the resident's medical record showed no documentation the facility provided the resident with the facility's bed hold policy and a written notice of transfer when the resident was transferred to the hospital on [DATE]. Review of the resident's medical record showed the resident returned to the facility from the hospital on [DATE]. During an interview on 06/04/26 at 1:20 P.M., the resident said he/she did not receive a copy of the bed hold policy or a notice of transfer when he/she went to the hospital on [DATE]. 4. Review of Resident #53's undated face sheet showed he/she had a responsible party. Review of the resident's progress note, dated 04/12/26 at 8:39 A.M., showed the nurse was getting report from previous shift when resident came to the nurses' station stating he/she wanted to go to the hospital. The resident's family member took the resident to the hospital. Review of the resident's medical record showed no documentation the facility provided the resident's representative with the facility's bed hold policy and a written notice of transfer when the resident was transferred to the hospital on [DATE]. Review of the resident's medical record showed the resident returned to the facility from the hospital on [DATE]. During an interview on 06/09/26 at 11:40 A.M., the resident's responsible party said he/she did not receive a copy of the bed hold policy or a written notice of transfer when the resident was transferred to the hospital on [DATE]. 5. Review of Resident #70's undated face sheet showed a family member was listed as the resident's responsible party. Review of the resident's census record showed the resident was transferred to the hospital and was hospitalized on [DATE] through 03/17/26 and again on 03/31/26 through 04/09/26. Review of the resident's progress notes, showed the following: -On 03/08/26, at 10:16 P.M., a verbal order was received from a family member for the bed hold agreement. No documentation the facility provided the resident's family member with a written notice of transfer; -On 03/31/26, the resident went for an outpatient procedure and was admitted to the hospital for observation. No documentation the facility provided the resident's family member with a written notice of transfer or a written bed hold notice. During an interview on 06/09/26 at 12:11 P.M., Licensed Practical Nurse (LPN) H said the following:-When staff sent a resident to the hospital, staff requested the resident to sign the bed hold agreement if the resident was able to sign. If the resident was unable to sign, staff contacted the responsible party for a verbal bed hold and documented this in the nursing progress notes;-He/She had only completed a few bed hold agreements for transfers but had not done any transfer notices. He/She was unaware the transfer notice was required to be completed;-When Resident #70 went for a procedure on 3/31/26, he/she was anticipated to return that day. When the resident was admitted to the hospital, he/she did not contact the responsible party to discuss the bed hold agreement and did not mail anything to the responsible party. 6. Review of Resident #103's undated face sheet showed a family member was listed as the resident's responsible party. Review of the resident's census record showed the resident was transferred to the hospital and was hospitalized on [DATE]. Review of the resident's medical record showed no documentation the facility issued the resident or the resident's representative, a written notice of transfer to the hospital or a written bed hold notice when the resident was transferred to the hospital on [DATE]. During an interview on 06/11/26, at 3:48 P.M., the resident's responsible party said he/she did not receive a transfer notice or bed hold notice when the resident was transferred to the hospital. 7. During an interview on 06/04/26 at 3:00 P.M., Licensed Practical Nurse (LPN) K said the following: -He/She tried to get residents to sign the bed hold agreement at the time of transfer, but that was not always possible; -He/She did not do any complete a written transfer notice and was unaware it was required. During an interview on 06/03/26 at 2:55 P.M., the Social Service Director said the following:-She completed the transfer notice and bed hold notice if she was available;-All completed transfer and bed hold notices were scanned into the electronic medical record. During an interview on 06/04/26 at 11:40 A.M., LPN C said the following:-The nurse who transferred the resident was responsible for getting the bed hold consent signed;-If the resident has a responsible party, he/she would contact them and have two staff to witness the verbal consent, copy it and send all documents to the hospital. During an interview on 06/04/26, at 12:28 P.M., the Director of Nursing (DON) said she expected the nurse who was transferring a resident to complete the transfer notice and bed hold notice at the time the resident was transferred to the hospital. During an interview on 06/04/26 at 4:40 P.M., the Administrator said the following:-The charge nurse or MDS coordinator was responsible for completing the transfer notice and the bed hold notice and to provide those at the time the resident was transferred;-He was not aware of the specific transfer or bed hold process;-He was not aware notices should be sent monthly to the Ombudsman.

Based on observation, interview, and record review, the facility failed to serve food at an appetizing temperature. The facility census was 104. Review of the facility policy, Food Temperatures, dated 2015, showed the following:-Hot food should be at least 120 degrees F when served to the resident;-A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels. Record on Temperature Record of Test Trays form. Review of the facility policy, Nursing Responsibilities at Meal Service, dated 2015, showed the following:-Nursing services will cooperate with the Dining Services Department to ensure each resident is served according to regulations;-Nursing services will distribute meals to residents in resident rooms, dining rooms and ancillary dining rooms. Meals will be passed in a timely manner. 1. During an interview on 06/02/26 at 05:15 P.M., Resident #6 said the following: -He/She always ate in his/her room; -The food at all meals was usually cold by the time he/she received his/her meal tray. During the group interview on 06/03/26, at 10:36 A.M., residents said the following: -Resident #2 said the food on his/her hall tray was generally cold. The food was always cold at the evening meal; -Resident #4 said the food on his/her hall tray was generally cold. The scrambled eggs were always cold; -Resident #65 said the scrambled eggs were always cold. The food served on the hall trays was generally cold. The vegetables were never warm. 2. Record review of the Diet Spreadsheet for lunch on 6/01/26 showed staff were to serve American fried potatoes with the meal. Observation on 6/01/26 at 11:49 A.M. showed Dietary Aide P started plating the lunch meal in the main kitchen. Observation on 6/01/26 at 1:47 P.M. showed the lunch service ended. Observation on 6/01/26 at 1:48 P.M. showed Dietary Aide P prepared the sample test tray. Observation on 6/1/26 at 1:50 P.M. of the sample test tray showed the temperature of the fried potatoes was 87.6 degrees Fahrenheit (F). The fried potatoes tasted cold, hard and crunchy. 3. Record review of the Diet Spreadsheet for lunch on 6/02/26 showed staff were to serve seasoned carrots with the meal. Observation on 6/02/26 at 12:17 P.M. showed Dietary Aide Q began plating the lunch service in the main dining room. Observation on 6/02/26 at 12:50 P.M. showed Dietary Aide Q began plating the 200 Hall tray cart with resident lunch trays. Observation on 6/02/26 at 1:07 P.M. showed Dietary Aide Q plated a surveyor requested sample tray. The tray was placed in the bottom of the 200 Hall tray cart. Observation on 6/02/26 at 1:23 P.M. showed CNA F removed the last resident room tray from the cart and delivered the tray to a resident room. Observation on 6/02/26 at 1:25 P.M. of the sample test tray showed the temperature of the seasoned carrots was 115 degrees F. The carrots were cool to taste. 4. During an interview on 6/3/26 at 2:06 P.M., the Dietary Manager said the following:-She expected hot food items to be 145 degrees F when served to the resident;-She was aware the residents complained about the food being cold and had reheated trays in the past;-Dietary staff took the hall tray cart out to each hall when it was full and completed. It was nursing responsibility to pass out the trays to the residents.

Based on interview and record review, the facility failed to develop and implement a base line care plan consistent with the resident's specific conditions, needs and risks to provide effective person-centered care that met professional standards of quality care within 48 hours of admission to the facility for one resident (Resident #106), in a review of 28 sampled residents, and one additional residents (Resident #69). The facility census was 104. Review of the facility's undated policy, Temporary Care Plan, showed the following:-A temporary care plan will be implemented to meet the new resident's immediate needs;-To ensure the resident's immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within 24 hours of admission;-The interdisciplinary care plan team and/or admitting nurse will review the physician orders and implement a nursing care plan to meet the immediate care needs of the residents;-The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed. 1. Review of Resident #69's undated Face Sheet showed the following:-He/She was his/her own responsible party;-admitted to the facility on [DATE];-Diagnoses of Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), nasal congestion (stuffy nose), nausea, amnesia (the partial or total loss of memory), personal history of malignant neoplasm of other organs and systems (have had cancer, but are not being currently treated), dementia (a decline in cognitive functioning), ventricular premature depolarization (abnormal heartbeat) , chronic rhinitis (persistent inflammation of the mucous membranes lining the nose), gastro-esophageal reflux disease (stomach contents leak backwards into the esophagus), constipation, bilateral primary osteoarthritis of knee (a degenerative joint condition where the protective cartilage in both knees gradually wears down.), and iron deficiency anemia (a condition in which the blood lacks enough healthy red blood cells due to a lack of iron). Review of the resident's progress note, dated 05/15/26 at 3:07 P.M., showed the following:-The resident was admitted to the facility by his/her family;-The resident was ambulatory;-The resident was alert and orientated to self;-He/She was continent of bowel and bladder;-The resident takes his/her medications whole;-The resident did not require glasses, hearing aids or dentures. Review of the resident's medical record showed no documentation staff completed a baseline care plan to meet the resident's immediate needs within 48 hours of facility admission. During an interview on 06/04/26 at 1:05 P.M., the resident's family member said he/she signed/completed the resident's admission paperwork. He/She did not remember signing a baseline care plan or receiving a copy of his/her family member's baseline care plan. The resident was his/her own person. During an interview on 06/04/26 at 1:11 P.M., the resident said he/she was his/her own person. His/Her family member completed his/her admission paperwork. He/She did not remember signing a baseline care plan and did not receive a copy of his/her baseline care plan. He/She did not remember any nursing staff explaining his/her plan of care to him/her. 2. Review of Resident #106's continuity of care document showed the following:-His/Her spouse was his/her responsible party;-admitted to the facility on [DATE];-Diagnoses of dementia, metabolic encephalopathy (brain dysfunction caused by an underlying systemic illness rather than a direct physical injury or structural disease in the brain itself), high blood pressure, high cholesterol, hypothyroidism (the thyroid is not making enough thyroid hormone), atherosclerotic heart disease (plaque containing cholesterol and lipids that build up on the artery walls), anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and irrational fear or worry out of proportion to the actual situation), and depression (a serious medical mood disorder). Review of the resident's progress note, dated 05/22/26 at 12:31 P.M., showed the following:-Arrived at the facility; -He/She was alert and orientated to self only;-Regular diet;-Ambulatory with standby assistance;-He/She was able to feed himself/herself, but needed assistance with meal set up;-He/She wore a pull up for occasional incontinence;-He/She took his/her medication whole. Review of the resident's progress note, dated 05/22/26 at 5:58 P.M., showed the following:-He/She refused evening medications, blood sugar check and insulin;-He/She refused to have TB test (A TB test is medically referred to as a Tuberculin Skin Test (TST) or a Mantoux test.) administered at this time. Review of the resident's progress note, dated 05/23/26 at 3:43 P.M., showed the resident was ambulating the halls trying every door and trying to encourage another resident to go along with him/her. He/She had a bowel movement all over the floor. The resident refused his/her medication and blood sugars from being done. Review of the resident's medical record showed no documentation staff completed a baseline care plan to meet the resident's immediate needs within 48 hours of facility admission. During an interview on 06/04/26 at 12:45 P.M., the resident's responsible party said he/she was in the hospital when the resident was admitted . His/Her family member helped with the admission process. He/She did not receive a copy of the baseline care plan. The family member, who admitted the resident, did not mention receiving a baseline care plan or that the facility told him/her about the resident's plan of care. During an interview on 06/10/26 at 4:34 P.M., the resident's family member, who completed the resident's admission at the facility, said he/she did not receive a copy of the resident's baseline care plan and did not sign a copy of the baseline care plan. 3. During an interview on 06/04/26 at 12:20 P.M., Licensed Practical Nurse (LPN) C said he/she admitted Resident #69 and #106 to the facility. He/She did not complete a baseline care plan for the residents. The third nurse who took care of the residents after admission was responsible to complete the baseline care plans. During a phone interview on 06/04/26 at 3:08 P.M., LPN K said he/she was the second nurse taking care of Resident #62 and Resident #106. He/She did not complete a baseline care plan for the residents. He/She worked at the facility for a little over one year and had never completed a baseline care plan for any newly admitted residents. He/She did not know anything about baseline care plans. He/She did not know how to complete a baseline care plan. During an interview on 06/04/26 at 3:11 P.M., LPN B said he/she was the third nurse to take care of Resident #62. He/She did not complete a baseline care plan for the resident. He/She did not know the time frame for the completing a baseline care plan. During an interview on 06/04/26 at 3:18 P.M., LPN L said the admitting nurse started an admission checklist when a resident was admitted . The admission checklist was passed along to the next shift nurse during report. Each nurse was responsible for completing certain areas, and the last nurse (third nurse) was responsible to ensure all the admission steps were followed. The third nurse was also responsible for completing the 24-hour care plan. During interview on 06/04/26 at 10:45 A.M., the Director of Nursing (DON) said the following:-Staff should complete the baseline care plan within 48 hours of a resident's admission;-The third nurse, counting the admitting nurse as the first nurse, was responsible for completing baseline care plans;-The third nurse who was responsible for completing Resident #106's baseline care plan was no longer employed at the facility;-The baseline care plans for Residents #62 and #106 could not be located.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #17), in a review of 28 sampled, and two additional residents (Residents #62 and #66) who received insulin injections, were free from significant medication errors when staff failed to prime (remove the air from the needle) the resident's insulin (a hormone used to treat diabetes by controlling blood sugar levels) pen during the preparation of the medication, potentially affecting the amount of insulin dispensed with each dose. Staff failed to administer the insulin pen per the manufacturer's guidelines. The facility census was 104. The facility did not provide a policy on insulin pen administration upon request. 1. Review of the Lantus Solostar (a prefilled insulin pen) manufacturer's administration guidelines, revised 11/2018, showed the following:-Always perform the safety test (prime the needle) before each injection. Performing the safety test ensures that you get an accurate dose by ensuring the pen and needle work properly and removing air bubbles;-Select a dose of 2 units by turning the dosage selector;-Hold the pen with the needle pointing upwards;-Tap the insulin reservoir so any air bubbles rise up towards the needle;-Press the injection button all the way in. Check if insulin comes out of the needle tip; -You may have to perform the safety test several times before insulin is seen;-If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them;-If no insulin comes out, the needle may be blocked. Change the needle and try again. 2. Review of the Humulin 70/30 kwik pen Flex Pen (prefilled insulin pen) manufacturer's administration guidelines, revised June 2022, showed the following: -Preparing your pen;-Prime before each injection;-Priming your pen means removing the air from the needle and cartridge that may collectduring normal use and ensures the pen is working correctly;-If you do not prime before each injection, you may get too much or too little insulin;-To prime your pen, turn the dose knob to select 2 units;-Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top;-Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Push dose knob in and count to five slowly;-You should see insulin at the tip of the needle; -If you do not see insulin, repeat priming steps, no more than four times.-If you still do not see insulin, change the needle and repeat priming steps. 3. Review of Resident #62's physician orders, dated May 2026, showed the following:-The resident had a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease (occurs when high blood sugar damages the kidney's filtering units, impairing their ability to remove waste.);-Lantus Solostar (injectable long-acting medication used to treat diabetes) 100 units/mL, inject 45 units subcutaneously (under the skin) in the morning. Observation on 06/03/26 at 4:52 A.M., showed the following:-Licensed Practical Nurse (LPN) L removed the resident's Lantus insulin pen from the medication cart, removed the cap from the insulin pen and applied a needle to the end of the Lantus Solostar insulin pen;-LPN L did not prime the needle;-LPN N dialed up 45 units of Lantus;-He/She administered the Lantus into the resident's right upper arm. 4. Review of Resident #17's Physician Orders, dated May 2026, showed the following:-The resident had a diagnosis of type 2 diabetes with hyperglycemia (a chronic condition characterized by insulin resistance and relative insulin deficiency, leading to persistently elevated blood glucose levels);-Lantus Solostar 100 units/mL, inject 20 units subcutaneously between 3:00 P.M. and 6:00 P.M. Observation on 06/03/26 at 3:45 P.M., showed the following:-LPN L removed the resident's Lantus insulin pen from the medication cart, removed the cap from the insulin pen, and applied a needle to the end of the Lantus Solostar insulin pen;-LPN L did not prime the needle;-LPN N dialed up 20 unites of Lantus;-He/She administered the Lantus into the resident's abdomen. 5. Review of Resident #66's Physician Orders, dated May 2026, showed the following:-The resident had a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease;-Humulin 70/30 (a combination of intermediate-acting insulin and short-acting insulin), 100 units/mL Kwik pen, inject 5 units subcutaneously between 3:00 P.M. and 6:00 P.M. Observation on 06/03/26 at 4:03 P.M., showed the following:-LPN L removed the resident's Humulin 70/30 kwik (insulin) pen from the medication cart, removed the cap from the insulin pen and applied a needle to the end of the Humulin 70/30 kwik (insulin) pen;-LPN L did not prime the needle;-LPN L dialed up 5 units of Humulin 70/30;-He/She administered the Humulin 70/30 into the resident's right lower abdomen. 6. During an interview on 06/03/26 at 4:13 P.M., LPN L said the following:-He/She did not prime the insulin pen needles when administering insulin to Resident #17, #62 or #66;-He/She did not know if the residents received the proper dose of insulin because he/she did not prime the insulin pen needle. 7. During an interview on 06/04/26 at 10:45 A.M., the Director of Nursing (DON) said the following:-When administering insulin with an insulin pen, staff should prime the insulin pen needles prior to administering the insulin;-A resident would not receive an accurate dose of insulin if staff did not prime the insulin pen needle before administration.

Based on observation and interview, the facility failed to post required nurse staffing information, which included the date, total actual hours worked by both licensed and unlicensed nursing staff to include Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA)s directly responsible for resident care and the resident census on a daily basis. The facility census was 104. During an interview on 06/04/26, at 10:11 A.M., the Administrator said the facility did not have a policy for posted nurse staffing information. 1. Observation on 06/01/26 at 10:45 A.M. and 12:25 P.M., showed the following: -A dry erase board, located behind the 100/200 hall nursing station, was dated 06/01/26 and listed the staffing assignments for the 100, 200, 300 and 400 halls;-The dry erase board did not include the actual working hours or the facility census;-A binder, containing the shift assignments, sat on top of the nurses station. The binder was not readily accessible to residents who were in wheelchairs; -The binder included the staff assignments for day shift, evening shift and night shift, but did not show the census or total hours worked for each RN, LPN or CNA. Observation on 06/02/26 at 8:57 A.M., showed the following: -A dry erase board, located behind the 100/200 hall nursing station, was dated 06/01/26 and listed the staffing assignments;-The dry erase board did not include the actual working hours or the facility census;-The binder, located on top of the nurses station, included the staff assignments for day shift, evening shift and night shift, but did not show the census or total hours worked for each RN, LPN, CMT or CNA. Observation on 06/02/26 at 09:55 A.M. showed no posted facility staffing at the nurses' station for the 300-400 hall. Observation on 06/03/26 at 11:30 A.M., showed the following: -A dry erase board behind the 100/200 hall nursing station, was dated 06/01/26 and listed the staffing assignments;-The dry erase board did not include the actual working hours or the facility census;-The binder, located on top of the nurses station, included the staff assignments for day shift, evening shift and night shift, but did not show the census or total hours worked for each RN, LPN, CMT or CNA. Observation on 06/03/26 at 12:00 P.M. showed no posted facility staffing at the nurses station for the 300-400 hall. Observation on 06/04/26, at 7:45 A.M., showed the following: -A dry erase board, located behind the 100/200 hall nursing station, was dated 06/01/26, with listed staffing assignments;-The dry erase board did not include the facility name, actual working hours or the facility census;-The binder, located on top of the nurses station, included the staff assignments for day shift, evening shift and night shift, but did not show the census or total hours worked for each RN, LPN, CMT or CNA. Observation on 06/04/26 at 8:00 A.M. showed no posted facility staffing sheet at the nurses' station for the 300-400 hall to include the facility name, date, total working hours for CNAs, CMTs, LPNs, RNs, or the facility census. During an interview on 06/04/26 at 10:11 A.M., the Administrator said he was unaware of the required nurse staffing information posting requirement. During interviews on 06/04/26 at 03:00 P.M. and on 06/16/26 at 09:42 A.M., the Director of Nursing (DON) said the following: -The Staffing Coordinator was responsible for staff assignments for each eight-hour shift;-The Staffing Coordinator completed the assignments for each shift and placed them in a binder at the central nursing station on the 100-200 hall; -Usually, the charge nurse transferred the staffing assignments for each shift from the binder to the dry erase board behind the central nursing station every morning; -The dry erase board was really just a more visible way of indicating where all staff would be located for a particular shift; -She was not familiar with the requirement for a daily posted nursing staffing sheet to indicate the facility name, date, facility census, and total hours for each nursing area (CNAs, CMTs, LPNs, and RNs).

Based on interview and record review, the facility failed to ensure one resident (Resident #1), who resided on the dementia care unit, in a review of ten sampled residents, was free from verbal abuse when Certified Nurse Assistant (CNA) A used derogatory language including cursing at the resident, while providing personal care and assisting the resident. This incident was witnessed by CNA B and CNA C. The facility census was 97. The administrator was notified of the past noncompliance on 05/30/25, which occurred on 05/03/25. On 05/05/25, the administrator became aware of a staff to resident abuse allegation involving Resident #1. Upon discovery, the facility began an investigation and terminated the staff member. In-servicing of staff members had begun on the facility abuse policy, including the different forms of abuse, when to report abuse and who to report allegations of abuse to. This deficiency was corrected on 05/05/25. Review of the facility's policy, Abuse Prohibition, dated November 2016, showed the following: -It is the purpose of this facility to prohibit mistreatment and abuse. To assist the facility staff members in recognizing incident of abuse, the following definitions of abuse are provided. -Abuse is the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, and mental abuse; -Verbal abuse is defined as any use of oral, written or body language that includes disparaging or derogatory terms to a resident or their families, or within their hearing-distance, regardless of their age, ability to comprehend or disability. 1. Review of Resident #1's undated face sheet showed diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel and behave) and unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a type of dementia-a progressive decline in cognitive function, including memory, thinking, and reasoning, severe enough to affect a person's daily life-where the specific cause is unknown or unspecified). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 04/09/25, showed the following: -Hearing: moderate difficulty; -Sometimes understands; -The resident was rarely understood; -No behaviors or rejection of cares; -Dependent on staff for personal hygiene; -Substantial to maximal assistance for mobility. Review of the resident's care plan, dated 04/30/24, showed the following: -Problem: behavioral symptoms; -Approach: maintain a calm, slow, understandable approach with the resident; -Activities of Daily Living (ADLs): resident is a stand-by assist (SBA) by one person for transfers, toileting, and personal hygiene. - The care plan included no information the resident rejected cares other than the resident would refuse medications at times. 2. Review of an undated facility investigation showed the administrator documented the following: -Investigation for incident on 05/03/25 at 4:00 P.M.; -Two CNAs reported CNA A had sworn at Resident #1 while attempting to provide care to the resident; -When asked to come in (to the facility) and give a statement, CNA A said yes, he/she had sworn, but not at Resident #1 directly, but as a response to being attacked by the resident; -CNA A's actions were unacceptable and he/she was terminated from the facility. 3. During an interview on 05/14/25 at 10:20 A.M., CNA B said the following: -He/She worked on the dementia unit on the evening of 05/03/25; -He/She attempted to redirect another resident out of Resident #1's room when he/she saw CNA A trying to change Resident #1's incontinence brief while Resident #1 lay in bed; -Resident #1 yelled at CNA A and said No, leave me alone!; -CNA A said Son of a mmmmm; -He/She (CNA B) directed the unnamed resident out of Resident #1's room when he/she heard CNA A say, You fucking bitch to Resident #1; -CNA A left Resident #1's room and said Resident #1 ripped his/her glasses off, scratched CNA A, and bit his/her shoulder; CNA A then left the unit; -He/She (CNA B) went back into Resident #1's room and the resident was on the floor by his/her bed but did not appear hurt; -He/She stayed with the resident until CNA A and CNA C returned; -He/She (CNA B) left the dementia unit to get the charge nurse (Registered Nurse (RN) D); -He/She told RN D that Resident #1 bit and scratched CNA A, and the resident was on the floor by his/her bed; -He/She told RN D that CNA A had cussed at Resident #1 when RN D asked what had happened; -He/She had never seen the resident be aggressive like that before with staff. Review of a facility statement, dated 05/03/25, showed CNA B wrote the following: -CNA A went into Resident #1's room to change the resident's brief and was rough (talking loudly and harshly) with Resident #1; Resident #1 was a little combative; -CNA A continued to be rough with Resident #1 as CNA B tried to help another resident out of Resident #1's room; -When he/she walked out of Resident #1's room, he/she heard CNA A call Resident #1 a fucking bitch and Resident #1 was yelling; -CNA A came out of Resident #1's room and said the resident bit him/her; -CNA A left the unit but then returned with CNA C; -The resident was on the floor when he/she went back into the room; -CNA A called the resident a fucking bitch more than once. During an interview on 05/13/25 at 3:50 P.M., CNA C said the following: -Resident #1 would yell Mom sometimes or get loud when staff changed him/her, but the resident had never bitten or yelled at a staff person before that he/she was aware of; -He/She worked on another hall on the evening of 05/03/25 when he/she saw CNA A sitting across from the nurses' station; -CNA A said he/she needed help with Resident #1 because the resident scratched and bit him/her when CNA A was trying to change the resident's brief; -He/She went with CNA A to Resident #1's room where the resident was on the floor by his/her bed; -When the resident saw CNA A, the resident said, You're a monster and CNA A hurt him/her and to not touch him/her; -CNA A said to the resident, You're a fucking witch, and kept repeating this; -He/She would consider CNA A's behavior (yelling and cursing at Resident #1) as verbal abuse. Review of a facility statement, dated 05/03/25, showed CNA C wrote the following: -CNA A said he/she was scratched and bitten by Resident #1 and CNA A needed help; -He/She went with CNA A back to Resident #1's room and he/she saw the resident on the floor and CNA B was with the resident; -While he/she told CNA B to go get the charge nurse, CNA A called Resident #1 a fucking witch multiple times. During an interview on 05/13/25 at 3:05 P.M. and 05/14/25 at 10:00 A.M., the Director of Nurses (DON) said the following: -She was made aware that CNA A yelled and cussed at Resident #1 on the evening of 05/03/25 by the administrator, following her return from vacation on or about 5/5/25; -CNA A was terminated by telephone on 05/05/25, for reported cursing at the resident; -CNA A had had many inservices on A/N; -CNA A usually worked the dementia unit; -Yelling and cursing at a resident was a form of abuse; -Resident #1 did not typically have any behaviors, but he/she would shake his/her head no if he/she wanted to be left alone. During an interview on 05/13/25 at 5:20 P.M., the Administrator said the following: -He found a written statement from CNA B and CNA C under his door the morning of 05/05/25; -He began an investigation on the morning of 05/05/25; -Both CNA B and CNA C said they heard CNA A curse at Resident #1; -CNA A should have stepped away when the resident became agitated; -CNA A had been counseled in the past about speaking gruffly to others; some residents and staff had complained before; -Yelling and cursing at a resident was considered a form of abuse. MO00253797

Based on interview and record review, the facility failed to report a staff to resident allegation of verbal abuse to the State Agency per regulation and facility policy for one resident (Resident #1), who resided on the dementia care unit, in a review of ten sampled residents. Certified Nurse Assistant (CNA) B and CNA C witnessed CNA A yell and use demeaning and derogatory language, including cursing directed at the resident, while providing care. CNA B and CNA C left written statements under the administrator and Director of Nurses (DON) office door on 05/03/25, but did not report the abuse to the registered nurse (RN) D on duty. The administrator did not find the written statements until two days later, at which time it was reported to the State Agency, at least 40 hours following the occurrence of the alleged event. The facility census was 97. The administrator was notified of the past noncompliance on 05/30/25, which occurred on 05/03/25. On 05/05/25, the administrator became aware of a staff to resident abuse allegation involving Resident #1. Upon discovery, the facility began an investigation and terminated the staff member. In-servicing of staff members had begun on the facility abuse policy, including the different forms of abuse, when to report abuse and who to report allegations of abuse to. This deficiency was corrected on 05/05/25. Review of the facility's policy, Abuse Prohibition, dated November 2016, showed the following: -It is the purpose of this facility to prohibit abuse of any resident. To assist the facility staff members in recognizing incident of abuse, the following definitions of abuse are provided. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; -Verbal abuse is defined as any use of oral, written or body language that includes disparaging or derogatory terms to a resident or their families, or within their hearing-distance, to describe residents, regardless of their age, ability to comprehend or disability. A review of the facility document, Guidelines for Facility Self-Reporting, dated November 28, 2016, showed the following: -It is the policy of this facility that abuse allegations are reported per Federal and State law. The facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury; -Employees must always report any abuse or suspicion of abuse immediately to the administrator, if the administrator is not there, report to the Director of Nurses or the immediate supervisor and they will report to the administrator; -The administrator will involve key leadership personnel as necessary to assist with reporting, investigation and follow-up; -Initial reporting of allegations: If an incident or allegation is considered reportable, the administrator or designee will make an initial (immediate-within 2 hours for allegations of abuse or an incident which results in serious bodily injury) to the State Agency. A follow-up investigation will be submitted to the State Agency within five (5) working days. 1. Review of Resident #1's undated face sheet showed diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel and behave) and unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a type of dementia-a progressive decline in cognitive function, including memory, thinking, and reasoning, severe enough to affect a person's daily life-where the specific cause is unknown or unspecified). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 04/09/25, showed the following: -Hearing: moderate difficulty; -Sometimes understood; -The resident was rarely understood; -No behaviors or rejection of cares; -Dependent on staff for personal hygiene; -Substantial to maximal assistance for mobility. Review of the undated facility investigation showed the administrator documented the following: -Investigation for incident on 05/03/35 at 4:00 P.M.; -Two CNAs reported that CNA A had sworn at Resident #1 while attempting to provide care to the resident; -CNA A said yes, he/she had sworn, but not at Resident #1 directly, but as a response to being attacked by the resident; -CNA A's actions were unacceptable, and he/she was terminated from the facility. During an interview on 05/14/25 at 10:20 A.M., CNA B said the following: -He/She worked on the dementia unit on the evening of 05/03/25; -He/She attempted to redirect another resident out of Resident #1's room when he/she saw CNA A trying to change Resident #1's (incontinence) brief while Resident #1 lay in bed; -Resident #1 yelled at CNA A and said No, leave me alone!; -CNA A said Son of a mmmmm; -He/She directed the unnamed resident out of Resident #1's room when he/she heard CNA A say, You fucking bitch to Resident #1; -CNA A left the dementia unit; -He/She (CNA B) went back into Resident #1's room and the resident was on the floor by his/her bed; -He/She stayed with the resident until CNA A and CNA C returned; -He/She (CNA B) left the dementia unit to get the charge nurse, Registered Nurse (RN) D; -He/She told RN D that CNA A had cussed at Resident #1 when RN D asked what had happened; -He/She (CNA B) completed a written statement on a facility form that CNA C gave him/her, then gave the paper back to CNA C; -He/She did not speak with RN D anymore that shift. Review of a facility statement, dated 05/03/25, showed CNA B documented the following: -CNA A went into Resident #1's room to change the resident's (incontinence) brief and was rough (talking loudly and harshly) with Resident #1; -CNA A continued to be rough with Resident #1 as he/she (CNA B) tried to help another resident out of Resident#1's room; -When CNA B walked out of Resident #1's room, he/she heard CNA A call Resident #1 a fucking bitch and Resident #1 was yelling; -CNA A left the unit but then returned with CNA C; -The resident was on the floor when he/she went back into the room; -CNA A called the resident a fucking bitch more than once; -Review of CNA B's written facility statement did not show that he/she reported to RN D that he/she (CNA B) heard CNA A yell and curse at Resident #1. During an interview on 05/13/25 at 3:50 P.M., CNA C said the following: -He/She worked on another hall on the evening of 05/03/25 when he/she saw CNA A sitting across from the nurses' station; -CNA A said he/she needed help with Resident #1 because the resident scratched and bit him/her when CNA A was trying to change the resident's (incontinence) brief; -He/She went with CNA A to Resident #1's room where they found the resident on the floor by his/her bed; -When the resident saw CNA A, the resident said, You're a monster and that CNA A hurt him/her and to not touch him/her; -CNA A told the resident, You're a fucking witch, and kept repeating it; -He/She started to write out a statement about what had happened on a plain piece of paper; -Licensed Practical Nurse (LPN) E came on duty and gave CNA C a facility statement paper to use instead of a piece of plain paper; -He/She completed the written statement and left it under the administrator and Director of Nursing's (DON's) office doors; -He/She did not tell RN D that CNA A had yelled and cursed at Resident #1; -Yelling and/or cursing at a resident was a form of abuse and should be reported to the charge nurse right away. Review of a facility statement, dated 05/03/25, showed CNA C documented the following: -He/She (CNA C) went with CNA A back to Resident #1's room and he/she saw the resident on the floor, and CNA B was with the resident; -While he/she told CNA B to go get the charge nurse, CNA A called Resident #1 a fucking witch multiple times; -Resident #1 called CNA A a monster and did not want anyone touching him/her; -Review of CNA C's written facility statement did not show that he/she reported to RN D that he/she (CNA C) heard CNA A yell and curse at Resident #1. During an interview on 05/14/25 at 11:32 A.M., LPN E said the following: -He/She worked the evening shift on 05/03/25; -RN D did not tell him/her about any alleged verbal abuse of Resident #1 by CNA A during shift report; -CNA C asked him/her for two facility statement forms, but did not tell him/her why he/she (CNA C) wanted it; -He/She gave CNA C two facility statement forms and did not ask CNA C why he/she wanted them because he/she didn't think it was his/her business; -He/She was not aware that CNA A had yelled and cursed at Resident #1 until a couple of days later when he/she heard that CNA A had been terminated; -Yelling and cursing at a resident was a form of abuse; -Any abuse or neglect allegation should be reported to administration immediately. During an interview on 05/13/25 at 3:05 P.M., and 05/14/25 at 10:00 A.M., the DON said the following: -She was unaware that CNA A yelled and cussed at Resident #1 on the evening of 05/03/25 until the administrator made her aware following her return from vacation on or about 05/05/25; -She was not sure why RN D did not report this event to administration when it occurred (if CNA B had reported the allegation to him/her); there was always an on-call weekend nursing manager available; -She would expect facility staff to report any allegation of abuse or neglect immediately so administration could start an investigation; -Yelling and cursing at a resident was a form of abuse; -CNA A completed his/her shift after the event with Resident #1 occurred, and then returned for his/her next shift the following day, where he/she worked on the dementia unit again and had continued contact with Resident #1; -If administration had been made aware of the allegations of verbal abuse by CNA A towards Resident #1, he/she (CNA A) would have been suspended and an investigation started. During an interview on 05/13/25 at 5:20 P.M. and 05/29/25 at 11:15 A.M., the Administrator said the following: -He was not made aware that CNA A had yelled or cursed at Resident #1 on 05/03/25; he was only made aware after he had come to work on the morning of 05/05/25 and found a written statement from CNA B and CNA C under his door; -Written statements by both CNA B and CNA C said they heard CNA A curse at Resident #1 but did not show that they reported it to RN D when it occurred; -CNA B and CNA C failed to report the incident to the administrative staff; -He expected all facility staff to report allegations of abuse immediately to the administrative staff; -He was not sure why CNA B and CNA C did not tell RN D that CNA A yelled and cursed at Resident #1; -A written statement about an alleged abuse event, placed under his office door, was not an acceptable means of reporting an abuse allegation; -RN D was the charge nurse on 05/03/25 and RN D told him that he/she was not aware that CNA A had yelled or cursed at Resident #1 on the evening of 05/03/25; -If RN D was aware that CNA A yelled and cursed at Resident #1, he/she (RN D) should have removed CNA A from his/her duties and reported the event immediately to administration. MO00253797

Based on interview and record review, the facility failed to conduct a timely and thorough investigation of reported abuse for one resident (Resident #1), who resided on the dementia care unit, in a review of ten sampled residents, when certified nurse assistants (CNA) B and CNA C witnessed CNA A use demeaning and derogatory language including cursing directed at the resident while providing personal care. CNA B and CNA C left written statements under the administrator and Director of Nurses (DON's) door on 05/03/25. The administrator did not find the written statements until two days later. CNA A continued to work on the dementia unit with Resident #1 for the remainder of his/her shift on 05/03/25 and worked on 05/04/25 where CNA A had continued contact with Resident #1 and other residents on the dementia unit. The administrator did not conduct a thorough investigation, per facility policy, when he did not interview all involved staff, did not interview or obtain a statement from Resident #1, or interview three to four residents who received care from the alleged staff per facility policy. The facility census was 97. Review of the facility's policy, Abuse Prohibition, dated November 2016, showed the following: -It is the purpose of this facility to prohibit mistreatment, abuse, of any resident. To assist the facility staff members in recognizing incident of abuse, the following definitions of abuse are provided; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, and mental abuse; -Verbal abuse is defined as any use of oral, written or body language that includes disparaging or derogatory terms to a resident or their families, or within their hearing-distance, to describe residents, regardless of their age, ability to comprehend or disability. Review of the facility's policy, Abuse Investigation, undated, showed the following: -It is the policy of this facility that reports of abuse are promptly and thoroughly investigated; -The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration; -When an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: -Who was involved; -Residents' statements; -For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings; -Resident's roommate statements (if applicable); -Interviews obtained from three to four residents who received care from the alleged staff; -Interviews obtained from three to four different department staff, (if applicable); -Involved staff and witness statements of events; -A description of the resident's behavior and environment at the time of the incident; -Injuries present including a resident assessment; -Observation of resident and staff behaviors during the investigation; -Environmental considerations. 1. Review of Resident #1's undated face sheet showed the resident with diagnoses including schizophrenia (a serious mental health condition that affects how people think, feel and behave) and unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a type of dementia-a progressive decline in cognitive function, including memory, thinking, and reasoning, severe enough to affect a person's daily life-where the specific cause is unknown or unspecified). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 04/09/25, showed the following: -Hearing: moderate difficulty; -Sometimes understands; -The resident was rarely understood; -No behaviors or rejection of cares; -Dependent on staff for personal hygiene; -Substantial to maximal assistance for mobility. 2. Review of an undated facility investigation showed the administrator documented the following: -Investigation for incident on 05/03/35 at 4:00 P.M.; -Two CNAs reported that CNA A had sworn at Resident #1 while attempting to provide care to the resident; -CNA A's actions were unacceptable, and he/she was terminated from the facility. 3. During an interview on 05/14/25 at 10:20 A.M., CNA B said the following: -He/She worked on the dementia unit on the evening of 05/03/25; -He/She attempted to redirect another resident out of Resident #1's room when he/she saw CNA A trying to change Resident #1's (incontinence) brief while Resident #1 lay in bed; -Resident #1 yelled at CNA A and said No, leave me alone!; -CNA A said Son of a mmmmm; -He/She directed the unnamed resident out of Resident #1's room when he/she heard CNA A say, You fucking bitch to Resident #1; -CNA A left Resident #1's room and told him/her (CNA B) that Resident #1 ripped his/her glasses off, scratched CNA A, and bit CNA A's shoulder; -CNA A left the dementia unit; -He/She (CNA B) went back into Resident #1's room and the resident was on the floor by his/her bed but did not appear hurt; -He/She stayed with the resident until CNA A and CNA C returned; -CNA A continued to work that shift and care for Resident #1; -He/She (CNA B) completed a written statement on a facility form that CNA C gave him/her, then gave the paper back to CNA C. Review of a facility statement, dated 05/03/25, showed CNA B documented the following: -CNA A went into Resident #1's room to change the resident's (incontinence) brief and was rough (talking loudly and harshly) with Resident #1; -CNA A continued to be rough with Resident #1 as he/she (CNA B) tried to help another resident out of Resident #1's room; -When CNA B walked out of Resident #1's room, he/she heard CNA A call Resident #1 a fucking bitch and Resident #1 was yelling; -CNA A left the unit but then returned with CNA C; -The resident was on the floor when he/she went back into the room; -CNA A called the resident a fucking bitch more than once. During an interview on 05/13/25 at 3:50 P.M., CNA C said the following: -He/She worked on another hall on the evening of 05/03/25 when he/she saw CNA A sitting across from the nurses' station; -CNA A said he/she needed help with Resident #1 because the resident scratched and bit him/her when CNA A was trying to change the resident's (incontinence) brief; -He/She went with CNA A to Resident #1's room where they found the resident on the floor by his/her bed; -When the resident saw CNA A, the resident said, You're a monster and the resident said that CNA A hurt him/her and to not touch him/her; -CNA A told the resident, You're a fucking witch, and kept repeating it; -He/She (CNA C) put a gait belt on the resident and both he/she and CNA A assisted the resident back to bed; -CNA A proceeded to change Resident #1's (incontinence) brief; -CNA A continued to work on the dementia unit that night; -He/She started to write out a statement about what had happened on a plain piece of paper; -Licensed Practical Nurse (LPN) E came on duty and gave CNA C a facility statement paper to use instead of a piece of plain paper; -He/She completed the written statement and slipped it under the administrator and DON's door; -He/She thought CNA A also worked on the dementia unit the next day. Review of a facility statement, dated 05/03/25, showed CNA C documented the following: -CNA A said he/she was scratched and bitten by Resident #1 and CNA A needed help; -He/She (CNA C) went with CNA A back to Resident #1's room and he/she saw the resident lying on the floor, and CNA B was with the resident; -While he/she told CNA B to go get the charge nurse, CNA A called Resident #1 a fucking witch multiple times; -Resident #1 called CNA A a monster and did not want anyone touching him/her. Review of the facility electronic timecard for CNA A, dated 05/01/25 through 05/15/25, showed the following: -On 05/03/25, CNA A clocked in at 02:00 P.M., and clocked out at 09:00 P.M.; -On 05/03/25, CNA A clocked in at 09:30 P.M., and clocked out at 06:54 A.M. on 05/04/25; -On 05/04/25, (the day after the alleged abuse), CNA A clocked in at 02:00 P.M., and clocked out at 09:00 P.M.; -On 05/04/25, CNA A clocked in at 09:30 P.M. and clocked out at 06:43 A.M. on 05/05/25. During an interview on 05/28/25 at 10:23 A.M., CNA A said the following: -He/She went to Resident #1's room around 3:00 P.M. on 05/03/25 and the resident lay in bed; -He/She told Resident #1 it was time for a shower and the resident said No, so he/she (CNA A) left the room; -He/She went back into Resident #1's room around 4:30 P.M. to assist the resident up for supper; -Resident #1 required one to two staff for transfers; -The resident allowed him/her to assist him/her up out of bed and he/she (CNA A) began to transfer Resident #1 across the floor when the resident bit down on his/her (CNA A's) left shoulder and scratched his/her face with his/her fingernails, knocking his/her glasses off and onto the floor; -No other staff or residents were present in Resident #1's room when this incident occurred; -He/She lowered Resident #1 to the floor since he/she was combative, to provide for the resident's safety; -He/She left Resident #1's room and told CNA B (who was in the hallway) to stay with Resident #1 because he/she had to lower the resident to the floor; -He/She left the dementia unit and went to another hall of the facility to get the charge nurse (RN D); -He/She, RN D and CNA C went back to the dementia unit; -CNA C used a gait belt and transferred Resident #1 back to bed; -He/She and CNA C assisted the resident to reposition in bed, and he/she changed the resident's (incontinence) brief; -CNA C left the resident's room; -He/She served Resident #1 supper in the resident's room and continued working on the dementia unit; -He/She went to Resident #1's room around 8:30 P.M. on 05/03/25 because the resident still needed a shower; -He/She had CNA B accompany him/her to the resident's room, because he/she was not sure if Resident #1 would become combative again; -He/She assisted Resident #1 to get up on the morning of 05/04/25 without the help of CNA B; -He/She returned for another 16-hour shift on the dementia unit at 02:00 P.M. on 05/04/25 and continued to care for Resident #1 and other residents; -He/She clocked out on the morning of 05/05/25 around 06:00 A.M. and left the facility. During an interview on 05/14/25 at 11:32 A.M., LPN E said the following: -He/She worked the evening shift on 05/03/25; -CNA C asked him/her for two facility statement forms, but did not tell him/her why he/she wanted them; -He/She gave CNA C two facility statement forms and did not ask CNA C why he/she wanted them because he/she didn't think it was his/her business; if CNA C wanted him/her to know something had happened, CNA C would have told him/her; -CNA A continued to work his/her shift on the dementia unit on 05/03/25 and returned for his/her next shift on the dementia unit on 05/04/25; -He/She was not aware that CNA A had yelled and cursed at Resident #1 until a couple of days later when he/she heard that CNA A had been terminated; -Yelling and cursing at a resident was a form of abuse; During an interview on 05/13/25 at 3:05 P.M. and 05/14/25 at 10:00 A.M., the Director of Nurses (DON) said the following: -She was unaware that CNA A yelled and cussed at Resident #1 on the evening of 05/03/25 until the administrator made her aware following her return from vacation on or about 05/05/25; -She thought CNA A was terminated by telephone on 05/05/25 by the administrator; -When she was made aware of this event, she reviewed what employees had been in-serviced on abuse and neglect, but could not say for sure that every employee had been in serviced immediately following the incident; -CNA A usually worked the dementia unit but had worked on the other facility halls in the past; -Yelling and cursing at a resident was a form of abuse; -If administration had been made aware of the report that CNA A had yelled and cussed at Resident #1, CNA A would have been immediately sent home and an investigation started; -CNA A completed his/her shift after the event with Resident #1 occurred, and then returned for his/her next shift the following day, where he/she worked on the dementia unit again and had contact with Resident #1; -Administration (to include the administrator or his designee, the DON, or the on-call weekend nursing manager) were responsible for abuse investigations; -Investigation of abuse would include interviews and written statements from the resident(s) and staff involved or who may have witnessed the incident, interviews with other residents that may have had contact with the staff accused of abuse, and an assessment of the resident(s) involved; -An employee accused of resident abuse would immediately be suspended pending an investigation of the alleged abuse; -A resident who may have been abused would be assessed for any physical or mental changes immediately with follow-up assessments completed as necessary to make sure the resident was at or returned to his/her baseline. During an interview on 05/13/25 at 5:20 P.M., the Administrator said the following: -He was not made aware that CNA A had yelled or cursed at Resident #1 on 05/03/25 until he came to work on the morning of 05/05/25 and found a written statement from CNA B and CNA C under his door; -He began an investigation on 05/05/25; RN D was the charge nurse on 05/03/25 and RN D told him that he/she was not aware that CNA A had yelled or cursed at Resident #1 on the evening of 05/03/25; -Both CNA B and CNA C said (based on written statement provided under his door) they heard CNA A curse at Resident #1; -CNA A had worked on other halls in the facility, but for the past several months, had primarily worked on the dementia unit; -He spoke with CNA A for the first time about the event on the morning of 05/05/25; -CNA A had been counseled in the past about speaking gruffly to others; some residents and staff had complained before; -CNA A completed his/her shift the night that he/she yelled and cursed at Resident #1 and returned the following day to work another shift on the dementia unit where Resident #1 resided; -Yelling and cursing at a resident was considered abuse; -He expected all facility staff to report allegations of abuse or neglect immediately if they occur so an investigation could be started; -He did not speak with CNA B or CNA C after he reviewed their written statements; -He did not interview LPN E; (facility policy directs all involved staff were to be interviewed); -He did not attempt to interview Resident #1 or any of the residents on the dementia unit where the incident took place; (facility policy directs a statement from the resident as well as interview should be obtained if possible); -He did not interview any other residents or staff on the other halls of the facility, even though CNA A had worked in some of those areas in the past; (facility policy directs interviews should be obtained from three to four residents who received care from the alleged staff); -He started an in-service on abuse and neglect for the day and evening shifts on 05/05/25, after he was made aware of the verbal abuse allegations, but he did not offer an in-service to the incoming night shift; -He was not sure what his plan was to in-service the night shift employees on abuse and neglect; -Some employees had still not been in-serviced since this abuse allegation occurred; -The DON had been on vacation and he relied on her to help with investigations, so there were likely some things missed. MO00253797

Refer to QPGW12. Based on observation, interview and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 87.

Based on interview and record review, the facility failed to ensure three residents (Residents #3, #5 and Resident #11), in a review of seven sampled residents, were free from abuse when Resident #1 caused physical harm to Resident #5 when he/she pulled him/her out of his/her wheelchair, resulting in a left shoulder fracture, and when he/she hit an additional resident, Resident #11, in the face and grabbed Resident #3's arm, causing the resident pain. The census was 85. Review of the facility policy, Abuse Prohibition, dated 11/2016, showed the following: -The purpose of the facility policy is to prohibit mistreatment, neglect or abuse of any resident; -Abuse is the willful infliction of injury with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the undated facility policy, Resident Rights, showed residents have the right to be free from abuse. 1. Review of Resident #1's progress notes, dated 05/29/24 at 6:30 A.M., showed staff documented the nurse was called to the main dining room related to an incident where this resident punched another resident (Resident #11) in the face. Resident #1 said Resident #11 was cussing and would not stop so he/she hit Resident #11. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/28/24 showed the following: -Severely impaired cognition; -No hearing impairment; -Able to understand others and make self understood; -No psychosis; -Verbal behavioral symptoms occurred one to three days of look back period; -No behaviors impacting residents or others; -Independent with transfers and ambulating ten feet; -Used a manual wheelchair. Review of the resident's progress notes, dated 09/19/24 at 2:44 A.M., showed staff documented the resident hit another resident (his/her roommate, Resident #3) at the 100 nurse station saying Resident #3 took his/her money. Review of the resident's progress notes, dated 09/22/24, showed staff documented the following: -At 2:00 A.M., the resident was walking up the hallway yelling at staff and when approached, stated don't you touch me! and started swinging his/her fists at staff threatening to hit them. Resident sat in a wheelchair and propelled his/herself in the hallway, pulled the alarm on the 100 hall and pushed on the door; -At 2:28 A.M., new order received for Haldol (antipsychotic) five milligram (mg) intramuscularly (IM). Three staff stabilized the resident and injection administered; -At 3:06 A.M., resident a little calmer but made threats at anyone that approached him/her; -At 4:27 A.M., resident grabbed another resident (Resident #5) by the arm and pulled him/her out of his/her chair in the dining room. New order obtained to send Resident #1 to the emergency room for evaluation. Review of the resident's care plan, last revised 09/25/24, showed the following: -Behavioral symptoms: Potential for reoccurrence of agitation/physical aggression. Resident will not harm self or others. Assess whether the behavior endangers resident or others. Intervene if necessary and report to nurse. Redirected by staff and 15 minute checks done as needed at nurse's discretion if he/she becomes agitated or aggressive towards others; -On 09/19/24, the resident grabbed/hit another resident's forearm and accused him/her of stealing money; -On 09/22/24 the resident pulled another resident out of his/her chair by the arm in the dining room. The other resident was sent to the emergency room (ER) and found to have a left shoulder fracture. Review of the resident's Physician Order Sheet, dated 10/2024, showed the following: -Diagnoses included vascular dementia (memory loss) with other behavioral disturbances and Alzheimer's disease (memory loss and confusion) with late onset; -Behavior monitoring every shift (06/23/23). 2. Review of Resident #5's significant change MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Independent with transfers and ambulation. Review of the resident's care plan, last revised 09/25/24, showed the following: -Diagnoses included pain in left arm, shoulder and hand; -Resident to resident altercation on 09/22/24 at 4:40 A.M. when another resident (Resident #1) pulled the resident out of his/her chair onto the floor in the dining room. Resident complained of pain and found to have a left shoulder fracture. Observation on 10/02/24 at 12:35 P.M., showed the resident lay in his/her bed and wore a sling to his/her left arm. During an interview on 10/02/24 at 12:35 P.M., the resident said he/she remembered when (Resident #1) pulled him/her out of his/her chair and that it had hurt. His/Her arm was painful, but pain medicine helped. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors; -Independent with transfers/ambulation; -Used a manual wheelchair. During an interview on 10/02/24 at 11:09 A.M., the resident said the following: -Resident #1 used to be his/her roommate; -He/She recalled an altercation with Resident #1 which occurred about two weeks ago in the evening; -He/She was going down the hall and said hello to Resident #1 who grabbed his/her (Resident #3's) forearm with one hand, balled up his/her fist and drew it back in an attempt to hit him/her in the face and said, You son-of-a-bitch, you stole my money; -He/She had just had abdominal hernia surgery and had a plate in the arm the resident grabbed, so it hurt when Resident #1 did this. His/Her arm was sore from the wrist half-way up to the elbow. During an interview on 10/09/24 at 3:24 P.M., Nurse Assistant (NA) E said the following: -He/She had worked on 09/19/24 when Resident #1 had grabbed Resident #3's arm and attempted to hit him/her. He/She and another staff separated the two residents; -He/She worked on 09/22/24 when Resident #1 had multiple behaviors. Around 1:15 A.M., he/she went to perform the (already in place) 15 minute check on the resident and the resident came running towards him/her and swung at him/her multiple times. He/She yelled for help, kept his/her distance and watched the resident. The resident went down the hall and chased another co-worker around the table in the conference room. He/She hit another co-worker who was working 600 hall and a nurse who was working the lower 300 hall. He/She (NA E) saw the resident go towards the dining room in his/her wheelchair and then heard Resident #5 scream and found Resident #5 on the floor. He/She did not see Resident #1 pull Resident #5 out of his/her chair. During an interview on 10/10/24 at 11:52 A.M., NA H said the following: -He/She had worked 10:30 P.M. to 6:30 A.M. starting on 09/21/24 into 09/22/24; -Resident #1 was sitting in his/her usual spot in the dining room and he/she saw Resident #1 get up as he/she went to answer a call light. As he/she was returning to the area, he/she saw Resident #1 grab Resident #5's chair and pull him/her over. During an interview on 10/03/24 at 9:40 A.M., Licensed Practical Nurse (LPN) I said the following: -He/She was called in around 12:30 A.M. the morning of 09/22/24; -Resident #1 was really agitated, trying to get into rooms and chasing around an aide; -Around 3:30 A.M., staff felt the resident was calming down and took their eyes off of him/her for a minute or two; that was when he/she (Resident #1) got to Resident #5. During an interview on 10/03/24 at 12:29 P.M., LPN A said the following: -He/She was the charge nurse for Residents #1 and #5 the early morning of 09/22/24; -He/She was in the middle of passing medications when the altercation between Resident #1 and Resident #5 occurred, about 4:05 A.M.; -Resident #1 had been in and out of bed all night. He/She had had quite a few incidents with other residents in the past; -Resident #5 sits up at night in the dining room and colors. He/She did not have behaviors; -NA E came down the hall and said Resident #1 had pulled Resident #5 out of his/her chair; -NA H was already present in the dining room with the residents when he/she arrived. Resident #5 had already been assisted back into his/her chair. During an interview on 10/03/24 at 4:15 P.M., the Director of Nursing (DON) said the following: -Residents should be free from abuse; -The incidents with Resident #1 constituted resident to resident abuse. During an interview on 10/03/24 at 4:30 P.M., the Administrator said the following: -Residents should be free of abuse; -Resident #1's actions toward Residents #3, #5, and #11 constituted abuse. MO242564

Based on observation, interview and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 87. Review of the facility policy, Food Temperatures, dated April 2011, showed the following: -The Dietary Services Manager (DSM) or designee is responsible for seeing that all food is the proper temperature before trays are assembled; -Hot food should be at least 120 degrees Fahrenheit (F) when served to the resident; -Hot/cold foods should not be placed together on the same plate. During an interview on 11/18/24 at 11:40 A.M., Resident #5 said he/she always eats in his/her room and the food was never hot. During an interview on 11/18/24 at 2:10 P.M., Resident #6 said he/she always eats in his/her room and the food was not always hot when it should be, he/she just figured it was cold because the facility had so many people to feed. During an interview on 11/19/24 at 9:30 A.M., Resident #8 said he/she always eats in his/her room and the food was always cold. Review of the Dietary Manager's, food temperatures-hall trays, showed she documented the following temperatures: -On 09/10/24 200 hall tray, protein temperature 94 degrees F; -On 09/27/24 200 hall tray, protein temperature 98 degrees F; -On 10/21/24 200 hall tray, protein temperature 94 degrees F; -On 10/30/24 300 hall tray, soup temperature 86 degrees F; -On 11/14/24 200 hall tray, protein temperature 97 degrees F. Review of the facility lunch menu for 11/19/24, showed the lunch meal included chili, hot dogs, and a lettuce salad. Review of the facility's temperature log, dated 11/19/24, showed staff documented the holding temperature of the lunch meat (protein) at 175 degrees F. Observation on 11/19/24 at 1:00 P.M., of the test tray obtained after staff served the last resident on the 200 Hall, showed the following: -The test tray showed a plate with a cold salad (lettuce), a hot dog on a hot dog bun, and a bowl of chili; -The temperature of the hot dog was 90 degrees F, and the temperature of the chili 110 degrees F. During an interview on 11/19/24 at 2:00 P.M., the Dietary Manager said the following: -She was not aware that any residents had complained that their food was cold; -She realized the temperature of food would decrease the minute it was plated and sent to the residents who ate in their rooms; -She will temp test one tray each week from each hallway in the facility where staff served residents meals in their rooms; -The plate warmer will hold the heat of the plate to 125 degrees F; she would like to see it at 135 degrees F, but the kitchen staff complained the plates were too hot to hold; -The cold salad (lettuce) plated with the hot dog probably reduced the temperature of the hot dog; -Food should be served at an appropriate and appetizing temperature. During an interview on 11/19/24 at 3:15 P.M., the administrator said the following: -She was not aware any resident had complained of their food being cold; -Food should be served at an appropriate and appetizing temperature. MO00243111

Based on observation, interview and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 87. Review of the facility policy, Food Temperatures, dated April 2011, showed the following: -The Dietary Services Manager (DSM) or designee is responsible for seeing that all food is the proper temperature before trays are assembled; -Hot food should be at least 120 degrees Fahrenheit (F) when served to the resident; -Hot/cold foods should not be placed together on the same plate. During an interview on 11/18/24 at 11:40 A.M., Resident #5 said he/she always eats in his/her room and the food was never hot. During an interview on 11/18/24 at 2:10 P.M., Resident #6 said he/she always eats in his/her room and the food was not always hot when it should be, he/she just figured it was cold because the facility had so many people to feed. During an interview on 11/19/24 at 9:30 A.M., Resident #8 said he/she always eats in his/her room and the food was always cold. Review of the Dietary Manager's, food temperatures-hall trays, showed she documented the following temperatures: -On 09/10/24 200 hall tray, protein temperature 94 degrees F; -On 09/27/24 200 hall tray, protein temperature 98 degrees F; -On 10/21/24 200 hall tray, protein temperature 94 degrees F; -On 10/30/24 300 hall tray, soup temperature 86 degrees F; -On 11/14/24 200 hall tray, protein temperature 97 degrees F. Review of the facility lunch menu for 11/19/24, showed the lunch meal included chili, hot dogs, and a lettuce salad. Review of the facility's temperature log, dated 11/19/24, showed staff documented the holding temperature of the lunch meat (protein) at 175 degrees F. Observation on 11/19/24 at 1:00 P.M., of the test tray obtained after staff served the last resident on the 200 Hall, showed the following: -The test tray showed a plate with a cold salad (lettuce), a hot dog on a hot dog bun, and a bowl of chili; -The temperature of the hot dog was 90 degrees F, and the temperature of the chili 110 degrees F. During an interview on 11/19/24 at 2:00 P.M., the Dietary Manager said the following: -She was not aware that any residents had complained that their food was cold; -She realized the temperature of food would decrease the minute it was plated and sent to the residents who ate in their rooms; -She will temp test one tray each week from each hallway in the facility where staff served residents meals in their rooms; -The plate warmer will hold the heat of the plate to 125 degrees F; she would like to see it at 135 degrees F, but the kitchen staff complained the plates were too hot to hold; -The cold salad (lettuce) plated with the hot dog probably reduced the temperature of the hot dog; -Food should be served at an appropriate and appetizing temperature. During an interview on 11/19/24 at 3:15 P.M., the administrator said the following: -She was not aware any resident had complained of their food being cold; -Food should be served at an appropriate and appetizing temperature. MO00243111

Based on observation, interview and record review, the facility failed to ensure residents on the 200 hall (Room #'s 211, 212 and 200) had access to hot water in their rooms, including two residents (Resident #9 and #13) in a review of seven sampled residents. The census was 85. During an interview on 10/17/24 at 12:55 P.M. the Administrator said she could not locate a policy on hot water temperatures but the temperature range should be between 105-120 degrees Fahrenheit. 1. Review of Resident #9's care plan, last revised 08/14/24, showed the following: -Incontinent of bladder and bowel; -Provide peri-care routinely and as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 09/20/24, showed the following: -Partial to moderate assist with bed mobility; -Always incontinent of bladder and bowel. Observation on 10/03/24 at 8:38 A.M., showed the following: -Certified Nurse Assistant (CNA) C entered the room and prepared to perform incontinent care on the resident; -Before beginning perineal care, CNA C told the resident there was no hot water and warned the resident it was going to be cold. During an interview on 10/03/24 at 9:00 A.M., CNA C said the 200 hall had not had hot water for two or three months. The water was cold. If he/she had to give a bed bath, he/she would fill a basin with warm water from the 100 hall. Observation on 10/03/24 at 10:33 A.M., showed the hot water temperature from the faucet in the resident's room (room [ROOM NUMBER]), measured with an electronic thermometer, was 90.1 degrees Fahrenheit. During an interview on 10/03/24 at 10:33 A.M., the resident said he/she had gotten used to the water being cold, but it was a shock. 2. Review of Resident #13's care plan, last revised 04/11/24, showed to provide incontinence care after each incontinent episode. Review of the resident's annual MDS, dated [DATE], showed the following: -Always incontinent of bladder and bowel; -Dependent for toileting and perineal care. Observation on 10/02/24 at 5:15 P.M. showed CNA L and Nurse Assistant (NA) E entered room [ROOM NUMBER] and performed incontinent care on the resident. Staff informed the resident the cloths would be cold. During an interview on 10/03/24 at 10:35 A.M., the resident said the water was cold and it bothered him/her when staff cleaned him/her up. Observation on 10/03/24 at 10:43 A.M. showed the hot water temperature from the faucet in the resident's room was 97.1 degrees Fahrenheit. 3. Observation on 10/03/24 at 10:35 A.M. showed the hot water temperature from the faucet in room [ROOM NUMBER] (a resident occupied room) was 69.4 degrees Fahrenheit. During an interview on 10/03/24 at 2:00 P.M., the maintenance director said the following: -Halls 300 and 400 each had their own water heaters; -Halls 100 and 200 share a water heater; -He had had complaints from staff about not having hot water; -This had been an issue for a long time, at least two- three months; -The 100 hall had adequate hot water but if turned up enough to allow 200 hall the same temperatures, it would make the water on 100 hall too hot; -He had spoken with corporate at some point, but had not informed the administrator; -He did take water temperatures bi-weekly and it could take up to five minutes to get hot water; -He had measured temperatures of up to 100 degrees Fahrenheit in room [ROOM NUMBER]. During an interview on 10/03/24 at 4:15 P.M., the Director of Nursing (DON) said the following: -Residents should have access to hot water; -She was not aware of the 200 hall did not have hot water; -She had had complaints from staff that it could take up to 30 seconds to get water but thought it then got warm. During an interview on 10/03/24 at 4:30 P.M., the Administrator said the following: -She had not had any reports of 200 hall not having hot water; -She had heard it took a long time to get hot water on the 200 hall. -She had not looked into it or inquired with maintenance until today.

Based on interview and record review, the facility failed to ensure staff treated one resident (Resident #4), in a review of seven sampled residents, and one additional resident (Resident #8) with dignity and respect. Without saying anything, staff pulled back the covers and yanked on Resident #4's arm and it hurt and scared him/her. Staff yelled Resident #8's name and spoke angrily toward the resident, frightening the resident. The census was 85. Review of Resident Rights, found in the employee handbook, last revised 10/01/17, showed treating residents with dignity and respect was not only the facility's policy, but also the law. Treat all residents with consideration, respect and dignity at all times. Your behavior must reflect your beliefs in this right in your daily interactions with the residents, families and visitors to our facility. Review of the undated facility policy, Resident Rights, showed the resident has a right to a dignified existence. The resident had the right to privacy and respect. 1. Review of Resident #4's face sheet showed his/her diagnoses included legal blindness and dementia. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 09/11/24, showed the following: -Mildly impaired cognition; -Severely impaired vision (no vision or only sees light, color or shapes); -No corrective lenses; -No delirium, behaviors, mood or rejection of cares. During an interview on 10/02/24 at 12:40 P.M., the resident said an unknown staff member entered his/her room early in the morning, and without saying anything, pulled back the covers and yanked on his/her arm. It hurt and scared him/her. It could have pulled his/her arm out of socket. He/She could not describe the staff as he/she could not see. Review of the resident's Care Plan, last revised 10/03/24, showed the resident's vision was highly impaired and to provide verbal and physical cues to enhance independence. During an interview on 10/03/24 at 11:51 A.M., Certified Medication Technician (CMT) B said he/she was in the dining room on 09/30/24 around 6:30 A.M. when Resident #4 and his/her roommate (Resident #12) were upset. Resident #4 was crying and too upset to speak, so his/her roommate told him/her (CMT B) that a staff member had been rough and mean with Resident #4 when getting him/her out of bed that morning. The residents described the staff. The two residents asked if he/she could help and he/she reported it first to the Assistant Director of Nursing (ADON) when she arrived at work between 7:30 A.M. and 8:00 A.M. and then the Director of Nursing (DON) when she arrived around 15 minutes later. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Adequate hearing and vision; -Physical (kicking, hitting, grabbing) and verbal (threatening, screaming and cursing) behavior directed at others one to three days of the seven day look back period; -Supervision or touch assist for bed mobility. During an interview on 10/03/24 at 12:05 P.M., Nurse Assistant (NA) G said the following: -He/She went to relieve an aide on the 300 hall early on 09/30/24; -The other aide and Certified Nurse Assistant (CNA) F had been helping to get Resident #8 out of bed when he/she entered the room to take over; -The resident was not wanting to cooperate and roll over; -CNA F yelled the resident's name and said angrily, We're not doing this!; -CNA F's face was bright red; -He/She told CNA F to leave and he/she would finish cares; -The resident was quiet after that and told him/her that CNA F had been coming into his/her room causing problems; -He/She told had told a medication technician or a nurse. During an interview 10/03/24 at 4:00 P.M., the resident said CNA F yelled at him/her and it scared him/her. 3. During an interview on 10/02/24 at 1:30 P.M., the ADON said the following: -On the morning of 9/30/24, CMT B reported the incident involving Resident #4; -She visited with the resident and his/her roommate and filled out their statements; -He/She was not aware of CNA F yelling at Resident #8. During an interview on 10/03/24 at 8:25 A.M. and 4:15 P.M., the DON said the following: -She was aware of a staff being rough with Resident #4; -Staff should not yell at a resident; -Staff should announce their presence, explain the cares they are going to provide and be patient with the resident; -Residents were to be treated with dignity and respect. During interview on 10/03/24 at 12:15 P.M. and 4:30 P.M., the Administrator said it was a resident's right to be treated with dignity and respect at all times. MO239725

Based on interview and record review, the facility failed to report a staff to resident allegation of abuse to the state agency for one resident (Resident #4), in a review of seven sampled residents. Resident #4 alleged, and Resident #12 witnessed and reported, an allegation of abuse by a staff member that occurred on 9/30/24 to the Assistant Director of Nursing (ADON) on 9/30/24. Certified Medication Technician (CMT) B reported the allegation of abuse to the Director of Nursing (DON) on 9/30/24. Neither the ADON or the DON reported this allegation to the administrator or state agency per facility policy. The census was 85. Review of the undated facility policy, Abuse Reporting Guidelines, showed all alleged violations involving abuse or mistreatment are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the state survey agency). Investigation guidelines: At such time that the Administrator and/or Director of Nursing believe that abuse occurred, the Administrator or DON will notify the appropriate personnel. These may include the appropriate state agencies. Review of the facility policy, Abuse Prohibition, dated 11/2016, showed the following: -The purpose of the facility policy is to prohibit mistreatment, neglect or abuse of any resident; -Abuse is the willful infliction of injury with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Examples of abuse include rough handling during care or when moving a resident. 1. Review of Resident #4's face sheet showed he/she had diagnoses that included legal blindness and unspecified dementia. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 09/11/24, showed the following: -Mildly impaired cognition; -Severely impaired vision-(no vision or only sees light, color or shapes); -No corrective lenses; -No delirium, behaviors, mood or rejection of cares; -Independent with transfers; -Supervision or touch assist to ambulate. Review of a statement written by an unknown staff member and dated 9/30/24 at 7:30 A.M. read, They yanked me out of my chair and rushed me around. No one likes to be yanked around. The statement was initialed by the resident. During an interview on 10/02/24 at 12:40 P.M., the resident said an unknown staff member entered the room early in the morning and without saying anything, pulled back the covers and yanked on his/her arm. It hurt and scared him/her. It could have pulled his/her arm out of socket. He/She could not describe the staff as he/she could not see and he/she did not know if the staff member had ever provided care to him/her before or not. Review of the resident's care plan, last revised 10/03/24 showed the following: -Vision highly impaired, provide verbal and physical cues to enhance independence; -On 09/30/24, resident reported a Certified Nurse Assistant (CNA) pulled on his/her arm and was disrespectful with rushing him/her around early in the morning. 2. Review of Resident #12's significant change MDS, dated [DATE] showed the following: -Mildly impaired cognition; -Adequate hearing, vision and wore glasses; -Understood others. Review of the a written statement, dated 9/30/24 7:40 A.M. and documented by an unknown staff showed, Girl came in and said I'm running late. Went to Resident #4, grabbed his/her arm and pulled him/her up. The document was signed by Resident #12. During an interview on 10/02/24 at 12:40 P.M., Resident #4's roommate, Resident # 12 said that on Monday, (9/30/24), he/she was in the room when a short, blonde haired staff member, who wore a ponytail, entered their dark room. The staff member said, I'm behind, and without saying a word to his/her roommate, he/she yanked the resident by the arm to get him/her out of bed and walked the resident to the bathroom. He/She reported this to the Assistant Director of Nursing (ADON) that morning who wrote it down and interviewed him/her and Resident #4. During an interview on 10/03/24 at 11:51 A.M., Certified Medication Technician (CMT) B said the following: He/She was in the dining room on 9/30/24 around 6:30 A.M., when Resident #4 and his/her roommate were upset. Resident #4 was crying and too upset to speak, so the roommate told him/her a staff member had been rough and mean with Resident #4 when getting him/her out of bed that morning. The residents described the staff member appearance and voice. The two residents asked if he/she could help and he/she reported it first to the ADON when she arrived to work between 7:30 and 8:00 A.M. and then to the Director of Nursing (DON) when she arrived around 15 minutes later. During an interview on 10/2/24 at 1:30 P.M. the ADON said the following: -The incident was reported to her by CMT B the morning of 09/30/24; -She visited with the resident and his/her roommate and filled out their statements, turning them in to the DON; -She gave the DON the description of the staff that the roommate had reported to her; -They were looking at staffing to see who fit the description; -She had not reported it to the state agency as she had been told by the Administrator in the past that the DON or Administrator were responsible for reporting. During an interview on 10/03/24 at 8:25 A.M. and 4:15 P.M., the DON said the following: -She said she was made aware on 9/30/24 between 7:30 and 8:30 A.M. upon arriving at work. There were two written statements under her door; -She did not report this concern of an incident involving staff being rough with Resident #4, as the resident's statement said she had been rushed. She did not know about the yanking on the arm; -She had not spoken with Resident #4 or Resident #12; -She had not reported it to the administrator; -She said the allegation should have been reported to the state agency within two hours. During interview on 10/03/24 at 12:15 P.M. and 4:30 P.M., the Administrator said the following: -She said she was not aware of any staff to resident roughness and she felt staff would have reported it to her if there was an issue; -The DON had not reported it to her but she would have expected her to; -Staff should follow their policy on reporting abuse allegations; -The DON or Administrator was responsible for reporting to the state agency; -An allegation of yanking on a resident's arm would be considered abuse; -An allegation of abuse should be reported within two hours; MO242564

Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for five residents (Resident #27, #29, #59, #501, #502 and #503) in a sample of 23 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #27 and #29 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #29 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). Staff documented performing an accucheck on one resident, Resident #59, with the same glucometer that was not properly disinfected, after using it on Resident #29. The facility identified staff utilized this multi-resident use glucometer for five residents who resided on the 300 hall. Additionally, staff failed to use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infection causing contaminants, and when indicated by professional standards of practice, during incontinence care for two residents (Resident #12 and #27). The facility census was 95. The administrator was notified on 04/04/24 at 2:55 P.M. of an Immediate Jeopardy (IJ) which began on 03/20/24. The IJ was removed on 4/5/24 as confirmed by surveyor on-site verification. Review of the facility's policy for Standard and Transmission Based Precautions from the Nursing Guidelines Manual dated 2007 showed the following: -Standard precautions would be used in the care of all residents regardless of their diagnoses or suspected and/or confirmed infection status. Standard precautions presume all blood, body fluids, secretions, and excretions, non-intact skin, and mucous membranes that may contain transmissible infectious agents; -Hand hygiene referred to handwashing with soap or using alcohol-based hand rubs that do not require access to water; -Hands should be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such, and before eating and after using the restroom; -In the absence of visible soiling of hands, alcohol-based hand rubs were preferred for hand hygiene; -Wash hands after removal of gloves; -Wear gloves when you anticipate direct contact with blood, body fluids, mucous membranes non-intact skin, and other potentially infected materials; -Wear gloves when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms; -Change gloves as necessary during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one); -Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Review of the facility's undated policy, Blood Glucometer Disinfecting, showed the following: -Purpose: to prevent the spread of infection; -Equipment: approved wipes with 10% bleach or comparable product; -Wash hands and put on gloves; -Provide a clean field in which to place the glucose meter (a paper towel worked well); -Clean the blood glucose meter prior to using with approved wipes with 10% bleach or comparable product, place on clean field and let air dry according to the manufacturer's directions. Do not touch the clean field with gloves including the test port. Glucometer may be wrapped in another wipe and stored; -Remove gloves and wash hands. Review of the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) recommendations, dated August 2010, showed the following: -Blood contamination is often evident on glucometers even if one cannot see it; -Facilities must use an EPA-registered disinfectant to clean glucometers; -Rubbing alcohol is not an effective disinfectant against Hepatitis B and should not be used; -It is important to use a glucose monitoring device designed for institutional use that can be disinfected frequently; -The manufacturer's instructions should say which cleaning solution a device can withstand; -If the manufacturer's instructions do not specify steps for cleaning and disinfecting between uses of glucose monitoring devices, the devices generally should not be shared among residents according to CMS; -Environmental surfaces such as glucometers should be decontaminated regularly and anytime contamination with blood or body fluids occurs or is suspected; -Glucometers should be assigned to individual patients. If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected. Review of the Evencare G3 blood glucose monitoring guidelines from medline.com showed the following: -Cleaning and Disinfecting Procedures: -The meter should be cleaned and disinfected between each patient; -The following products have been approved for cleaning and disinfecting the meter: Dispatch(R) Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8), Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10), Clorox Healthcare(R) Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12), Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1); -Steps to cleaning/disinfecting a meter: -Step 1. Wash hands with soap and water; -Step 2. Put on single-use medical protective gloves; -Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter; -Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoid wetting the meter test strip port; -Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Caring for the meter: -Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry; -Step 6. Remove gloves. Review of the EvenCare G3 (glucometer) manufacturer guidelines from medline.com, testing a resident's glucose, showed the following: -Users need to adhere to standard precautions when handling or using this device; -All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. Review of a resident list, provided by the facility, showing which residents used the multi-resident use glucometer for the 300 hall, showed the list included Resident #29, #59, #501, #502, and #503. 1. Review of Resident #29's face sheet showed the following: -He/She resided on the 300 hall; -His/her diagnoses included Type 2 diabetes mellitus with hyperglycemia (elevated blood sugar (the amount of sugar in the blood)), and chronic viral Hepatitis C. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks (finger stick procedure where a droplet of blood is obtained for sampling to determine the amount of sugar in the blood) two times a day and as needed (PRN). Observation on 3/20/24 at 7:03 A.M. showed the following: -Licensed Practical Nurse (LPN) H removed a universal (multi-resident shared) blood glucose monitoring machine from the locked 300 hall medication/treatment cart and cleaned it with an alcohol wipe; -LPN H washed his/her hands and applied gloves; -LPH N placed a glucose test strip into the glucometer; -LPN H cleaned the resident's finger with an alcohol wipe and used a lancet to stick the resident's finger to obtain a blood droplet; -LPN H wiped the first drop of blood from the resident's finger and then obtained another drop of blood from the resident's finger and drew it up into the glucometer test strip to check the resident's blood sugar; -LPN H removed his/her gloves and washed his/her hands; -With his/her bare hands, LPN H cleaned the glucometer with an alcohol wipe and laid the glucometer on a tissue on top of the medication/treatment cart to dry. -LPN H did not disinfect the multi-resident shared blood glucose monitor with the proper disinfectant wipes. During an interview on 3/20/24 at 7:03 A.M. and 7:30 A.M. and 4/4/24 at 2:30 P.M., LPN H said the following: -He/She was taught to clean the multi-resident use glucometers with alcohol wipes; -He/She used this glucometer on all residents requiring blood glucose checks assigned to that cart (300 hall); -The way he/she cleaned the glucometer was how the facility instructed him/her to do so; -He/She was taught years ago to clean with alcohol wipes and that's the way he/she has always done it; -He/She could have found bleach wipes to use and didn't; -The bleach wipes were available for use; -He/She was aware Resident #29 had Hepatitis C. 2. Review of Resident #59's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks three times daily with meals. Review of the resident's electronic medical record, specifically vital sign results, showed LPN H documented he/she obtained the resident's accucheck on 3/20/24 at 7:30 A.M. 3. Review of Resident #501's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks twice daily, before breakfast and at bedtime. 4. Review of Resident #502's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for daily accuchecks. 5. Review of Resident #503's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks twice daily with meals. 6. Review of Resident #27's undated continuity of care document (CCD) showed his/her diagnoses included diabetes (elevated blood sugars), dementia, and urinary tract infections (UTI). He/She resided on the 400 hall. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/20/24, showed the following: -Cognition was severely impaired; -He/She was always incontinent of bowel and bladder; -He/She was dependent on staff for toileting hygiene. Review of the resident's physician's orders, dated March 2024, showed an order for accuchecks three times a day. Review of the resident's care plan, last reviewed/revised on 3/20/24, showed the following: -He/She required assistance with toileting and personal hygiene; -Provide incontinence care after each incontinent episode. Observation on 3/20/24 at 6:30 A.M. showed the Nurse Aide (NA) A and NA E entered the resident's room to assist the resident with morning cares. Without performing hand hygiene, NA D and NA E put on gloves and walked over to the resident. The resident was incontinent of bladder. NA D cleaned the resident's perineal area, assisted the resident onto his/her left side and NA E cleaned the resident's buttocks. Without changing gloves and performing hand hygiene after providing incontinence care, NA E placed a clean bed pan under the resident, rolled the resident to his/her right side and NA D removed the soiled linens from under the resident, pulled the clean bed pad under the resident, removed the resident's soiled gown, obtained a clean shirt from the resident's closet, and placed it on the resident. Without removing his/her gloves and performing hand hygiene after providing incontinence care, NA E opened the door and exited the room to discard the soiled linens to the dirty utility room. NA E returned to the resident's room with a new package of incontinence briefs. NA E did not wear gloves when he/she returned to the room. During an interview on 3/20/24 at 7:10 A.M., NA E said he/she was to wash and/or sanitize his/her hands between gloves changes, when entering a room, before exiting a room, and anytime gloves became contaminated. He/She should not touch anything clean with contaminated gloves and/or hands. Observation on 3/20/24 at 7:30 A.M. showed LPN H removed the glucometer from the treatment cart, cleaned it with an alcohol wipe, obtained the blood sample from the resident and then placed it on the strip in the glucometer, returned to the treatment cart, placed hand sanitizer on a tissue and wiped the glucometer with the tissue, removed his/her gloves, sanitized his/her hands, and finished cleaning the glucometer with an alcohol wipe. 7. Review of Resident #12's MDS, dated [DATE], showed the following: -Dependent for personal hygiene; -Always incontinent of bladder and bowel. Review of the resident's progress notes, dated 3/14/24 at 3:38 P.M., showed the resident had a new order to insert a 16 French/10 cubic centimeter (cc) urinary catheter due to wound on the coccyx (tailbone). Review of the resident's care plan, last revised 3/20/24 showed the following: -Poor mobility and incontinence; -Provide incontinence care after each incontinent episode. Observation on 3/20/24 at 8:30 A.M. showed the following: -The resident lay on his/her back in the bed; -Certified Nurse Assistant (CNA) W entered the room, donned gloves, emptied the resident's urinary drainage bag into a urinal and emptied it into the toilet; -Without removing his/her gloves, CNA W pulled the bed linens down from the resident and assisted the resident to turn onto his/her right side, touching the linens and the resident's hip with contaminated gloves; -Using a wet washcloth, he/she removed formed feces from between the resident's buttocks, threw this in the trash can nearby, and used a clean cloth to clean the resident's buttocks. He/She removed his/her gloves, and without performing hand hygiene, put on new gloves; -He/She tucked the soiled pad under the resident, placed a clean, cloth pad under the soiled pad and rolled the resident onto his/her left side; -He/She pulled the soiled linens out from under the resident, placed them in a plastic bag on the bed and pulled the clean linens through and beneath the resident; -Without removing his/her gloves, CNA W used a wet, clean cloth and wiped the large urinary catheter drainage tubing and then used the same area of the cloth to wipe the resident's groin area. With the same cloth, he/she wiped from the urinary catheter insertion site outward three times with the same area of the cloth. 8. During an interview on 3/21/24 at 7:35 A.M., 4/4/24 at 11:27 A.M., the Director of Nurses (DON) said the following: -Staff were to clean the glucometer with bleach wipes because they were a better disinfectant. Alcohol wipes were not good enough; -She would expect staff to clean the glucose monitor after each use with bleach wipes; -She was unaware of any resident having Hepatitis C or any bloodborne virus that received routine accuchecks; -The facility has one glucose monitor for each hall, so one at each nurse's station/cart; -There are approximately five to ten residents that received accuchecks on each hall; -Staff identify that a resident has a bloodborne virus by it being listed on their diagnoses list with ICD-10 codes; -She would expect the following measures to be in place if a resident has a bloodborne virus and is receiving accuchecks: gloves/proper PPE, handwashing and ideally, they would have their own glucose monitor; -Staff were to wash their hands and change their gloves when they become contaminated; -Staff were to wash hands when entering a resident's room, exiting a resident's room, and in between dirty to clean surfaces. Staff should not touch clean surfaces with contaminated gloves and/or hands; -Staff were to remove soiled gloves and wash hands after emptying a urinary drainage bag and before beginning perineal/catheter care. During an interview on 4/4/24 at 11:37 A.M., the Administrator said the following: -There were five glucose monitors in the building; -There are five residents on the 300 hall that receive accuchecks from the same multi-resident use glucose monitor (Residents #29, #59, #501, #502, and #503); -She expected the DON and nurse managers to do walking rounds to ensure staff are cleaning the glucose monitors properly; -The infection preventionist can pull a report with those residents having a diagnosis of any bloodborne virus; -She would expect staff to manage a resident with Hepatitis C and accuchecks with proper PPE including gloves and to clean the blood glucose monitor properly with bleach wipes and according to manufacturer's guidelines; -She was not aware the resident had Hepatitis C and received routine accuchecks. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). 32899

Based on interview, and record review, the facility failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction), when the facility failed to consistently and accurately assess and monitor pressure ulcers, provide routine dressing changes and prevent new ulcers from developing for two residents (Resident #5 and #7) in a review of nine sampled residents. Facility staff failed to implement and follow new orders for Resident #5 for seven days, causing the resident's wound to increase in size. Facility staff also failed to change a dressing for Resident #. The dressing was saturated with yellow to tan drainage. The facility census was 91. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (unstageable, Stage III or Stage IV pressure ulcer). Review of the facility policy, Pressure Ulcer Care and Prevention, dated March 2015, showed the following: -Purpose: To prevent and treat further breakdown of pressure ulcers; -Treatment of pressure ulcers will vary depending on the order of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Prevention strategies: Ongoing skin assessment with weekly documentation of status and positioning and pressure reduction; -Consultations: Obtain suggestions on needed dietary modifications and/or protein caloric supplementation, assess need for house vitamin when wound is present and resident is losing weight, Quality Assurance (QA) nurse: obtain consultation when the following exist: Multiple (three or more) stage II pressure wounds, stage III or greater, non-improvement in existing wounds following 2-3 week plan of care. 1. Review of Resident #5's undated face sheet showed the following: -The resident was admitted to the facility on [DATE]; -Diagnoses included pressure ulcer of the right heel and a pressure ulcer of the right buttock, unspecified stage. Review of the resident's admission assessment observation, dated 6/9/23 at 3:15 P.M. and completed on 6/13/23 at 11:07 A.M., showed the following: -Staff documented the resident had a new skin issue; -Decreased activity level and immobility and predisposing diseases; -Dry and scaly bilateral lower legs, purple blister on left heel (size of two quarters) and greenish quarter size discoloration on the right heel. Review of the resident's physician order sheet (POS), dated 6/9/23, showed skin prep to left and right heel at bedtime. Review of the resident's weekly skin assessment, dated 6/14/23 at 8:16 A.M., showed the following: -Existing skin issue; -Pressure ulcers to bilateral heels, right heel was open and left heel was closed. Open area to right buttock. Surgical incision to the left hip that was closed and scabbed over. Review of the resident's POS, dated 6/14/23, showed skin prep to the left and right heel three times a day. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/15/23, showed the following: -Extensive assistance of two staff members with transfers, walking in room and toileting; -Dependent on one staff member with locomotion on and off the unit; -Occasionally incontinent of bladder; -Always continent of bowels; -The resident was at risk for pressure ulcers; -The resident had one or more stage I or higher pressure ulcers; -The resident had one stage II pressure ulcer upon admission; -The resident had two unstageable pressure ulcers upon admission. Review of the POS, dated 6/15/23, showed the following: -Apply betadine to left and right heel, cover with foam, wrap with gauze, secure in place; -Skin- Buttocks: cleanse with cleanser of choice, nurse to apply zinc every shift and the CNAs may apply as needed. Review of the resident's Braden Scale assessment form, dated 6/16/23, showed the following: -Sensory perception- slightly limited; -Moisture- rarely moist; -Activity-walks occasionally; -Mobility- slightly limited; -Nutrition- adequate -Friction and Sheer- no apparent problem; -The resident had a total score =19, indicating the resident was not at risk for pressure ulcer development. Review of the resident's care plan, last revised 6/20/23, showed the following: -Unstageable pressure ulcer to right and left heel. Stage III pressure ulcers to right and left buttocks; -Delay in healing factors included impaired mobility and incontinence; -Treatment will be completed as ordered per the physician's orders; -Assess and record the condition of the skin surrounding the pressure ulcer; -Assess the pressure ulcer for location stage, size (length, width and depth), presence/ absence of granulation tissue (the healing process lumpy pink tissue that forms around the edges of the wound) and epithelization (refers to the development of new epidermis (outermost layer of the skin) and granulation tissue; -Assess for signs and symptoms of osteomyelitis (a serious infection of the bone with symptoms of pain, redness and swelling in the affected joint) muscle spasms, chills, fever, restlessness, and irritability. Review of the resident's record showed no documentation staff assessed the resident's pressure ulcers for size, including the length, width and depth, presence or absence of granulation tissue and epithelization as directed by the care plan from admission on 6/9/23 through 7/6/23. Review of the resident's weekly wound documentation, dated 7/7/23 at 2:22 P.M., showed the following: -Unstageable pressure ulcer to left heel that was present on admission on 6/9/23; -Left heel measurement: 5.5 centimeters (cm) by 5.5 cm; -Unstageable pressure ulcer to right heel present on admission on 6/9/23; -Right heel measurement: 5.0 cm by 6.0 cm; -No exudate or odor, periwound intact and healthy; -Continue current plan of care. The resident's wound documentation, dated 7/7/23, did not include any measurements or assessments of the two stage III pressure ulcers to the right and left buttocks as identified on the resident's care plan, dated 6/20/23. Review of the resident's POS, dated 7/12/23, showed an order to cleanse buttocks with cleanser of choice. Nurse to apply zinc every shift and the CNAs may apply as needed. Review of the resident's weekly skin assessment, dated 7/15/23 at 12:25 P.M., showed the following: -Right and left heels were unchanged; -Left heel measurement: 5.0 cm by 5.0 cm; -Right heel measurement: 5.0 cm by 6.0 cm right; -Treatment change: skin prep twice a day and leave open to air. Review of the resident's POS, dated 7/15/23, showed skin prep to right and left heel allow to dry and leave open to air. Review of the resident's weekly wound documentation, dated 7/20/23 2:02 P.M., showed the following: -Unstageable pressure ulcer to right heel had deteriorated and measured 6.0 cm by 7.0 cm; -Prior week measurement was 5.0 cm x 6.0 cm; -Physician updated; -Continue current plan of care. The resident's wound documentation, dated 7/20/23, did not include any measurements or assessments of the two stage III pressure ulcers to the right and left buttocks as identified on the resident's care plan, dated 6/20/23, and no measurements or assessments of the unstageable pressure ulcer to the left heel. Review of the resident's record showed no documentation staff assessed the resident's pressure ulcers for size, including the length, width and depth, presence or absence of granulation tissue and epithelization as directed by the care plan from 7/21/23 until 8/16/23 when the resident was evaluated by the consultant wound care company. Review of the resident's POS, dated 8/10/23, showed an order for consultant wound care company to evaluate and treat the resident's wounds. Review of the resident's POS, dated 8/14/23, showed to cleanse wound to right and left sacral area (the area of the buttock surrounding the bone at the bottom of the spine) with wound cleanser, apply hydrogel (provides a moist environment and promotes healing) to wound bed, cover with foam dressing and secure daily and as needed (start date 8/14/23). Review of the resident's consultant wound care company note, dated 8/16/23, showed the following: -Wound #1, left buttock, was a chronic, stage III pressure ulcer; measurements are 0.5 cm by 1 cm by 0.2 cm depth. There was a small amount of serosanguinous drainage (a thin watery drainage that contains a small amount of blood) with no odor; -Wound #2, right buttock, was a chronic, stage III pressure ulcer; measurements are 0.8 cm by 0.5 cm by 0.2 cm. There was scant serosanguinous drainage with no odor; -Wound #3, left heel, was an unstageable pressure ulcer; measurements are 3.8 cm by 4 cm by 0.1 cm. There was a small amount of serosanguinous drainage with mild odor; -Wound #4, right heel, was an unstageable pressure ulcer; measurements are 3.5 cm by 4.2 cm by 0.1 cm. There was a small amount of serosanguinous drainage with mild odor; -A skin surgical debridement (the removal of damaged tissue) was completed of the left heel. Post debridement measurements were 3.8 cm by 4 cm by 0.5 cm; -A skin surgical debridement was completed of right heel. Post debridement measurements were 3.5 cm by 4.2 cm by 0.7 cm; -Wound orders: Left and right buttock cleanse wound with saline, use to irrigate or scrub the wound bed. Protect periwound with skin protectant. Apply santyl (removes dead tissue from wounds so they can start to heal) nickel thick to entire wound bed, edge to edge. Apply calcium alginate (highly absorbent antibacterial dressing) to wound base. Self-adherent super absorbent dressing. Change dressing daily and as needed for soiling, saturation or unscheduled removal; -Left and right heel: cleanse wound with saline irrigate or scrub the wound bed. Protect peri wound with skin protectant. Apply santyl nickel thick to entire wound bed edge to edge. Apply bactroban (used to treat skin infections) to wound bed daily. Apply calcium alginate to wound base. Self-adherent super absorbent dressing change dressing daily and as needed for soiling, saturation and unscheduled removal; -Bedside nurse was instructed on proper dressing changes/techniques to enhance wound healing. Review of the resident's POS, dated 8/16/23, showed no documentation the new orders for wound care as ordered by the wound care consultant on 8/16/23 were added to the resident's POS. Review of the resident's Treatment Administration Record (TAR) dated 8/16/23 to 8/23/23, showed the following: -On 8/17/23 through 8/23/23, staff documented they cleansed the wound to right and left sacral area (buttocks) with wound cleanser, applied hydrogel to wound bed, covered with foam dressing and secured daily and as needed (original order dated 8/14/23); -On 8/17/23 through 8/23/23, staff documented they applied skin prep to the left and right heel (original order dated 7/24/23); -There was no documentation to show staff implemented the new orders following the wound care consultation on 8/16/23. (Staff failed to complete the wound treatments as ordered for seven days.) Review of the resident's consultant wound care company note, dated 8/23/23, showed the following: -The resident was seen for evaluation and management of multiple wounds; -Wound #1, left buttock, was a chronic, stage III pressure ulcer and has received a status of not healed. Measurements are 1.0 cm by 1.0 cm by 0.1 cm depth. There was a small amount of serosanguionous drainage which had no odor. The periwound skin was friable (the tissue is pale, unhealthy granulation), shiny and moist; -Wound #2, right buttock, was a chronic, stage III pressure ulcer injury pressure ulcer. Measurements are 0.8 cm by 1 cm by 0.1 cm. There was a small amount of sersanguinous drainage noted which had no odor. The periwound was friable and moist; -Wound #3, left heel, was a chronic, unstageable pressure injury, obscured full-thickness skin and tissue loss pressure ulcer and received a status of not healed. Measurements were 6.0 cm by 5.0 cm by 0.1 cm. There was no drainage and the peri-wound exhibited edema, scarring and erythema. The periwound skin was friable; -Wound #4, right heel, was a chronic, unstageable pressure ulcer obscured full-thickness skin and tissue loss and has received a status of not healed. Measurements are 5.5. cm by 5.0 cm by 0.1 cm. There was a small amount of serosanguinous drainage noted which had a mild odor. Facility staff did not provide wound care for the resident as ordered by the consultant wound care company on 8/16/23 through 8/23/23. The wound to the left heel measured 3.8 cm by 4.0 cm by 0.1 cm depth on 8/16/23. The measurements increased in size to 6.0 cm by 5.0 cm by 0.1 cm. on 8/23/23. The right heel measured 3.5 cm by 4.2 cm by 0.1 cm on 8/16/23. The measurements increased in size to 5.5 cm by 5.0 cm by 0.1 cm on 8/23/23. During an interview on 10/2/23 at 10:26 A.M., the assistant director of nursing said the orders from the consultant wound care company from 8/16/23 were not put on the resident's POS or the TAR. The new wound care orders were not followed. The charge nurse was responsible to transcribe the wound care orders to the residents electronic record when they were received. He/She would expect staff to follow the wound care orders from wound care plus. During an interview on 10/2/23 at 3:25 P.M., the consultant wound care company nurse practitioner said the resident's wounds increased in size from 8/16/23 to 8/23/23. He/She was not aware staff did not complete the dressing changes as ordered during that time frame. The wounds could deteriorate if the dressing changes were not completed as ordered. 2. Review of Resident #7's undated face sheet showed the following: -The resident was readmitted to the facility on [DATE]; -Diagnoses included pressure ulcer of sacral region (the triangle shaped bone located at the bottom of the spine), unspecified stage. Review of the resident's Braden Scale assessment form, dated 8/26/23, showed the following: -Sensory perception - ability to respond meaningfully to pressure-related discomfort: slightly limited; -Moisture - he/she was occasionally moist; -Activity - chair fast, ability to walk severely limited or non-existent; -Mobility - very limited, makes occasional slight changes in body or extremity position; -Friction and Sheer - requires moderate to maximum assist in moving. Complete lifting without sliding against sheets is impossible, frequently slides down in bed or chair; -Score=12, indicating the resident was at high risk for pressure ulcer development. Review of the resident's admission clinical assessment, dated 8/26/23 at 4:30 P.M., showed the following: -The resident had a pressure ulcer present on admission; -Abnormal feet findings indicated allevyn (a soft silicone gel adhesive which minimizes trauma to wound) to bilateral heels. Review of the resident's nurse's note, dated 8/26/23, showed no documentation regarding the resident's wound. Facility staff did not provide any assessments or measurements regarding the pressure ulcer to the sacral region that was present on admission on 8/26/23. Review of the resident's POS dated 8/27/23, showed the following: -Hospice services; -Wet to dry dressing (a saline moistened dressing which is placed in the wound bed) to coccyx, cover wound with abdominal gauze pad dressing, and tape as the resident picks at the wound (start date 8/27/23); -There was no order for allevyn dressing for bilateral heels as listed on the resident's admission assessment. Review of the resident's TAR, dated August 2023, showed the following: -Order for wet to dry dressing to coccyx, cover wound with abdominal gauze pad dressing and tape as the resident picks at the wound, start date 8/27/23. Record review of the resident's significant change MDS, dated [DATE], showed the following: -The resident required extensive assistance of two staff members with bed mobility, transfers, and toilet use; -The resident was dependent of one staff member with locomotion on and off the unit, personal hygiene and bathing; -The resident was always incontinent of bowels; -The resident was at risk for developing pressure ulcers; -The resident had a stage one or more unhealed pressure ulcers; -The resident had one unstageable pressure ulcer, suspected deep tissue injury; -The unstageable pressure ulcer was present upon admission. Review of the resident's care plan, last revised 8/28/23, showed the following: -Skin impairment: readmitted from the hospital with a stage III pressure ulcer and thin yellow slough, 75% and brown slough 25% to saccrococcygeal bone (triangle shaped bone that is found at the bottom of the spine) region. Stage II pressure ulcer to the right buttock and stage II pressure ulcer to left buttock, complicated by immobility and incontinence, inability to retain education or direction due to severe cognitive impairment and inadequate nutrition and hydration; -Avoid friction and shearing forces during transfer and position changes, keep clean and dry as possible, incontinence care every two hours as needed, keep bony prominence's with direct contact with one another with pillows, pads and other foam wedges, keep clean and dry as possible; -Treatment as ordered and monitor for effectiveness. Turn and reposition every two hours while in bed; -Provide incontinence care after each incontinent episode, report any signs of skin breakdown (sore, tender, red or broken areas). Review of the resident's record showed no documentation staff measured the resident's wounds that were present on admission between 8/26/23 and 8/30/23. Review of the resident's initial and weekly wound documentation, dated 8/31/23, showed the following: -Stage III pressure ulcer to coccyx measured 3.8 cm by 2.1 cm by 0.7 cm that was present on admission on 8/26/23; -Slough was present; -Exudate (fluid that leaks out of blood vessels into nearby tissues), scant serosanguinous (a type of wound drainage containing blood and serous (clear or yellow) fluid; -Treatment changed, physician notified and initiated plan of care; -Stage II pressure ulcer to right buttock measured 0.9 cm by 0.9 cm by 0.1 cm that was present on admission on 8/26/23. (Review of the resident's medical record showed no documentation of this area upon readmission on the clinical assessment); -Granulation tissue present (pink or red tissue with shiny, moist appearance); -Exudate: minimal and clear; -Continue plan of care, no change, physician notified. -Stage II pressure ulcer to left buttock measured 1.3 cm by 1.2 cm by 0.1 cm that was present on admission on 8/26/23. (Review of the resident's medical record showed no documentation of this area upon admission on the clinical assessment); -Granulation tissue pink or red tissue with shiny, moist, granular appearance; -Exudate: minimal and clear; -Treatment change, physician notified and initiate plan of care. Review of the resident's physician orders, dated 8/31/23, showed the following: -Cleanse wound to coccyx with wound cleanser, apply santyl (ointment that removes dead tissue from a wound so that it can start to heal) to wound bed, cover with foam dressing and secure daily and as needed (start date 8/31/23); -Cleanse wound to right buttock with wound cleanser, apply medihoney (decreases bacterial growth within the wound) to wound bed, cover with foam dressing and secure daily and as needed (start date 8/31/23); -Cleanse wound to left buttock with wound cleanser, apply medihoney to wound bed, cover with foam dressing and secure daily and as needed (start date 8/31/23). Review of the resident's hospice note, dated 9/6/23 at 10:30 A.M., showed the following: -New ulcers noted to bilateral heels. Skin prep ordered and applied to the resident's feet; -Stage I pressure ulcer to right heel measured 3.0 cm by 2.0 cm; -Stage I pressure ulcer to left heel measured 0.9 cm by 1.0 cm; -Stage I to left outer aspect of the left foot measured 2.0 cm by 1.1 cm; -Sacral spine ulceration, dressing loose/moist, with moderate amount of brown drainage and foul odor. The wound was irregular shaped with yellow slough to the base, periwound was moist and pink. The wound measured 3.2 cm by 3.9 cm. The hospice nurse changed the dressing. Review of the resident's POS, dated 9/6/23, showed to cleanse wound to coccyx with wound cleanser, apply santyl to wound bed, barrier paste to surrounding skin cover with a 4x4 (gauze pad) then ABD pad daily and as needed. Review of the resident's weekly skin assessment, dated 9/7/23 at 11:55 P.M., completed by LPN I, showed the following: -Existing pressure ulcers to bilateral buttocks and coccyx (facility staff did not document any further assessment of these pressure ulcers); -Treatment in place: effective. Review of the resident's TAR for September 2023 showed on 9/7/23 LPN I documented he/she completed the dressing change to the resident's coccyx wound. Review of the resident's hospice wound assessment, dated 9/8/23, showed the following: -Worsening coccyx wound; -Wound tunneling (the wound has progressed to form passageways underneath the surface of the skin) was now noted and the dressing was still in place from 9/6/23 when last changed by the hospice nurse; -The dressing was loose with copious (large amount) brown/yellow drainage, strong odor, irregular shaped and the wound base was reddened with yellow slough; -The periwound (tissue surrounding a wound) area had redness with satellite lesions (a smaller lesion accompanying a main one); -Hospice nurse provided wound care. Coccyx wound dressing saturated with strong odor from 9/6/23. Dressing saturated with tan/yellow drainage, soaking the resident's brief; -LPN I said he/she did not change the dressing yesterday. During an interview on 9/19/23 at 2:15 P.M., the hospice nurse said the following: -The resident was admitted to hospice care on 8/26/23; -The resident had one unstageable pressure ulcer to the coccyx upon admission and the order was for a wet to dry dressing to be changed daily; -He/She changed the resident's coccyx dressing on 9/6/23, dating the dressing after it was completed; -He/She wrote out specific orders for the resident's wound care for LPN I on 9/6/23; -On 9/8/23, he/she made a hospice visit to see the resident in the afternoon. The same dressing was still in place from 9/6/23. The wound had extensive periwound break down (damage to the skin) and the pressure ulcer had become larger with tunneling and more drainage present. During an interview on 9/20/23 at 1:08 P.M., LPN I said the following: He/She worked as the charge nurse on 9/6/23, 9/7/23, and 9/8/23; -He/She was responsible to complete Resident #7's dressing change; -He/She may have missed the resident's dressing change, because of communication issues with the hospice nurse. LPN I thought the hospice nurse completed the dressing change on 9/7/23; -On occasion, LPN I documented that wound care was completed assuming the hospice nurse completed it, but he/she actually did not complete the dressing change; -He/She should follow up to make sure the hospice nurse provided the dressing change, then document the hospice nurse changed the dressing (under the notes section); -He/She had found the resident without a dressing in place on occasion. The CNAs should report if the dressing was off so LPN I could replace it; -He/She did not measure wounds; -The wound nurse measured the wounds. During an interview on 9/20/23 at 3:15 P.M. the resident's nurse practitioner said he/she would expect staff to provide wound care as ordered. The facility did notify him/her the resident's coccyx wound had gotten larger with increased drainage. 3. During an interview on 9/20/23 at 2:00 P.M., LPN C said the following: -The charge nurses did not measure pressure ulcers or wounds upon admission or with weekly skin assessments; -The wound nurse measured the wounds when he/she worked; -The nursing staff notified the physician if there were concerns with a wound. During an interview on 9/20/23 at 9:45 A.M., LPN A/acting wound nurse said the following: -He/She was one of the charge nurses in the facility, but was currently acting as the wound nurse; -He/She worked weekly on Thursdays; -If a resident had a new wound, he/she followed and assessed the wounds for those residents; -The charge nurses did their own weekly skin assessments on each resident and were to obtain any orders if there were concerns with the wound status or new wounds were identified; -He/She completed an assessment of Resident #7's skin on 8/31/23 (the resident was admitted on [DATE] with pressure ulcers present); -He/She went by what another nurse told him/her; that the resident had three wounds on the coccyx at admission; -There was nothing identified in the resident's nurse's notes or admission assessment except for a coccyx wound. During an interview on 9/20/23 at 3:45 P.M. and 9/28/23 at 10:52 A.M. the Director of Nursing (DON) said the following -She expected the admitting nurse to assess the resident's skin and give a description of all pressure ulcers, but not necessarily measure the wounds; -The charge nurses did the weekly skin assessments, but did not measure any wounds; -She wanted the nurse who measured the wounds to be the same nurse; one consistent staff member; -The wound nurse would measure any wounds when he/she was scheduled to work next at the facility; -The current wound nurse was on medical leave, so a floor nurse (LPN A) was measuring the wounds weekly on Thursdays; -She (the DON) filled in as the wound nurse for a couple weeks in August 2023, but had to be off and wound assessments did not get completed during that time; -The consultant wound care company typically followed residents with a stage III pressure ulcer or a wound the facility just couldn't get to heal; -She would expect weekly skin assessments to be completed on all residents; -She would expect staff to complete dressing changes as ordered. If not completed as ordered, the wounds could deteriorate or worsen. During an interview on 9/20/23 at 3:35 P.M., the administrator said he expected staff to follow physician's orders regarding wound care and dressing changes. MO224182 MO224419

Based on interview and record review, the facility failed to ensure two residents (Residents #1 and #12), in a sample of 16 residents, were free from significant medication errors. Staff failed to correctly transcribe an admission order for metoprolol tartrate (a medication used to treat high blood pressure), writing instead the order as haloperidol (an antipsychotic medication used to treat mental health disorders) for Resident #1. Staff administered the incorrect medication, haloperidol, to the resident for 97 days, with no doses of metoprolol tartrate administered. As a result of the error, the resident experienced difficulty swallowing, excessive drooling and pocketing food, lethargy (drowsiness and an unusual lack of energy and mental alertness), and slurred speech which required a hospital transfer to evaluate his/her condition. Additionally, staff failed to correctly transcribe an order for Ozempic (a medication used to treat diabetes) correctly, which resulted in Resident #12 receiving two additional doses in error when the medication was to be administered weekly and was administered daily. The facility census was 87. The administrator was notified on 4/25/23, at 4:20 P.M., of an Immediate Jeopardy (IJ), which began on 1/6/23. The IJ was removed on 4/25/23 as confirmed by the surveyor's on-site verification. On 5/1/23, at 2:23 P.M., the administrator reported via email, the facility did not have a policy for following physician orders or transcribing physician orders. Review of the facility policy, Medication Administration Guidelines, dated March 2015, showed the following: -It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; -Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; -The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician orders, giving the individual does to the proper resident, and promptly recording the information; -If there is doubt concerning the administering of medications, the physician's order must be verified before the medication is administered; - A current drug reference is available at each nurse's station. Review of the online reference Drugs.com showed the following regarding haloperidol (Haldol): -Haldol is an antipsychotic medication that is used to treat schizophrenia (a mental health disorder in which people may interpret reality abnormally and may result in some combination of hallucinations, delusions, paranoia and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling); -The average dose of this medication for oral forms for mental conditions for older adults at first is 0.5 milligrams (mg) to 2 mgs, two or three times a day; the physician may increase the dose if needed, however the dose is not usually more than 100 mgs a day; -Side effects of Haldol can include difficulty with speaking or swallowing, dizziness, and confusion and unusual tiredness or weakness. 1. Review of Resident #1's face sheet showed the following: -admitted [DATE] at 1:10 P.M.; -Diagnoses include paranoid schizophrenia and essential primary hypertension (high blood pressure). Review of the resident's order summary report, dated 1/5/23, from a receiving facility, showed the following medication orders: -Metoprolol Tartrate 50 mg by mouth two times a day related to essential hypertension; -No order noted for haloperidol 50 mg twice a day. Review of the resident's January 2023 physician order sheets (POS) showed an order for haloperidol 10 mg twice a day with a start date of 1/6/23 and haloperidol 20 mg, 2 tablets, twice a day with a start date of 1/6/23 for a total of haloperidol 50 mg twice a day. Review of the resident's January 2023 Medication Administration Record (MAR) showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 1/8/23 through 1/20/23. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/20/23, showed the resident was cognitively intact. Daily antipsychotic given seven of seven days during observation period. Review of the resident's pharmacy medication review, dated 1/20/23, showed based upon the information available, at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's January 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 1/21/23 through 1/22/23. Review of the resident's history and physical, dated 1/22/23 showed the following: -History/Medication List: reviewed, updated and signed in POS or computer record in nursing home electronic medical record (EMR); -Follow-up on any medical complications related to current psychiatric medications and the patient is also followed by psychiatry; -He/She will need psychiatry to continue following up since he/she is on high doses of Haldol which has been routine for him/her. Review of the resident's January 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 1/23/23 through 1/31/23. Review of the resident's February 2023 POS showed an order for haloperidol 10 mg twice a day with a start date of 1/6/23 and haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23 for a total of haloperidol 50 mg twice a day. Review of the resident's February 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 2/1/23 through 2/9/23. Review of the resident's interdisciplinary team (IDT) meeting progress note on 2/9/23 showed the resident is on a significant dose of Haldol, no overt signs or symptoms of over sedation or adverse effects. Review of the resident's February 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 2/10/23 through 2/14/23. Review of the resident's pharmacy medication review, dated 2/14/23, showed based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's February 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 2/15/23 through 2/28/23. Review of the resident's March 2023 POS showed an order for Haloperidol 10 mg twice a day with a start date of 1/6/23 and Haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23 for a total of Haloperidol 50 mg twice a day. Review of the resident's March 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 3/1/23 through 3/21/23. Review of the resident's pharmacy medication review, dated 3/21/23, showed based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's 3/21/23 physician progress note showed the following: -History/Medication list: reviewed, updated and signed in POS or computer record in nursing home EHR (electronic health record); -Resident has underlying schizophrenia, there have been no behavioral reports since he/she has been at the facility; -He/She does remain on Seroquel (quetiapine) and Haldol as well as Depakote (a medication used to treat certain psychiatric conditions). Review of the resident's March 2023 MAR showed staff documented administering Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 3/22/23 through 3/31/23. Review of the resident's April 2023 POS showed the following: -Haloperidol 10 mg twice a day with a start date of 1/6/23; -Haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23. Review of the resident's April 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 4/1/23 through 4/6/23. Review of the resident's IDT progress noted, dated 4/6/23, showed the resident is more lethargic, eating less, and spends most of the time in bed. Review of the resident's April 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 4/7/23 through 4/11/23. Review of the resident's nursing progress note, dated 4/11/23, showed the resident appeared lethargic; slow to respond. Blood pressure 87/68 (normal blood pressure range -systolic: less than 120 mm Hg diastolic: less than 80 mm Hg) and pulse was 62 (normal range between 60-100 beats per minute) beats per minute. Contacted psych for medication evaluation related to increased drowsiness and lethargy. Review of the resident's April 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 4/12/23 through 4/15/23. Review of the resident's nursing progress note, dated 4/15/23, showed the following: -Medication Error Documentation; -On 4/14/2023 at approximately 10:45 P.M., the nurse received in report that the resident said he/she has been very tired and believes he/she is being over medicated. Nurse then updated another nurse it was probably the Haldol resident is on. Nurse had passed medications before on evenings and remembered the high dosage. Resident has been taking 100 mg a day since arrival. Upon investigation, nurses both found the resident never had an order for Haldol but had another order for metoprolol for the same dosage; -In the resident chart, the resident never had an order for metoprolol in which the resident should have been on. Nurses did note no order had been put in for metoprolol tartrate. The medications on the paper showed they were verified with the medical director (MD) (also the resident's physician) on the day of admission on the paperwork provided by a different nurse than the nurse putting in the Haldol order; -Nurses both noted that resident never had the order for Haldol. Nurses called the Director of Nursing (DON) and asked for advice. Nurses then saw that the resident did have a medication error and nursing has been giving this medication for three months now; -Nurses called the on call physician regarding the medication error. On call Nurse Practitioner (NP) said that was too much Haldol for an elderly person to receive every day; nursing is to monitor vital signs every shift and stop medications immediately; -Nurse asked if the facility should taper the dosage; our DON would like a tapering of the dosage; -NP said, No, the resident is not even supposed to be on that medication and there was too much psychiatric medication he/she was on anyway. Hold the medication and clarify the order as soon as the resident's physician gets in his office on Monday. Review of the resident's April 2023 POS showed the following: -Haloperidol 10 mg twice a day with a start date of 1/6/23 and a discontinue date of 4/15/23; -Haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23 and a discontinue date of 4/15/23. Review of the resident's pharmacy medication review, dated 4/17/23, showed based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's progress notes, dated 4/21/23 at 2:22 P.M., showed the nurse was informed by the speech therapist, the assistant director of nursing (ADON), as well as certified nursing assistants (CNAs) this shift, that the resident has had a major decline in condition as of today. Resident was lethargic, unable to swallow, pocketing food, has excessive saliva and is unable to hold self up in his/her wheelchair. Assessment of the resident showed he/she was not responding well and was lethargic. Message left with the group providing medical services for the facility. Review of the resident's progress note, dated 4/21/23 at 4:09 P.M., showed the resident's physician was made aware of the medication error this shift. After giving an update on the resident's current well-being, the physician sent the resident to the emergency room for evaluation and treatment related to his/her change in condition. Resident has been slurring words more than normal. Resident having trouble with swallowing saliva and even voiced difficulties. Resident was noticed pocketing lunch this shift. Review of the resident's hospital emergency room notes shows the resident presented with slurred speech and weakness. Review of the resident's progress note, dated 4/23/23 at 1:06 A.M., showed the resident remains in a trance state this shift. Resident will look at staff members and tried to mumble words. Resident was seen by emergency room (ER) staff yesterday. This is not the resident's normal. Resident is able to talk clearly. Resident is now declining. Resident has not been asleep so far this shift. Nursing noted his/her blood pressure (BP) being 106/68, CNAs have been updating nurse worrying about the resident. Physician is made aware. Psychiatric NP was here this morning and said if the resident continues getting worse, she will call the physician and ask for another hospital evaluation. Review of the resident's progress note, date 4/23/23 at 7:18 A.M., showed nurse giving report and nurses went to check on resident. Resident is now alert and oriented to self. Resident still tries to talk to staff but only comes in mumbles. Resident will be closely monitored at this time. Nurse contacted resident's physician regarding resident and condition. Resident has a new order for Haldol 10 mg twice a day for five days and then decrease to Haldol to 10 mg daily. Review of the resident's April 2023 POS showed the following: -Haloperidol 10 mg twice a day from 4/23/23 through 4/27/23; -Haloperidol 10 mg daily with a start date of 4/28/23. During an interview on 4/25/23, at 12:06 P.M., the resident said the following: -Staff gave him/her quite a bit of Haldol but he/she doesn't remember for how long; -The Haldol was discontinued after staff found out he/she was taking too much of it; -He/She does not think he/she has taken Haldol in the past; -Quite a few of the nurses gave him/her the wrong medication, he/she thinks it was given for about three months or so; -He/She was feeling better now and was not as sleepy since not taking the Haldol. During an interview on 4/25/23, at 1:07 P.M., Licensed Practical Nurse (LPN) E said the following: -The resident was noted to have excessive saliva and was pocketing food, head leaning to the side that was not his/her normal baseline and was not remembering specific dates; -He/She was aware of a medication error related to the resident receiving Haldol that he/she was not supposed to ever get; -He/She had not seen a Haldol dose of 50 mg and does not specifically remember seeing the Haldol order; -He/She would notify a physician if he/she had a question about a medication, but did not question the Haldol order for the resident. During an interview on 4/25/23, at 1:16 P.M. and 1:45 P.M., LPN D said the following: -The resident was noted to be very lethargic and was sent to the emergency room due to a change in condition at the change of shift on April 15th; -The resident had a transcription error that resulted in a medication error for Haldol; -He/She was unsure how the error happened; -He/She did notice the resident had a high dose of Haldol and reported it to the Director of Nurses (DON) but he/she wasn't sure when he/she had reported it; -He/She did admit the resident and verified the orders against pending orders; -He/She did not feel comfortable putting the Haldol order in and told the DON; -He/She called the nurse practitioner with psychiatry to verify the medication and was told the resident was not his/her patient and to fax the face sheet and Continuity of Care (CCD) document to psychiatry; -The CCD and face sheet was faxed to psychiatry; -He/She did not feel comfortable about the Haldol order from day one but did not approach the DON again. During an interview on 4/25/23, at 1:35 P.M., LPN A said the following: -When a resident is admitted to the facility, after hospitalization or new admission, orders are compared and put into the computer as pending; -The admitting nurse will check the pending orders for comparison, activate and send to the pharmacy; -He/She put in the pending orders for the resident; -New admission medication should be checked by two nurses; -He/She made a transcription error and entered Haloperidol 50 mg twice a day and it should have been metoprolol tartrate 50 mg twice a day; -He/She put the orders in the computer; -He/She was not sure who the admitting nurse was; -A normal dose of Haldol is a lot lower, more like 5 mg, it triggered in his/her mind to verify the order but he/she did not go back and check the order; -There should have been a Registered Nurse (RN) that did an audit of the orders and should have caught the error; -He/She was not sure if the audit was done; -There are a whole lot of fail safes or double checks that are supposed to be put in place to prevent errors, like two nurses checking the admission medications, an RN audit, physician reviews and pharmacy reviews; they all failed. During an interview on 4/25/23, at 5:22 P.M., LPN H said the following: -He/She was the second nurse the day the resident was admitted ; -He/She did not recall doing any of the orders and did not send anything to pharmacy; -He/She did not recall any specifics about the resident's Haldol order. During an interview on 4/26/23, at 9:58 A.M., LPN I said the following: -He/She was made aware that the resident was more lethargic during report on 4/14/23; -He/She, along with Registered Nurse (RN) K, investigated the resident's medications and noted there was not supposed to be an order for Haldol, but should have been Metoprolol. During an interview on 4/25/23, at 6:05 P.M., RN K said the following: -Haldol dosage is usually less than 10 mg; -On 4/15/23 he/she first noticed the Haldol dose for the resident being a large dose; -He/She, along with LPN I, investigated the resident's medication orders and found a medication error for the resident's Haldol. During interview on 4/26/23, at 11:23 A.M., RN F said the following: -He/She was made aware of the Haldol error for the resident on 4/25/23; -A typical dose of Haldol should be 20-30 mg twice a day and feels like 50 mg twice a day would be a large dose; if he/she found that order, he/she would question it with the DON. During interview on 4/26/23, at 10:39 A.M., the Quality Assurance Nurse said the following: -The IDT (interdisciplinary team) progress notes for 2/6/23 identified the resident was on a significant does of Haldol; -She did not notify the physician due to the fact the resident was exhibiting paranoid symptoms and was not showing adverse effects from the Haldol dose; -The dose appeared reasonable to her due to the residents' behavior; -For some residents 100 mg a day of Haldol is a normal dose; -She knew that ultimately the physician did not have any concerns with the dose due to the physician not changing anything with the medications; -She had not talked to the physician about the Haldol orders. During interview on 4/25/23, at 4:34 P.M., the consultant pharmacist said the following: -She completed the resident's pharmacy reviews in January, February, March and the last review of the resident's medications was on 4/17/23; that would have included the Haldol order; -She had not asked for a gradual dose reduction yet due to the resident being a new resident; -Haldol 50 mg twice a day is considered a high dose, but not over the maximum dose allowed. 2. Review of Resident #12's Continuity of Care (CCD) document showed a diagnosis of diabetes (a medical condition with too much sugar in the blood system). Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderately impaired cognition. Review of the resident's April 2023 POS showed an order for Ozempic (a once-weekly injection given to residents with type 2 diabetes) 0.25 mg subcutaneous injection daily with an order start date of 4/20/23. Review of the resident's April 2023 MAR showed staff documented administering the following: -On 4/22/23, 6:30 A.M., Ozempic 0.25 mg by RN F; -On 4/23/23, 6:30 A.M., Ozempic 0.25 mg by LPN J; -On 4/24/23, 6:30 A.M., Ozempic 0.25 mg by LPN J. Review of the resident's April 2023 POS showed the following: -Ozempic 0.25 mg subcutaneous injection daily with an order start date of 4/20/23 and a discontinue date of 4/25/23; -Ozempic 0.25 mg subcutaneous injection weekly on Monday with an order start date of 4/25/23. During an interview on 4/26/23 at 12:00 P.M., the resident said the following: -He/She was started on a new medication for diabetes; -He/She thinks the medication is Ozempic; -He/She got a shot two mornings in a row by LPN J. During an interview on 4/26/23, at 12:10 P.M., LPN A said the following: -He/She took the Ozempic order off for the resident and marked the weekly administration; -He/She must have hit a wrong button and the weekly order did not get saved; -He/She made a mistake. During an interview on 4/26/23, at 2:00 P.M., LPN J said the following: -He/She recalls giving the resident Ozempic on 4/23/23 and 4/24/23; -He/She had seen Ozempic orders for daily and weekly dosing so he/she did not question the order; -He/She thinks Ozempic was generally given weekly and he/she should have questioned the order. During an interview on 4/26/23, at 11:23 A.M., RN F said the following: -A few days ago he/she found a transcription error for the resident, where Ozempic was entered daily and should have been weekly; -He/She did not make the DON aware of the error and should have; he/she just corrected it. 3. During an interview on 4/26/23, at 12:50 P.M., the medical director/physician for Resident #1 and Resident #12 said the following: -He was aware of the medication errors for both residents; -He felt like the Haldol dose for Resident #1 was being monitored by psychiatry and was aware the dose was a high dose; -He felt like the high dose of Haldol should have been addressed by nursing, pharmacy, psychiatry and himself but it was not; -He was aware Resident #1 had a slight urinary tract infection (UTI) that was diagnosed at the resident's recent emergency room visit; -He felt the symptoms Resident #1 exhibited when he sent the resident to the emergency room were related to his/her increased dose of Haldol and could potentially been a little bit of both, the UTI and Haldol; -Resident #12 did receive two extra doses of Ozempic, but the dose was small enough to not cause negative side effects; -He would expect physician orders to be followed as written. During an interview on 4/26/23, at 11:15 A.M. and 2:04 P.M., the DON said the following: -A transcription error resulted in Resident #1 receiving Haldol 50 mg twice a day since 1/6/23; -Resident #1 was supposed to receive metoprolol tartrate 50 mg twice a day and was transcribed as haloperidol 50 mg twice a day; -She was not made aware of staff concerns related to haloperidol for Resident #1; -Haloperidol 50 mg twice a day was a big dose; -Long Term Psych Management (LTPM) was sent an email regarding the resident's Haldol dose on 4/6/23, related to lethargy and eating less, with no response to the email, but LTPM came in on 4/20/23; -She was made aware of another transcription error that resulted in a medication error for Resident #12's Ozempic order; -She was not sure how the transcription errors occurred, there are fail safes put in place between nursing, pharmacy, physician, nurse practitioner and herself; -The fail safes failed with Resident #1 and Resident #12. During an interview on 4/25/23 at 2:17 P.M., and 4/26/23 at 1:30 P.M., the administrator said the following: -He was made aware of the medication error for Resident #1, and that it had something to do with Haldol; -The Haldol order was too high or not supposed to be given at all; -He was aware the resident was sent to the emergency room after being lethargic and has recovered since the medication had been removed; -He would have expected the pharmacist to catch the error; -He was made aware of an additional medication error for Resident #12 that was discovered on 4/26/23 when an order was put in the computer incorrectly. 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 violations(s).

Based on interview and record review, the facility failed to provide one resident (Resident #1), who had diagnosis of schizophrenia (mental illness) and a history of elopement and exit seeking behaviors from the facility, with sufficient supervision and monitoring to ensure the resident did not leave the facility grounds without staff knowledge. Staff said they last saw the resident on 12/2/22 at approximately 9:45 P.M. in the resident smoking area outside the facility. Housekeeper A, who was responsible to supervise the residents' smoke break, did not ensure the resident returned inside the facility on 12/2/22 after the 9:30 P.M. scheduled smoke time. The resident said he/she walked away from the facility on 12/2/22 during the 9:30 P.M. smoke break. Facility staff identified the resident was missing on 12/2/22 at approximately 10:30 P.M. Staff contacted the police who located the resident on 12/2/22 at approximately 11:30 P.M. walking down a busy four lane divided highway. The facility census was 92. The administrator was notified of the Immediate Jeopardy (IJ) on 12/12/22 at 3:46 P.M. which began on 12/2/22. The IJ was removed on 12/13/22 as confirmed by surveyor onsite verification. Review of the facility's undated Smoking Policy showed the following: -Residents are supervised at all times when smoking; -An enclosed courtyard is available for residents to smoke during good weather. A staff person will supervise them; -Smoking times were 8:30 A.M. supervised by housekeeping staff, 11:00 A.M. supervised by activity staff, 1:30 P.M. supervised by dietary staff, 3:30 P.M. supervised by nursing staff, 7:00 P.M. supervised by the floor technician, and 10:00 P.M. supervised by night shift laundry staff. 1. Review of Resident #1's face sheet showed the following: -Original admitted [DATE]; -Diagnoses included anxiety, seizures, altered mental status, schizophrenia, major depressive disorder, and stroke. Review of the resident's care plan, dated 8/20/22, showed the following: -The resident had impaired decision making related to schizophrenia; -Calm the resident if signs of distress develop during the decision making process; -Determine if decisions made by the resident endanger the resident or others; -Encourage the resident to verbalize feelings, concerns, and fears, and clarify misconceptions; -Give objective feedback when inappropriate decisions are made; -Set expectations and limits; -Support and reassure the resident in new situations; -The resident was a supervised smoker. He/She would smoke in a safe environment with supervision. Review of the resident's care plan, updated 10/11/22, showed the following: -On 10/11/22 at 1:23 A.M. the Certified Nurse Aide (CNA) alerted the nurse the resident was not on the special care unit and the exit door at the end of the hall was alarming; -The facility contacted the police who assisted in searching for the resident; -On 10/11/22 the resident was located at the church next to the facility; -Assess the resident for signs of restlessness, anger, or distress, and report to the physician; -The resident would reside on the secured unit with monitoring of whereabouts; -Possible evaluation for discharge to a more appropriate and secure environment. Review of the resident's smoking assessment, dated 10/30/22, showed the resident required supervision from staff while smoking. Review of the resident's Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 11/10/22, showed the following: -Diagnoses included non-traumatic brain dysfunction, stroke, seizure disorder, and schizophrenia; -Cognition was intact; -Independent with activities of daily living. Review of the resident's elopement risk assessment, dated 11/22/22, showed the resident was at high risk for elopement. Review of the facility's undated investigation showed the following: -Elopement 12/2/22; -The resident managed to escape the facility and was found by police walking down the road; -Staff realized the resident was missing right after change of shift (2nd to 3rd shift) and they started elopement procedures; -The resident was last seen during resident supervised smoking (approximately 9:45 P.M.) by Housekeeper A; -Housekeeper A did not recall seeing the resident after smoking due to another resident causing a disturbance during the break; -Summary: During or after resident supervised smoking, the resident managed to get away from supervision unnoticed. The resident claims to have left during smoking time. Review of a written statement from Housekeeper A, obtained by the facility, dated 12/6/22 at 9:30 P.M. showed the following: -Housekeeper A took the smokers out for smoke break; -Housekeeper A did not remember if Resident #1 came back inside. During an interview on 12/12/22 at 1:35 P.M. Housekeeper A said he/she took residents out to smoke like he/she usually did on 12/2/22 around 9:30 P.M. There were about seven or eight residents, including Resident #1, outside during the smoke break. Housekeeper A had to assist some of the residents in wheelchairs over the threshold of the door and then pass out cigarettes and ensure residents who needed smoking vests had them on. Housekeeper A also had to assist residents back into the facility as they finished smoking. Resident #1 would have had plenty of time to walk off undetected while Housekeeper A was assisting others. Housekeeper A was not aware Resident #1 was at risk for elopement. Housekeeper A did not recall Resident #1 coming back inside after the smoke break. Housekeeper A said he/she should have double checked, but got busy with something else and forgot. Typically, Housekeeper A would watch the residents walk back to the unit and let themselves in through the unit doors which did not require a code. Review of a written statement from CNA B, obtained by the facility and dated 12/8/22 at 3:44 P.M., showed the following: -Around 9:30 P.M., Housekeeper A came back (to the special care unit) to clean and took Resident #1 out to smoke; -CNA B assisted Resident #1's roommate at approximately 10:15 P.M. While assisting the roommate, CNA B heard the toilet and figured Resident #1 was in the bathroom. CNA B did not open the bathroom door due to privacy; -CNA B gave report to the oncoming aide and left. During an interview on 12/12/22 at 3:00 P.M. CNA B said he/she saw Housekeeper A take Resident #1 off the unit to go out and smoke about 9:45 P.M. CNA B never saw the resident come back to the unit. CNA B assisted the resident's roommate about 10:15 P.M. and could hear the toilet running and assumed Resident #1 was in the bathroom. CNA B did not open the door to the bathroom to verify the resident was in the bathroom. CNA C arrived about 10:20 P.M. CNA B gave report and left. CNA B got a call about 11:00 P.M. from staff saying the resident was missing. The last time CNA B saw the resident was when Housekeeper A had taken him/her outside to smoke at 9:45 P.M. CNA B said he/she should have gone back to check to ensure Resident #1 was actually back on the unit, but didn't. CNA B felt there should be better communication between the aides and the staff who supervise the smokers when they take residents off the unit and when they bring them back. It would be nice to know when the residents leave the unit and when they come back because the staff on the unit don't always see this happen if they are in a room with another resident. During an interview on 12/12/22 at 1:30 P.M. CNA C said he/she arrived at the facility around 10:20 P.M. on 12/2/22. The evening shift aides told CNA C they had just done rounds and everything was fine. CNA C noticed Resident #1's room door was open, which was unusual, about 10:30 P.M. CNA C looked and did not see the resident in his/her room or anywhere else on the unit. CNA C alerted the charge nurse who looked for the resident off the unit and did not find him/her. The charge nurse contacted the off going aide staff to find out when they had last seen the resident and contacted the police. The police located the resident and returned him/her to the facility around 11:40 P.M. The resident told CNA C he/she walked off during the smoke break. The resident was calm at that time, but it appeared he/she had been crying. During an interview on 12/12/22 at 3:45 P.M. Registered Nurse (RN) D said Resident #1 went out for a smoke break on 12/2/22 around 9:30 P.M. After shift change, CNA C reported the resident was missing. RN D notified the administrator and Director of Nursing (DON) and called 911. The police located the resident walking down the highway. It was typically housekeeping and dietary staff that took the residents to smoke. RN D said all residents who required supervision for smoking should be monitored closely, regardless of their elopement risk, during smoke times to ensure everyone who goes outside comes back in to the facility. During an interview on 12/12/22 at 1:18 P.M. the resident said he/she walked away during the smoke break. The resident did not want to be in this facility or any facility. Housekeeper A was outside with the resident during the smoke break and must not have seen him/her walk off. The resident said he/she walked down to the highway, but did not remember how far he/she walked. The police picked the resident up and returned him/her to the facility. The resident said he/she did not have a plan in place when he/she left. The resident just wanted to get away from the facility. During an interview on 12/27/22 at 3:30 P.M. police department staff said the call log showed officers picked up the resident on 12/2/22 who was walking north bound along the highway approximately a half mile away from the facility. Review of www.wunderground.com showed the weather on 12/2/22 at 11:00 P.M. in the town the facility is located the temperature was 56 degrees Fahrenheit and there was no precipitation. The sun set at 5:11 P.M. The sky was overcast with low visibility. Observation on 12/12/22 at 4:30 P.M. showed the highway where the resident was located was a high traffic, four lane, divided highway. The speed limit was 60 miles per hour. There was a grassy slope with a slight decline that led to the highway, approximately an eighth of a mile from the facility. Observation on 12/12/22 at 1:50 P.M. showed dietary staff E was outside with residents during the scheduled smoke times. During an interview on 12/12/22 at 1:50 P.M. dietary staff E said he/she was not aware of which residents were at risk for elopement. During an interview on 12/12/22 at 3:40 P.M. the DON said anyone from the special care unit should be considered at risk for elopement. The DON expected staff who took residents off the unit to escort them back to the unit and they should also communicate with staff on the unit when leaving with residents and upon returning them to the unit. The DON expected staff to lay eyes on the residents during rounds to ensure there whereabouts. It was most likely that Resident #1 walked off during the smoke break undetected by staff. Police did locate the resident walking down the highway and returned him/her to the facility. During an interview on 12/12/22 at 12:40 P.M. and 3:10 P.M. the administrator said the resident went out for smoke break on 12/2/22 at 9:30 P.M. with Housekeeper A. There was another resident causing a disturbance about wanting to be an unsupervised smoker. Resident #1 said he/she snuck away during the smoke break. Staff realized the resident was missing at shift change between second and third shifts (10:30 P.M.). Staff contacted the police who found the resident walking along the highway, and returned the resident to the facility before midnight. Housekeeping and dietary staff usually supervised the resident's smoking as not to pull nursing staff away from their duties. The administrator expected any staff supervising residents' smoking to monitor them closely and ensure the residents come back inside the facility. The administrator figured everyone knew Resident #1 was at risk for elopement because of his/her history of elopement. The administrator expected Housekeeper A to ensure Resident #1 came back inside and expected Housekeeper A to walk with the resident back to the special care unit. The administrator said staff who supervise smoking should communicate with the staff working on the special care unit when they take residents off the unit and when they bring them back. Staff should also visually see residents when conducting rounds. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO210789

Based on interview and record review, the facility failed to provide one resident (Resident #1) who had a diagnosis of schizophrenia and a history of elopement and exit seeking behaviors with sufficient supervision and monitoring to ensure the resident did not exit the facility without staff knowledge. Staff left the resident's secured unit unattended for approximately 10 minutes, during which time the resident exited the facility through a delayed egress door just before midnight. The resident was not located until he/she called his/her family member over seven hours after leaving the facility. A sample of four residents was selected for review. The facility census was 84. On 10/19/22 at 4:00 P.M. the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 10/11/22. The facility took disciplinary action with the staff member who left the unit unattended. Facility staff conducted an audit of all residents' elopement risk assessments to ensure they were accurate. The facility began in-servicing all staff on the expectation not to leave the special care unit, or any unit in the facility, unattended, as well as the facility's elopement policy and procedure. The facility continued to in-service staff on 10/13/22 and 10/14/22. The IJ was removed and corrected on 10/14/22. During an interview on 10/19/22 at 1:55 P.M. the administrator said there was no written policy regarding staff not leaving the special care unit unattended. Review of the facility's undated Elopement Procedure Policy showed the following: -When an alarm sounds or a resident is suspected of eloping, alert the charge nurse at the 100-200 nurse's station to page Code White; -Any available administrative staff exit the building to check the perimeter of the building. Search the streets, the church next door, the cottages, the high school, and the neighborhoods across the highway; -The 100-200 charge nurse does a head count on his/her floor and stands by to be alerted of the other nurses' head counts; -The 100 hall Certified Nurse Aide (CNA) and 200 hall CNA complete a head count of all residents on those halls and report the number of residents to the 100-200 unit charge nurse; -The Certified Medication Technician (CMT) or nurse passing medications will check the shower room and copy room, hallway to employee smoke area, and count any residents in those areas. Report the head count to the 100-200 unit charge nurse; -The 300 hall charge nurse will do a head count on the upper 300 hall, check supply room, physical therapy, report the head count to the 100-200 unit charge nurse; -The 300 upper hall CNA checks the beauty shop, activity room, resident smoking area; report the head count to the 100-200 unit charge nurse; -The 300 lower hall CNA checks the shower rooms and does a head count for the lower 300 hall; report the head count to the 100-200 unit charge nurse; -The 400 hall (secured unit) CNA checks the unit for residents; report the head count to the 100-200 unit charge nurse. 1. Review of Resident #1's face sheet showed the following: -Original admitted [DATE]; -Diagnoses included anxiety, seizures, altered mental status, schizophrenia, major depressive disorder, and stroke. Review of the resident's elopement risk assessment, dated 8/16/22, showed the resident was not at risk for wandering or elopement. Review of the resident's care plan, dated 8/20/22, showed the following: -The resident had impaired decision making related to schizophrenia; -Calm the resident if signs of distress develop during the decision making process; -Determine if decisions made by the resident endanger the resident or others; -Encourage the resident to verbalize feelings, concerns, and fears, and clarify misconceptions; -Give objective feedback when inappropriate decisions are made; -Set expectations and limits; -Support and reassure the resident in new situations. Review of the resident's nurse's notes showed the following: -On 10/3/22 at 4:00 A.M., the resident left the secured unit by holding the door until it opened and went right out the smoking door, which is just outside the secured unit. Staff was immediately behind the resident, but could not get the resident to come back in. The resident was very confrontational, speaking in a very angry voice. The resident said he/she was sick of this place and was leaving. The resident had a packed backpack with him/her. The resident stated he/she would rather go to the hospital than be in the facility. After about 15 minutes the resident came back to the secured unit and, slammed open the unit door and slammed his/her room door shut; -On 10/3/22 at 6:22 A.M. the resident sat in a recliner and was tearful, stating he/she wanted to go live with his/her significant other in his/her [NAME]. Review of the resident's plan of care, dated 8/20/22, showed facility staff did not update the resident's plan of care or reassess the resident's risk of elopement after the incident on 10/3/22. Review of the resident's nurse's notes showed the following: -On 10/11/22 at 1:23 A.M. the Certified Nurse Aide (CNA) came to the nurse and said the resident was not on the secured unit and the end of the hall door alarm was going off. Elopement procedures initiated. Room to room searches and facility grounds being searched. Staff searched properties around the area. The police, administrator, and DON were notified. Information requested by the police was given to them. The resident's family member was notified. Instructed the family member to call the facility if he/she heard from the resident; -On 10/11/22 at 7:40 A.M. the resident was located in the church south of the facility. The family and police were notified. The administrator was with the resident and tried to get him/her to return to the facility. The resident's power of attorney was in route to the site. Review of the facility's undated investigation showed the following: -Elopement on 10/11/22; -The resident exited the building through the 400 hall exit door, setting off the delayed egress door alarm; -The resident went through the courtyard gate and to the church next door and entered the building; -The resident fell asleep until the following morning; -The resident called his/her family. The family member contacted the facility. Facility staff found the resident walking around the school (connected to the church); -The administrator and the staffing coordinator tried to get the resident to return to the facility, but the resident refused; -The administrator sat with the resident until a family member showed up; -The resident refused to return to the facility and called 911; -The police arrived and the resident went to the hospital behavioral unit rather than returning to the facility; -Based on interviews and statements it was established the resident was able to leave the unit because Nurse Aide (NA) L stepped off the unit for just a minute to grab a personal item without notifying the nurse and did not get coverage; -NA L did not get back to the unit to see the resident go out the door but NA L did respond to the alarm; -The resident was able to hide to avoid the initial search outside because of black clothing; -Based on evaluation, it took the resident less than three minutes to get to the far side of the church after initially hiding; -The church is normally locked at night, which kept the staff from attempting to check inside; -The resident called his/her family as the church opened and was found as he/she came out of the front of the building; -Search of facility grounds and surrounding areas did not turn up anything, because the resident was inside the church; -Disciplinary action was taken on NA L for not following proper procedure. During an interview on 10/19/22 at 10:27 A.M., Resident #1's family member said the resident had recurrent delusions and could be very convincing. The resident did not want to be in the facility and was transferred to this facility after eloping from the previous facility. The resident was very sneaky and probably waited for his/her opportunity to get out the facility. The resident walked out of the facility and to the church next door where the resident entered through an open door. Facility staff and the resident's family searched for the resident through the night. The resident did have a cell phone with him/her and called a family member the next morning and the resident told the family member where he/she was. By the time family members arrived to the location, police officers and facility staff were already there with the resident. The resident did not want to go back to the facility, but agreed to go to the hospital where the resident remained for a medication adjustment. Review of a written statement from NA L and obtained by the facility showed the following: -NA A completed bed checks around 11:45 P.M. and everyone was in bed; -NA A walked off the unit to grab a charger quickly; -NA A came back to the unit and heard the door alarm go off. NA L pushed the door open and did not see anyone; -NA A texted CNA M to help him/her with the alarm and do a bed count; -NA A and CNA M noticed Resident #1 was gone and notified the nurse; -Staff continued to look for the resident. Review of the written statement from CNA M, dated 10/11/22, obtained by the facility, showed the following: -NA L sent CNA M a text asking if CNA M had a charger; -At 1152 P. MM.,NA AA L sent CNA M a text and said NA L had a charger and he/she was going to run out to his/her car; -At 12:02 A.M. NA L asked CNA M for help because the alarm (door alarm) was going off; -While NA L tried to turn off the alarm, CNA M checked everyone's rooms, beds, and bathrooms and did not find Resident #1; -CNA M checked all the rooms, bathrooms, beds, and surrounding areas again; -CNA M then notified NA L and the charge nurse and then proceeded with elopement procedures. During an interview on 10/19/22 at 11:31 A.M., CNA M said NA L sent him/her a text around 11:45 P.M. that said NA L needed a phone charger and NA L was going to his/her car to get the charger. NA L did not ask CNA M to cover for him/her while NA L was of the secured unit. CNA M thought maybe the nurse was covering the unit for NA L. About ten minutes after receiving the text from NA L, CNA M saw NA L entering the facility through the front door. About the same time CNA M heard an alarm sound. NA L went back to the special care unit. About three or four minutes later NA L texted CNA M saying he/she could not get the door alarm turned off. CNA M went to the special care unit and began looking for residents in their rooms while NA L continued to get the door alarm off. CNA M was not sure if NA L had opened the door and searched outside. CNA M told NA L he/she could not locate Resident #1. NA L thought CNA M was joking. CNA M went and told the charge nurse, Registered Nurse (RN) A, and CNA N that Resident #1 was missing. CNA M and CNA N started looking outside for Resident #1. They looked in the courtyard and walked around the building twice. CNA M and CNA N walked to the hospital emergency room , as well as the highway, and the grounds of the church next door to the facility looking for the resident. They did not find the resident by the end of CNA M's shift. Review of the written statement from CNA N, dated 10/11/22, obtained by the facility, showed the following: -At 12:10 A.M. the CNA from the 100 hall (CNA M) came to the nurse station and told RN A that a resident was missing; -CNA N and CNA M went to the memory care unit and searched for the missing resident; -CNA N and CNA M checked every room and then went outside and searched the grounds; -CNA N and CNA M checked the hospital and neighboring grounds; -CNA N came in and rechecked rooms and all areas. During an interview on 10/19/22 at 11:22 A.M., CNA N said he/she was completing midnight rounds on his/her assigned hallway and saw CNA M at the nurse's station, telling the nurse about a missing resident. CNA N immediately went to the special care unit to search for the resident. NA L was on the unit at that time. CNA N searched inside the unit, but did not find Resident #1. CNA N then grabbed his/her coat and searched outside the facility. CNA N then walked over to the church and searched the grounds and the surrounding woods, but did not locate the resident. CNA N said he/she did not think to try and open any of the church doors, because he/she assumed they were locked. CNA N also walked to the hospital and spoke to emergency room staff and gave them a description of the resident. The police were also involved and assisted facility staff in the search for the resident. During an interview on 10/19/22 at 12:17 P.M. the administrator said Resident #1 left the facility through a delayed egress door, sometime around midnight, while NA L had left the unit unattended. Resident #1 walked through the facility courtyard and to the church next door to the facility. Per the resident, he/she was able to enter the church through an unlocked door and fell asleep in a classroom. The resident called his/her family member the next morning when people started entering the church. The family member called the administrator and told him/her where the resident said he/she was located. The administrator went over to the church to get the resident. Around 7:30 A.M. the administrator saw the resident walking around outside of the church. The resident was uninjured. The resident did not want to come back to the facility. The resident had a cell phone and called 911, stating he/she wanted to go to the hospital. The administrator said his/her expectation was staff never leave the special care unit or any assigned area of the facility unattended. The administrator said he/she was not aware of Resident #1's exit seeking behavior on 10/3/22 as described in the resident's nurse's note. The administrator expected staff to document follow up when exit seeking behaviors occurred. Observation with the administrator on 10/19/22 at 12:35 P.M. showed the following: -The delayed egress door of the special care unit led into an unlocked, fenced, courtyard; -The delayed egress door was approximately 50 feet from the unlocked courtyard gate; -The courtyard gate opened to a sidewalk and the facility parking lot with a steep grassy slope leading to the church parking lot next door to the facility; -It took the surveyor approximately three minutes to walk from the courtyard gate to the side of the church, walking at a moderate pace approximately 1/8 to 1/4 mile). MO208193

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #33) of 27 sampled residents was free from sexual abuse when resident (Resident #92) sexually abused the resident on three known occasions. The facility also failed to implement measures to ensure facility staff were educated and able to identify sexual abuse, and prevent additional sexual abuse from occurring. As a result one additional resident (Resident #51) sexually abused four residents (Resident #33, #70, #45 and #109) when facility staff witnessed the resident attempting to grope all four residents' genital areas and Resident #51 participated in a sexual act with Resident #109 in the hallway. The facility failed to assess both residents' competence and ability to consent to sexual activity. Further review showed Certified Medication Technician (CMT) U intimidated by yelling, making belittling and demeaning remarks, and gesturing in a threatening manner one resident (Resident #40), within his/her hearing distance. CMT U's behaviors and comments made Resident #40 mad, scared and fearful of CMT U. The facility census was 111. The administrator was notified on 10/21/20 at 4:53 P.M. of an Immediate Jeopardy (IJ) which began on 10/21/20. The IJ was removed on 10/27/20, as confirmed by surveyor onsite verification. Review of the undated facility policy, titled Abuse Prohibition Protocol Manual showed the following: -It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, resident would be protected from abuse, neglect and harm while they were residing at the facility. No abuse or harm of any type would be tolerated and residents and staff would be monitored for protection. The facility would strive to educate staff and other applicable individuals in techniques to protect all parties; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; -Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Examples of mental abuse include but are not limited to: demeaning remarks; - Accused residents would be isolated and monitored; -Allegations involving a sexual event (even if the event that caused the reasonable suspicion did not result in serious bodily injury), must be considered as serious bodily injury and reported to law enforcement agency and the State Survey Agency- Immediately. All precautions would be put in place to secure and protect the resident and /or items as to not interfere with or contaminate and allow for a thorough investigation by said entities; - Abuse prohibition alone did not relieve the nursing home of its reasonability to assure the resident was free from abuse. The nursing home must provide ongoing oversight and supervision of staff in order to assure that its policies were implemented as written; -Identification section in part. All staff were to monitor residents and would know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that might constitute abuse would be investigated. All staff would receive education about how to identify signs and symptoms of abuse. Residents would be monitored for possible signs of abuse. Because some cases of abuse were not directly observed, understanding resident outcomes of abuse could assist in identifying whether abuse was occurring or had occurred; - It was the policy of the facility that the residents would be protected from the alleged offender. Immediately upon receipt of a report of alleged abuse, the Administrator and or designee would coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and support to the resident, their roommate, if applicable and other residents with the potential to be affected would be provided. Procedures must be in place to provide the resident with a safe, protected environment during the investigation. If the alleged perpetrator was a facility resident, the staff member would immediately remove the perpetrator from the situation and another staff member would stay with alleged perpetrator and wait for further instruction from administration, if possible. 1. Review of Resident #33's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/6/20 showed the following: -[DIAGNOSES REDACTED]. -Severely impaired cognition; -No behavioral symptoms; -Independent in Activities of Daily Living (ADLs), required set up help with dressing and personal hygiene. Review of the resident's nurses' notes showed the following: -On 8/11/20 at 2:19 A.M. another resident was caught in Resident #33's room with his/her hand down Resident #33's pants; -On 8/12/20 at 2:12 A.M. staff documented Certified Nurse Aide (CNA) staff came to the desk and informed the nurse he/she heard a banging noise coming from the resident's room and when he/she went into the room he/she found the resident under another resident attempting to have sex. Resident #33's pants were partly down and the other resident's pants were partly down. The other resident was rubbing his/her genitals on Resident #33 perineal area/genitals. Two CNA staff separated the two residents. When asked about the incident, Resident #33 stated I don't know what you're talking about. You are thinking of someone else, when asked if the contact was consensual. The resident's physician was notified and the resident's responsible party. Staff documented the responsible party said the resident had never behaved in this manner. The resident was moved to the 100 hall. Review of the resident's care plan dated 8/12/20 showed the following: -[DIAGNOSES REDACTED]. -The resident had behaviors of hoarding, sitting personal items on the floor in a pattern and rearranging them throughout the day. Confused at times and anxious. Goal was the resident would not harm self or others. Staff should assess if behavior endangered others and intervene, assist with effective coping mechanisms, maintain a calm environment and calm approach. He/She no longer resided on the secure Special Care Unit to remove him/her from another resident; -The resident was independent with ADLs and required supervision with showers; -The resident had memory and recall problems related to [MEDICAL CONDITION]. Goal was the resident would remain safe from injuries from cognitive loss; -The resident's care plan did not include any documentation regarding another resident attempting to have sexual intercourse with the resident. 2. Review of Resident #92's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 6/9/20 showed the following: -Moderately impaired cognition; -Independent in all activities of daily living; -Delusional; -Verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). Review of the resident's care plan updated 8/12/20 showed the following: -[DIAGNOSES REDACTED]. -The resident had behaviors of staff manipulation, attempting to elope, aggression towards others, yelling at others, obsession over smoke breaks and making inappropriate sexual remarks to staff members without physical attempts. Complexity of mental condition was severe. Staff should monitor for increased anxiety, depression and for adverse effects of medications. Staff should monitor for behaviors, (yelling, physical aggression, sexually inappropriate, wandering affecting others, delusions, hallucinations) and chart if occurred; -The resident had behaviors of wandering, yelling, cursing, hitting at times, inappropriate sexual comments towards female staff and manipulation of staff or attempts to intimidate. Attempted physical sexual contact with female resident on 8/12/20. Goal was resident would not harm self and/or others. If occurred would be reviewed for cause and interventions. Staff should provide new order for [MEDICATION NAME] (female hormone medication), assess if behaviors endanger others, intervene if necessary, assist to identify effective coping mechanisms, maintain a calm environment and approach, provide outlets for expression of hostility and anger, and reside on locked unit (Special Care Unit) for smaller environment to decrease crowds, noise and availability to exit doors. Review of the resident's nurses' notes showed the following: -On 8/11/20 at 2:19 A.M. staff documented the resident was caught in another resident's room with his/her hand down the other resident's pants. The resident was told not to enter the other resident's room again; -On 8/12/20 at 12:31 A.M. staff documented a CNA came to the desk and said he/she heard a banging noise coming from the other resident's room and when he/she went into the room he/she found the resident on top of the other resident attempting to have sex. Resident #92's pants were down and the other resident's pants were partly down. Resident #92 was rubbing his/her genitals on the other resident's perineal area/genitals. Two CNA staff separated the two residents. When asked about the incident, Resident #92 said we never discussed it, when asked if the contact was consensual. The physician was notified, and every ten minute checks were started on the resident to ensure the safety of the resident and others. [MEDICATION NAME] (female hormone medication) 10 milligrams daily was scheduled for administration when arrived from the pharmacy; -On 8/12/20 at 12:19 P.M. staff documented they spoke with Registered Nurse/Nurse Practitioner (RN/NP) W regarding the event that occurred last night. RN/NP W said he/she would speak with the resident's family regarding the new medication order of [MEDICATION NAME] to curb sexual behaviors. RN/NP was agreeable with use of the medication pending family consultation. RN/NP W said medication may be held per the responsible party's preference until a consultation was completed by telehealth visit; -On 8/12/20 and 3:41 P.M. staff documented RN/NP W spoke with the resident's responsible party and [MEDICATION NAME] administration was refused. The responsible party said staff just needed to do more checks on Resident #92 and make sure he/she was not in other residents' rooms. Staff documented the resident was difficult to monitor due to history of elopement, impulsiveness, manipulation of staff, and self-ambulating. The resident's physician and medical director were made aware of the resident's responsible party refusal of [MEDICATION NAME] 10 mg daily. The physician said it would be appropriate to look for discharge to a facility that could accommodate sexual behaviors. Review of the resident's annual MDS dated [DATE] showed the following: -Moderately impaired cognition; -Independent in all activities of daily living; -Delusional; -Physical and verbal behavioral symptoms directed toward other (hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others and cursing at others) occurred and put others at risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or living environment; -The change in behavior status, care rejection or wandering was worse when compared to previous assessments. Review of the resident's care plan showed no additional update regarding the resident's sexual behaviors and interventions to prevent additional sexual behaviors. Observation of the Special Care Unit (SCU) on 10/13/20 showed Resident #92 in the common areas, walking independently in the hallways and back and forth to his/her room without staff supervision. Observation of the SCU on 10/14/20 showed the following: -At 12:20 P.M. Resident #92 sat in the common area with three additional residents without staff supervision. The resident ate lunch independently, walked around the common area without assistance or staff supervision and watched television; -At 8:45 P.M. Resident #92 sat outside smoking with numerous residents from the SCU and general population of the facility. Nurse Aide (NA) D and CNA JJ were on the SCU hallway talking. NA D left the hall; -At 8:55 P.M. Resident #92 returned to the SCU from smoking outside, walked independently down the hallway into his/her room; -At 9:30 P.M. CNA JJ remained the only staff member on the SCU hall. During interview on 10/13/20 at 7:55 P.M. NA D said the following: -He/She worked the evening and night shifts usually on the 300 hall or the SCU; -On 8/12/20 at about 8:30 P.M. or 9:00 P.M. he/she and CNA X sat in the SCU office room and heard a banging noise from the room next door (Resident #33's room ). Resident #92 was on top of Resident #33 banging against Resident #33's groin area with his/her bare genitals. Resident #92's pants were down. Resident #33's jeans were unzipped, but not pulled down and his/her legs were together; -He/She and CNA X pulled Resident #92 off of Resident #33. Resident #92 did not say anything and went to his/her room across the hall; -He/She told the charge nurse at the change of shift around 10:30 P.M.; -He/She worked a double shift that night and Resident #33 was moved off of the SCU. Staff started 15 minute checks on Resident #92's location and activity on a log form for a while. He/She was not sure when staff stopped the 15 minute checks. They were no longer doing the 15 minute checks on Resident # 92; -He/She heard earlier in the same week, Resident #92 had his/her hands down Resident #33's pants. He/She did not witness it, but heard it from other staff members; -Resident #33 was confused and unable to make decisions. He/She required constant staff supervision; -Resident #92 knew right from wrong; -He/She was supposed to report to the charge nurse within two hours of any incident involving abuse and the charge nurse would take it from there. During additional interview on 10/14/20 at 11:45 A.M. CNA Y said the following: -On 8/11/20 Resident #33 was dressed in shirt and jeans that tied up in the front when he/she observed Resident #92 groping Resident #33's breasts. The incident occurred on the evening shift after 7:00 P.M. He/She had Resident #92 leave Resident #33's room; -On 8/13/20 Resident #92 told him/her while they sat in the SCU television room, he/she did not know why everyone said he/she had sex with Resident #33 the night before. He/She could not get Resident #33's pants down, his/her pants were too tight; -Staff did 15 minute checks on Resident #92 for awhile and documented on a form the resident's location and activity. He/She did not know when or why the 15 minute checks were stopped. During interview on 10/14/20 at 10:55 P.M. CNA Z said the following: -He/She worked the night shift on the SCU; -He/She was aware of Resident #92 found on top of Resident #33 and was also told Resident #92 previously had his/her hands down Resident #33's pants; -On the night shift when Resident #92 and Resident #33 were awake and in the television room, they sat together and held hands. He/She had not witnessed any hugging or sexual activity; -Staff monitored Resident #92's location and activity every 15 minutes following the incident for a while. The 15 minute checks were stopped the first part of September 2020; -Resident #92 and Resident #33 both smoked and smoked at the same time outside with staff supervision. Resident #33 was unable to make a decision and required staff supervision while smoking for safety. Resident #92 required staff supervision while smoking for safety. During interview on 8/13/20 at 1:56 P.M. CNA P said the following: -He/She usually worked the day shift and currently worked on the SCU; -Resident #92 had sexual behaviors. Staff found the resident on top of Resident #33 attempting to have sex back in August. Fifteen minute checks of the resident's location were started following the incident. Staff were no longer monitoring the resident every 15 minutes. During interview on 10/13/20 at 2:48 P.M. CNA Y said the following: -He/She usually worked the evening and night shifts on the Special Care Unit; -On 8/11/20 he/she heard Resident #33 talking, entered the resident's room and found Resident #92 groping Resident #33's breasts while Resident #33 lay on the bed and Resident #92 sat on the resident's bed; -Resident #92 told him/her Resident 33's pants were too tight and he/she was unable to put his/her hands down Resident #33's pants; -He/She did not report Resident #92 groped Resident #33's breasts to the charge nurse or anyone else; -He/She did not monitor Resident #92 following the incident. The resident returned to his/her room. During interview on 10/13/20 at 3:30 P.M. CNA X said the following: -He/She worked the SCU sometimes during the evening and night shifts; -Resident #92 had behaviors towards staff and he/she made inappropriate comments; -On 8/12/20 just before 9:00 P.M. he/she and NA D were in the room next door and heard banging noises in Resident #33's room. They found Resident #92 on top of Resident #33 in Resident #33's bed with Resident #92's pants down to the knees and Resident #33's pants were open and down around the hip area. Resident #33 wore a shirt and jeans. Resident #92 was thrusting his/her bare genitals against Resident #33 groin area, rocking the headboard and bed into the wall; -He/She and NA D separated the two residents. Resident #92 pulled up his/her pants and left the room; Staff implemented no monitoring of Resident #92 from the time of incident until after 10:30 P.M. During interview on 10/13/20 at 5:30 P.M. Licensed Practical Nurse (LPN) I said the following: -On 8/11/20 he/she documented in Resident #92's nurses' notes CNA staff reported Resident #92 had his/her hands down Resident #33's pants. Nothing was put into place to monitor Resident #92 and prevent additional sexual incidents from occurring; -He/She heard through other staff Resident #92 had fondled Resident #33 previously while they sat in the Special Care Unit television room; -On 8/12/20 he/she came to work at 7:00 P.M. At approximately 10:30 P.M. he/she received report from the 300 hall staff and was informed earlier in the evening, staff heard a noise from Resident #33's room. CNA X and NA D found Resident #92 on top of Resident #33 trying to have sex in Resident #33's bed. Both residents' pants were unzipped and partially down. CNA staff said there was no penetration; -He/She went to the Special Care Unit and asked Resident #33 what happened, the resident had no recollection. He/She questioned Resident #92 and thought the resident knew what happened and did not want to talk about it; both residents have dementia; -Staff moved Resident #33 out of the Special Care Unit to the 100 hall; -At 11:00 P.M. staff placed Resident #92 on 15 minute checks. CNA staff were assigned to check on the resident every 15 minutes and document on a form the resident's location. He/She did not know what staff did to prevent Resident #92 from entering Resident #33's room or any other resident's room on the Special Care Unit between the time of the incident and 11:00 P.M. During interview on 8/13/20 at 2:00 P.M. LPN M said the following: -He/She was the charge nurse for the SCU; -Resident #92 had behaviors. Staff found the resident on top of Resident #33 trying to have sex a while back and previously he/she had his/her hands down Resident #33's pants. Resident #33 was moved off the SCU following the most recent incident; -There was no current scheduled staff monitoring of Resident #92's location and activity. Review of Resident #92's 15 minute check monitoring logs on 10/15/20 at 4:20 P.M. showed the following: -On 8/11/20 no documentation staff monitored the resident's location every 15 minutes following the report of the resident with his/her hands down Resident #33's pants or following staff observation of the resident groping Resident #33's breasts; -On 8/12/20 at 11:00 P.M. through 8/31/20 staff documented the resident's location every 15 minutes; -No additional staff documentation of 15 minute checks of Resident #92's location. During interview on 10/13/20 at 2:20 P.M. and 3:20 P.M. and 10/15/20 at 12:30 P.M. the Director of Nursing (DON) said the following: -Resident #92 lived on the SCU because he/she was an elopement risk. CNA X and NA D found him/her on top of Resident #33 and thought they were attempting to have sex; -Staff moved Resident #33 out of the SCU for his/her safety and implemented 15 minute checks on Resident #92's location and activity; -Resident #92's responsible party refused the physician prescribed [MEDICATION NAME] medication. The administrator was supposed to issue Resident #92 a 30 day discharge notice and locate a new facility for the resident. The resident's responsible party was not agreeable to the discharge and he/she did not know if the 30 day discharge notice was sent to the responsible party or not; -He/She was unaware staff observed Resident #92 groping Resident #33's breasts on 8/11/20 and unaware of staff documenting on 8/11/20 Resident #92 had his/her hands down Resident #33's pants; -Resident #33 was unable to make decisions. During interview on 10/19/20 at 8:17 A.M. Resident #33's family member said the following: -Staff called him/her at midnight regarding a sex incident when staff heard a banging noise and walked into Resident #33's room and found him/her having sex with another resident; -He/She was sick to think his/her parent might remember such a thing. Resident #33 would be terrified of someone coming into his/her room and doing that; -His/Her parent was a domestic abuse survivor, did not have a boy/girlfriend and was afraid of the opposite sex due to years of abuse. Resident #33 would never invite someone into his/her room for sex and never agree to have sex with someone; -Staff had only told him/her about this one incident of another resident on top of Resident #33 trying to have sex with him/her. He/She was concerned there might have be other times. Staff said Resident #33's pants were yanked down to his/her hips and the other resident's pants were down to his/her knees and he/she was banging hard hitting the headboard on the wall; -Resident #33 was quiet, antisocial and very shut down; -He/She had not received any other calls from facility staff regarding any other sexual incidents of groping or hands down Resident #33's pants; -A sexual act by Resident #33 was not consensual, he/she was sure of that. During interview on 10/20/20 at 6:20 P.M. the DON said following the 8/12/20 sexual abuse incident regarding Resident #92 and Resident #33, she spoke directly with CNA X and NA D about sexual abuse, importance of reporting all allegations immediately to the charge nurse and importance of needing to know where Resident #92 was at all times. No facility wide in-service was provided regarding abuse. He/She thought the charge nurses passed on the information in report. During interview the Administrator said the following: -During interview on 10/14/20 at 2:30 P.M. he said he expected staff to inform him of all allegations of abuse. Staff did not always inform him of abuse allegations or when things happen. They should inform him anytime abuse allegations including sexual abuse occurred so an investigation could be done, residents protected and prevent further abuse from occurring. During interview on 10/19/20 at 8:12 A.M. the resident's physician said the facility notified him staff witnessed the resident on top of another resident attempting to have sex. He did not order the [MEDICATION NAME]. The medication was ordered by the psychiatric consultant. He was not aware of any additional allegations of sexual abuse. He expected staff to notify him of any allegations of abuse, protect the residents and follow the facility abuse policy. 3. Review of Resident #51's admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Cognitively intact; -Delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Verbal behavioral symptoms directed towards others two to four days out of seven; -Independent with mobility. Review of the resident's Physician order [REDACTED]. Review of the resident's care plan, dated 9/27/19, showed the following: -Resident has impaired decision making and low cognitive score; -Goal: the resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed; -Calm the resident if signs of distress develop during the decision-making process (feeling overwhelmed, fatigue, agitation, restlessness, withdrawal); -Determine if decisions made by the resident endanger him/herself or others. Intervene if necessary; -Clarify misconceptions; -Give objective feedback when inappropriate decisions are made; -Discuss future options to improve decision making skills; -Respect resident's rights to make decision(s). Review of Resident #51's nurses notes, dated 10/01/19, showed staff documented the resident is in the dining room sitting with another resident. Resident was seen by this nurse putting his/her hands near the other resident's genitalia. Staff intervened, redirected the resident to his/her room and informed resident that it was inappropriate to do that in the dining room. Social Services notified. Review of the resident's Social Services note, dated 10/08/19, showed staff documented a police detective called and informed this social worker that charges were pressed against the resident regarding inappropriate touching. Needed to make sure resident was here in case anything came of it. Said he would keep us informed of all changes in the case. Review of the resident's nurses notes, dated 10/28/19, showed staff documented a staff member observed inappropriate behavior with another resident in the dining room. Review of the resident's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions; -Verbal behaviors directed towards others three to six days out of seven. Review of the resident's nurses notes, dated 12/04/19, showed staff documented the resident was noted to be seen by staff members having his/her genitalia touched by another resident in the hallway. Educated both residents on finding a private area in one of their rooms to perform sexual acts. Redirected easily. Both residents alert, consenting. Review of the resident's POS, dated 1/16/20, showed the physician increased the resident's [MEDICATION NAME] to 25 mg once a day. Review of the resident's POS, dated 1/30/20, showed the physician increased the resident's [MEDICATION NAME] to 30 mg once a day. Review of the resident's nurses notes, dated 3/07/20, showed staff documented the resident was in hallway by the smoking area while another resident touched his/her genitalia. Both residents were consenting, but in a public area. Redirected. Review of the resident's care plan, last revised 5/14/20, showed the resident has behaviors of yelling, cursing, acting like may kick, hit, refusing personal hygiene needs, and use of [MEDICATION NAME] for sexually inappropriate behaviors. Restrict access to potentially harmful items (e.g., glass, scissors, needles, razors, lighters, knives, medications). The care plan did not define any further direction for sexual behaviors, or sexual relationships for the resident. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Behavior of inattention, comes and goes; -Physical, verbal, and other behaviors towards others one to three days out of seven. Review of the resident's POS, dated 7/24/20, showed the physician decreased the resident's [MEDICATION NAME] to 20 mg once a day. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Behavior inattention, comes and goes; -Physical, verbal, and other behaviors towards others one to three days out of seven. Review of the resident's nurses notes, dated 8/26/20, showed staff documented the resident was in the television room touching another resident. It was unclear what body part he/she was touching, redirected the resident to the dining room. The resident said he/she was poking the other resident's arm. Review of the resident's nurses notes, dated 8/26/20, showed staff documented the resident has to be redirected multiple times during the meal. The resident was attempting to touch other residents. 4. Review of Resident #109's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions. Review of the resident's nurses notes, dated 10/28/19, showed the resident put his/her hands down another resident's pants while in the dining room. Both residents consented and agreeable. Review of the resident's nurses notes, dated 12/4/19 showed the resident put his/her hands down another resident's pants while in the hallway. Both residents are alert, consenting adults. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions. Review of the resident's nurses notes, dated 3/7/20 showed the resident put his/her hands down another resident's pants while in the hallway. Both residents are alert, consenting adults. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions. Review of the resident's Care Plan, last revised on 7/3/20, showed the following: -Uses [MEDICAL CONDITION] for: anxiety and depression. -Followed by a psychiatric counseling service. During an interview on 10/19/20, at 9:59 A.M., Social Services (SS) P said Resident #51 and Resident #109 were in a relationship. He/She thought the residents' were consensual with the relationship. He/She did not report their relationship to the administrator or DON. He/She did not know if the residents were able to consent for sure, but he/she thought they were. He/She was contacted by the sheriff's office and Resident #51 did have charges pressed for inappropriate touching at another facility. During an interview on 10/19/20 at 10:50 A.M., LPN R said Resident #51 had a consensual relationship with Resident #109. He/She said that the incident he/she charted on 12/4/19, and 3/7/20 involved Resident #109 performing tactile sexual acts on Resident #51 in the hallway, in front of other residents. He/She did not know of any other sexual behavior for either resident with any other resident. He/She did not know if a physician deemed the residents competent to make decisions about a sexual relationship. He/She did not report the sexual actions to th (TRUNCATED)

Based on observation, interview, and record review, the facility failed to consistently monitor a resident's weight, ensure interventions to address weight loss, including supplements and snacks, were consistently implemented, re-evaluate interventions for effectiveness, and ensure meals were set up for one resident (Resident #51), with a significant weight loss (18.9% loss), of 27 sampled residents. The facility census was 111. Review of the facility's policy for nutrition from Nursing Guidelines manual dated March, 2015 showed the following: -The facility would provide nutrition as determined by the physician and in cooperation with the dietician for all residents according to state and federal guidelines; -Residents would be provided meals three times a day at the facility's determined times; -Diet orders by the physician would be followed and if a resident did not like the meal offered, they would be given an alternative choice; -Staff would feed all residents who were unable to feed themselves; -Residents would be assessed for adaptive devices to promote the highest level of independence. Residents with swallowing problems would be provided nutrition as directed by physician in accordance with state and federal guidelines and under the direction of the dietician; -Residents would be offered bed time snacks unless contraindicated. 1. Review of Resident #51's Face Sheet, showed the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 9/27/19, showed the following: -At risk for weight loss; -Goal: Resident will not have weight loss, if occurs will be monitored; -Regular diet; -Does not eat breakfast, will get coffee or juice in place of breakfast; -Offer alternatives when food is disliked; -Weigh weekly if having significant weight loss; -Update on 11/27/19 showed fortified (nutrients added to a food or drink) orange juice in the morning; -Update on 12/19/19 showed daily snack, ice cream with meals; -Update on 3/12/20 showed two desserts with lunch and supper. Review of the resident's physician's orders [REDACTED]. -Regular diet; -Ice cream with meals three times a day; -VHC (Very high calorie nutritional supplement) 60 ml two times a day. Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment completed by staff, dated 5/20/20, showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Behavior of inattention, comes and goes; -Requires set up help for eating; -Weight 151 lbs. (pounds); -Fever and vomiting. Review of the resident's Registered Dietician Progress Notes, dated 5/22/20 showed the following: -Regular diet; -Current Weight 150.2 lbs. -Supplement or snack orders include: - VHC 60 milliliters (ml) two times daily; -Two desserts at lunch and dinner; -Ice Cream three times daily; -Fortified orange juice at breakfast; -Snack at 10 A.M.; -May weight is pending; -No changes to plan of care. Review of the resident's Weight Record showed no weight for the month of June 2020. Review of the resident's physician's orders [REDACTED]. -Increase VHC to 120 ml three times a day; -Nutritional orange juice with breakfast. Review of the resident's care plan, updated 7/15/20, showed the following updates: -Significant weight loss; -Nutritional orange juice with breakfast; -VHC 60 ml two times daily increased to 120 cc three times daily on 7/15/20. Review of the resident's Registered Dietician Progress Notes, dated 7/20/20, showed the following: -Resident experienced a significant weight loss over three months (10.9%); -Current weight: 133.8 pounds; -Diet: regular, nutritional interventions include: -VHC 120 ml three times a day; -Two desserts with lunch and supper; -Ice cream with meals; -Nutritional orange juice daily; -Snacks twice a day; -VHC and fortified orange juice added on 7/15 in response to significant weight loss; -No further changes at this time, will continue to monitor. Review of the resident's care plan, updated 8/6/20, showed staff updated the care plan to include staff to encourage the resident to come to the dining room for meals. Review of the resident's nurses notes, dated 8/13/20, showed the following: -Inter-disciplinary team reviewed the resident's weight loss; -Weight is 133.8 lbs; -Diet regular; -Nutritional interventions include: -VHC 120 ml three times a day; -Two desserts with lunch and supper; -Ice cream with meals; -Nutritional orange juice daily; -Snacks twice a day; -Eats 25-50% of meals requested; -No further changes at this time, will continue to monitor; -Will educate staff to encourage the resident to come to dining room for meals. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Behavior of inattention, comes and goes; -Requires set up help for eating; -Weight 134, (11% weight loss, and weight loss was not marked); -Fever and vomiting. Review of the resident's nurses notes, dated 8/20/20, showed the following: -Inter-disciplinary team reviewed the resident's weight loss; -Weight is 133.8 lbs; -Diet regular; -Nutritional interventions include: -VHC 120 ml three times a day; -Two desserts with lunch and supper; -Ice cream with meals; -Nutritional orange juice daily; -Snacks twice a day; -Eats 25-50% of meals requested; -No further changes at this time, will continue to monitor; -Will educate staff to encourage resident to come to dining room for meals. Review of the resident's Medication Administration Record, [REDACTED] -Staff circled the resident's nutritional orange juice 13 times as not taken, the document did not include a reason; -Staff did not document the administration of the resident's VHC supplement 12 times, the document did not include a reason, and documented 0% taken 14 times; -Staff did not document the administration of the resident's snack two days, and documented 0% consumed for seven days. Review of the resident's Weight Record, dated 10/15/20, showed staff had not documented a weight for the resident since 9/5/20. Observation on 10/15/20 at 1:48 P.M., showed the following: -The resident lay in bed. He/She appeared emaciated (abnormally thin and weak); -The resident's lunch tray sat on his/her bedside table and contained two desserts wrapped in foil, mashed potatoes, sauerkraut and bread; -The resident consumed his/her polish sausage; -The resident's tray did not include ice cream, and his/her food items had not been unwrapped or set up for the resident; -The resident's tray did not include a meal ticket. During an interview on 10/15/20 at 2:00 P.M., Certified Nurse Assistant (CNA) H said: -He/She did not know if the resident has had weight loss; -He/She did not pass his/her tray; -Staff are responsible for unwrapping the resident's desserts; -The resident occasionally eats desserts, but not very often; -Breakfast was his/her best meal; -The resident used to get up and around, now he/she just lays in bed; -The resident does not do much of anything. During an interview on 10/20/20 at 2:00 P.M. and 10/20/20 at 11:45 A.M., CNA/Restorative aide (RA) L said: -He/She does all the residents' weights; -He/She had been pulled from restorative nursing to the floor and had not been able to do the October weights, or the weekly weights; -The resident had weight loss; -The resident was to receive fortified orange juice, ice cream, and two desserts; -He/She does not know where the resident's ice cream was; -The resident needs his/her meals set up and all food and drinks unwrapped; -The resident sits on the side of the bed, but cannot tolerate it long, so staff have to have everything ready for him/her or he/she will not eat well; -He/She weighed the resident on 10/16/20 and the resident weighed 122.4 lbs. Observation on 10/20/20 at 1:15 P.M., in the resident's room showed: -The resident lay in bed; -Staff served the resident chicken, mashed potatoes, carrots, a roll, one dessert, a red drink and ice cream; -Staff did not uncover the dessert or the resident's drink; -The resident consumed the chicken and the ice cream; -Staff did not serve the resident two desserts, or open all of the items on his/her tray; -The resident's tray did not include a meal ticket. During an interview on 11/9/20 at 10:00 A.M., the dietary manager said: -Residents' diets were written on a paper ticket which was sent with each meal tray; -Nursing staff should let dietary know if food/drink items are missing; -Supplements and extra food sent by dietary should be on the paper ticket; -CNAs passed the trays and should set trays up for the residents including opening items, buttering bread, ensuring everything was in reach; -He/She did not know if the resident had a current weight loss. During an interview on 11/9/20 at 4:00 P.M., the registered dietitian (RD) said: -During COVID he/she had done the kitchen inspections, and tried to stay out of the way of the staff; -Meal service had not been evaluated due to COVID; -He/She reviewed residents' nutrition information from his/her home; -The facility should have a process in place to ensure residents get appropriate portions, ordered snacks and supplements; -He/She did not receive the resident's October weight of 122.4 lbs.; -When the resident had further weight loss, he/she would have recommended looking at effectiveness of current interventions and seeing what he/she had not tried; -He/She would expect staff to notify him/her with further weight loss; -The resident's weight loss was significant and new or revised interventions needed to be attempted. During an interview on 10/20/20, at 2:00 P.M., licensed practical nurse (LPN) XX said: -The resident had weight loss; -CNAs pass the trays, which includes opening/uncovering all items on their tray; -CNAs should ask dietary if something was missing on the printed meal ticket; -Weight loss was discussed weekly in the interdisciplinary team (IDT) meeting; -The IDT meeting should review and discuss weekly weights on residents with weight loss; -He/She did not know if anyone was currently able to do the residents' weights because of staffing. During an interview on 11/5/20 at 11:00 A.M., and 11/9/20 at 10:10 A.M., the director of nursing (DON) said: -The IDT monitors weight loss, 5% loss in one month, 7.5% loss in three months, 10% loss in six months; -The RD monitored residents from his/her home during the COVID 19 pandemic; -Weekly weights were done when weight loss was identified; -When weight loss was identified, the IDT looks at the resident's diet, talks to the resident about chewing, consistency, if they are getting what they are asking for, add interventions that they like or supplements they like, or add desserts with the meal, super cereal for some; -Dietary gets the notifications and adds the interventions to the resident's meal cards, so staff knows what they need; -The charge nurse should make sure residents get the items on their meal ticket; -CNAs deliver the tray and need to ensure items are open and in reach of the resident, butter their bread, cut up anything they need cut up; -Paper dietary cards are sent with the meals trays, if something is missing staff should let the dietary staff know; -Food items are to be opened and uncovered for residents who need assistance and have weight loss; -Proper portion sizes are important for residents with weight loss. -The restorative aide does the weights for all residents; -He/She has not received weights for November; -The last weight she received for the resident was 122.4 lbs. on the October weight list; -The resident should be a weekly weight, she was not sure why she had not received the weights or if they have been done; -She does not know if the resident had any new or revised interventions with his/her further weight loss. During an interview on 11/11/20 at 7:48 A.M., the resident's physician said the following: -He was aware of the resident's weight loss in September; -He did not see the weight of 122.4 lbs in October; -If the new weight was accurate he would have looked at adjusting the resident medications, and evaluate all of the resident's interventions to see what was going on and what else could be tried; -He expected the facility to serve the resident a nutritional diet with all the supplements or interventions that were currently in place; -He expected the facility to verify weight loss and notify him with weight loss or make alerts in the medical record timely; -He expected the facility to monitor weekly weights with weight loss residents.

Based on observation, interview and record review, the facility failed to ensure one additional resident (Resident #74) was free from physical restraints when staff held the resident's wrists with arms out stretched over the resident's head while staff provided personal cares. The resident reacted and resisted by yelling out at staff, moving his/her legs and attempted to move his/her arms that staff held down. The facility census was 111. Review of the facility policy Resident Rights undated showed the intent of the facility is to promote and ensure that highest standards of conduct and reliability by its employees and consultants to in turn produce environments in the facility that promote the highest standards of care and security for our residents and families we serve. Our residents will always be provided with the highest level of care and service, and if for any reason a resident, and or responsible party feel that such needs are not being met by their facility staff, they are entitled to a variety of avenues in which to resolve their concerns. Each resident shall be afforded the opportunity to refuse treatment. Any refusals shall be documented and resident/guardian and/or responsible party shall be informed of possible consequences of not receiving treatment. The exercise of resident rights shall be free from restraint, interference and coercion, each resident shall be free from mental and physical abuse. Residents have the right to be free from any physical or chemical restraint except as follows: When used to treat a specified medical symptom as a part of a total program of care to assist the resident in attaining and maintaining highest practicable level of physical, mental or psychosocial well-being. The use of restraints must be authorized in writing by physician for a specified period of time or when necessary in an emergency to protect resident from injury to self or others, in which case restraints may be authorized by professional personnel so designated by facility. The action shall be reported immediately to resident's physician and an order obtained which shall increase reason for restraint, when restraint shall be removed, type of restraint and any other actions required. Each resident shall be treated with consideration, respect, a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Review of Resident #74's annual Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 7/21/20 showed the following: -[DIAGNOSES REDACTED]. -Severely impaired cognition; -Delusional; -Physical and verbal behavioral symptoms directed toward other (hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others and cursing at others) occurred, significantly interfered with the resident's care, significantly intruded on the privacy or activity of others and significantly disrupted care or living environment); -Required extensive assistance of two staff members with bed mobility; -Required extensive assistance of one staff member with dressing; -Required total assistance of one staff member with toileting and personal hygiene; -Functional limitation in range of motion with impairment of all extremities; -Always incontinent of bowel and bladder; -No restraints required. Review of the resident's physician progress notes [REDACTED]. -Staff reported the resident was combative, biting, kicking and could not provide adequate care for the resident; -Health history of [MEDICAL CONDITIONS] (harm to the brain due to lack of oxygen) with [MEDICAL CONDITION], aggressive behavior; -Plan was continue current medications and call when resident has behaviors. These behaviors were common for the resident. Explained to new nursing staff sometimes you just have to come back in a minute and redirect the resident. Review of the resident's care plan dated 8/20/20 showed the following: -The resident had impaired memory related to history of stroke and dementia. Goal was the resident would not have aggressive behaviors related to confusion. Staff should explain tasks to be performed before starting, provide cues and reminders for Activities of Daily Living (ADLs) and activities as needed, provide reassurance when confused and minimize distractions and not rush the resident; -The resident had difficulty understanding others at times related to cognitive loss. Staff should obtain the resident's attention before speaking, speak clearly and adjust tone as needed. Staff should provide a quiet, no-hurried environment free of background noises and distractions when needed; -The resident required staff assistance with ADLs. Staff should encourage the resident to participate in ADLs to best of ability; -The resident had behaviors of aggression. Staff should assess if the resident's behavioral symptoms presented a danger to the resident and/or others, monitor behaviors, try non-pharmacological interventions before initiating drug therapy and when the resident was agitated try talking to him/her about family. Review of the resident's Physician's Order Sheet dated October 2020 showed no physician orders for restraints. Observation on 10/14/20 at 8:35 P.M. showed the following: -Nursing Assistant (NA) D stood at the head of the resident's bed and held the resident's wrists with arms out stretched over the resident's head while Certified Nurse Assistant (CNA) LL provided the resident perineal care. The resident was unable to move his/her arms; -The resident yelled at NA D and CNA LL and moved his/her legs and attempted to pull his/her arms away from NA D's hold; -NA D released the resident's arms when he/she realized he/she was seen from the hallway. Observation on 10/14/20 at 8:45 P.M., showed the following: -The resident lay in his/her bed; -The resident had contractures of his/her hand with fingers in a flexed position, he/she could not fully move at his/her wrist; -The resident moved his/her arms around; -The resident was unable to independently straighten his/her arms at his/her elbows as they were fixed at a 90 degree angle; -Limited range of motion of his/her shoulders, could not actively raise his/her arms over his/her head. During an interview on 10/14/20 at 8:45 P.M., the resident said, He/She hurt my arm, they hurt my arm and hit my head. During interview on 10/14/20 at 9:40 P.M., the resident said the staff member was not good, people were mean to him/her. The resident glanced over his/her shoulder toward the door as he/she spoke. Observation on 10/14/20 at 9:58 P.M., showed the following: -NA D entered the resident's room. The resident yelled at NA D and said Get out of here; -CNA LL entered the resident's room. The resident yelled and said get out of here; -The resident was visibly agitated. During interview on 10/14/20 at 10:30 P.M., NA D said the following: -The resident sometimes refused care, became soiled with urine and feces and staff have to clean him/her up; -He/She held the resident's arms so care could be provided. Holding the resident's arms was not abusive. He/She was not abusive to the resident; -Holding the resident's arms above the resident's head was not appropriate, but was controlling the situation and allowed staff to provide cares. During interview on 10/14/20 at 10:00 P.M., CNA LL said the following: -NA D held the resident's arms over the resident's head to keep the resident from hitting him/her while changing the resident's incontinence brief and providing perineal care; -It probably was not appropriate to hold the resident's arms over his/her head. NA D helped with changing the resident two other times on the shift and held the resident's arms while he/she provided perineal care. During interview on 10/14/20 at 10:10 P.M. Licensed Practical Nurse (LPN) OO said the following: -He/She was the charge nurse for the 300 hall; -It was not appropriate to hold a resident's arms over the resident's head while another staff member provided the resident incontinence care; -He/She heard the resident yelling out and was unaware staff were holding the resident's arms by the wrists over the resident's head while providing cares; -Staff should not restrain the resident. During interview on 10/14/20 at 9:42 P.M. and 11:20 P.M., the Director of Nursing said the following: -The resident required a lot of care, was resistive to care at times, yelled a lot, and cussed at staff; -The resident was combative and difficult. Staff had difficulty providing the resident cares; -NA D and no other staff should hold the resident's arms above the resident's head while another staff provided cares. Staff should walk away, get additional help, inform the charge nurse and try different approaches to care; -Staff needed additional education; -Staff should never hold the resident down or restrain him/her.

Based on interview, and record review; the facility failed promote healing and prevent decline in two pressure ulcers for one resident (Resident #1) in a review of six residents sampled. Staff did not complete dressing changes as ordered. The resident's pressure ulcers declined and the resident was sent to the hospital for debridement (removal of damaged tissue) of his/her pressure ulcers. Following debridement, the hospital the classified the resident's pressure ulcers as Stage IV pressure ulcers. The facility census was 107. 1. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of [REDACTED]. -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. 2. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). (MONTH) also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling. 3. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. 4. Review of the facility's policy Care and Prevention of Pressure Ulcers, from the Nursing Guidelines Manual, dated (MONTH) (YEAR), showed the following: -treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers; -Guidelines: -Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk area for a pressure ulcer to begin; -Use pressure-reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominence's; -Active and passive range of motion may be ordered by the physician to improve circulation; -Whenever possible, teach the resident to change his/her own position at regular intervals and shift his/her weight in wheelchair; -Use elbow and heel protectors if needed; -Use bed cradle to relieve pressure of bed clothing, if needed; -Assist resident at mealtime to assure adequate nutrition; -Offer fluids frequently for adequate hydration. 5. Review of Resident #1's Braden Scale (tool used to assess the resident's level of risk for development of pressure ulcers) dated 3/28/19, showed a score of 10 indicating the resident was a high risk for developing pressure ulcers. Review of the resident's Observation Detail (skin assessment) report dated 5/18/19 showed the following: -The resident had reddened peri area; -Buttocks red; -No other areas of concern noted. Review of the resident's Physician order [REDACTED]. -an order for [REDACTED]. Review of the resident's care plan showed no interventions for pressure ulcer prevention or treatment to wounds. Review of the resident's Observation Detail report dated 5/26/19 showed the following: -Small open area to sacral area; -Area to upper spine; -Staff did not document measurements, type of wound, drainage, or surrounding tissue condition. Review of the resident's Observation Detail report dated 6/22/19 showed the following: -Open areas to coccyx and upper back; -Staff did not document measurements, type of wound, drainage, or surrounding tissue condition. Review of the resident's Observation Detail report dated 6/29/19 showed the following: -Open areas to coccyx and upper back; -Staff did not document measurements, type of wound, drainage, or surrounding tissue condition. Review of the resident's POS dated 7/1/19 to 7/31/19 showed and order for Duoderm dressing to the sacral area and upper spine area and change every three days. Review of the resident's Nursing Task's Flowsheet (treatment record) dated 7/1/19 to 7/31/19 showed the following: -Duoderm to the resident's coccyx, change every three days: -No documentation staff applied a Duoderm dressing to the resident's coccyx on 7/1/19 or 7/2/19; -No documentation staff applied a Duoderm dressing to the resident's upper spine area on 7/1/19 or 7/2/19. Review of the resident's Social Service's note dated 7/2/19 showed the resident had an open area on his/her bottom. Review of the resident's Nursing Task's Flowsheet showed the following: -No documentation staff applied a Duoderm dressing to the resident's coccyx on 7/3/19 through 7/6/19; -No documentation staff applied a Duoderm dressing to the resident's upper spine area on 7/3/19 through 7/6/19. Review of the resident's Observation Detail report dated 7/6/19 showed the following: The resident had an open area to his/her coccyx; -The resident had an open area to his/her back; -Staff did not document measurements, type of wound, drainage, or surrounding tissue condition. Review of the resident's Nursing Task's Flowsheet showed the following: -No documentation staff applied a Duoderm dressing the resident's coccyx on 7/7/19 through 7/19/19 (12 days); -No documentation staff applied a Duoderm dressing to the resident's upper spine area on 7/7/19 through 7/19/19 (12 days). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/20/19, showed the following: -The resident's [DIAGNOSES REDACTED]. -The resident weighed 111 pounds; -The resident's cognition was moderately impaired; -The resident required extensive assistance of two staff members to transfer; -The resident required extensive assistance of one staff member to dress and bathe; -He/She was always incontinent of bowel and bladder. -He/She was at risk for developing pressure ulcers; -He/She did not have pressure ulcers. Review of the resident's nurse's notes dated 7/26/19 showed a Stage I pressure ulcer on the resident's sacrum. Review of the resident's Observation Detail report dated 7/26/19 showed the following: -New Stage I pressure ulcer at the sacrum; -Measured 8cm (centimeters) length (L) x 10cm width (W) x 0 cm depth (D). Review of the resident's care plan dated 7/26/19 showed the following: -The resident had a Stage I pressure ulcer on the sacrum related to immobility and incontinence; -Turn and reposition the resident frequently; -Maintain the head of the bed at the lowest degree of elevation possible; -Keep bony prominence's from direct contact one another with pillows; -Avoid friction and shearing forces during transfers and position changes; -No documentation for treatment. Review of the resident's POS dated 8/1/19 to 8/31/19 showed the following: -On 7/31/19, apply Duoderm until healed to the resident's coccyx and change every three days; -Staff did not obtain an order for [REDACTED]. Review of the resident's Nurse's TAR showed the following: -Staff applied the Duoderm to the resident's coccyx on 8/3/19 and 8/6/19; -No documentation staff applied the ordered treatment 8//9/19 or 8/12/19. Review of the resident's POS dated 8/22/19 showed no order for an Isosorb dressing. Review of the resident's TAR showed the following: -On 8/14/19 a hand written entry showed Duoderm to coccyx change every three days; -No documentation staff applied the ordered treatment on either 8/14/19 or 8/17/19; -No documentation staff entered Isosorb dressing or completed Isosorb dressing on 8/22/19. Review of the resident's Observation Detail List Report dated 8/19/19 showed the following: -Prior week measurements of the coccyx wound Stage I showed 4.0cmL x 7.2cmW x 0.0cmD; -Sacral Stage II pressure ulcer with granulation tissue (new connective tissue and microscopic blood vessels that form on the surface of a wound during the healing process); -The sacral Stage II wound measured 2.4cmL x 1.2cmWx 0.2 cm D; -Scant amount of serosanguineous (thin clear watery plasma fluid) foul odorous drainage; -The peri-wound (surrounding tissue) had [DIAGNOSES REDACTED] (redness) and was macerated (tissue softened by wetness) -Staff notified the resident's physician and received no new orders. Review of the resident's Observation Detail List Report dated 8/23/19 showed the following: -Sacral area measured 1.0cmL x 1.2cmWx 0.2 cm D; -Stage II pressure ulcer with granulation tissue (pink or red); -No drainage or odor; -Staff notified the resident's physician; -New orders to Apply an Isosorb pad and change daily. Review of the resident's nurse's notes dated 8/23/19 at 4:47 P.M. showed the following: -Interdisciplinary Team (IDT) wound documentation: -The resident alert but very forgetful and confused; -He/She has very thin and fragile skin; -Sacral area open with a Stage II pressure ulcer; -The treatment changed to an Isosorb pad to site and change daily (no documentation of a physician's orders [REDACTED]. Review of the resident's POS dated 8/1/19 to 8/31/19 showed no order for Isosorb dressing. Review of the resident's TAR dated 8/1/19 to 8/31/19 no documentation on the TAR to use an Isosorb dressing or frequency of dressing changes. Review of the resident's undated care plan showed no treatment plan for the Stage II ulcer (on the coccyx). Review of the resident's POS showed the following: -On 8/28/19, an order to cleanse the coccyx wound with normal saline, apply calcium alginate (a biodegradable dressing derived from seaweed and used to maintain a physiological moist microenvironment to promote healing and formation of granulation tissue) to wound, skin prep around the wound, and cover the wound with Isosorb foam dressing twice daily; -Discontinue Duoderm on 8/28/19. Review of the resident's TAR showed the following: -No documentation staff entered the new order or evidence staff completed the treatment as ordered to cleanse the wound with normal saline, apply calcium alginate to wound, skin prep around the wound, and cover the wound with Isosorb foam dressing on 8/28/19, 8/29/19, 8/30/19 or 8/31/19. Review of the resident's undated care plan showed no update on wound condition or treatment plan. Review of the resident's POS dated 9/1/19 to 9/30/19 showed an order on 8/28/19 to cleanse the coccyx wound with normal saline, apply calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing change twice daily. Review of the resident's Observation Detail List Report dated 9/9/19 at 3:14P.M. showed the following: -Sacral area measured 1.0cmL x 0.5cmW x 0.3 cm D; -Stage II pressure ulcer with granulation tissue; -No drainage or odor; -Notified the resident's physician; -No treatment plan change. Review of the resident's nurse's notes dated 9/9/19 at 2:45 P.M. showed the following -Stage II pressure ulcer at coccyx; -Wound is pale with no drainage or odor; -Staff cleansed the wound with normal saline, applied Hydrogel ( a water based gel that protects and provides a moist wound healing environment and helps remove dead tissue form the wound during the healing process) to site and placed a Duoderm to the wound. Review of the resident's POS dated 9/9/19 showed no order to clean the coccyx wound with normal saline, apply Hydrogel to site and place a Duoderm to the wound. Review of the resident's nurse's notes dated 9/20/19 at 2:44 P.M. showed the following: -The resident had a Stage II pressure ulcer to his/her coccyx. The wound measured 2.5cmL x 1.9cmW x 2.4 cmD. The wound was 90% [MEDICATION NAME] (thin tissue forming) tissue and 10 % white tissue with serosanguineous drainage. Staff cleansed the wound with normal saline, applied Hydrogel to the wound, covered with an Isosorb pad and change daily; -The resident had a Stage II pressure ulcer to the cervical spine (upper area of the spine) that measured 4.5cmL x 1.4cmW, no depth documented, with moderate amount of serosanguineous no odorous drainage. Staff cleansed with wound cleanser, applied skin prep to the surrounding edges, applied Hydrogel to the wound bed and applied a foam dressing. Review of the resident's POS showed the following: -On 9/20/19 cleanse the cervical spine with normal saline, prep the edges of the wound with skin prep, apply Hydrogel to the wound bed, cover with a foam dressing, change daily and as needed -No order to clean the sacral Stage II pressure ulcer with normal saline, apply Hydrogel to the wound, and cover with an Isosorb pad. Review of the resident's undated care plan showed the following: -Stage II pressure ulcer on medial coccyx measured 2.5cmL x 1.9cmW x 2.4cm D. The wound was 90% [MEDICATION NAME] tissue and 10 % white tissue with serosanguineous drainage. Clean the wound with normal saline, apply Hydrogel to the wound, covered with an Isosorb pad and change daily. -Stage II pressure ulcer to the cervical spine, measured 4.5cmL x 1.4cmW. Clean with wound cleanser, apply skin prep to the surrounding edges, apply Hydrogel to the wound bed and apply foam dressing. Review of the resident's POS showed no order for the coccyx wound treatment noted on the resident's care plan. Review of the resident's TAR dated 9/1/19 to 9/30/19 showed the following; -No documentation staff completed the daily Hydrogel dressing to the resident's upper spine on 9/21/19, 9/27/19 or 9/29/19; -No documentation staff completed ordered treatment to the coccyx wound with normal saline, apply calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing change twice daily, on the 6:30 to 10:00 [NAME]M. shift of 9/3/19, 9/11/19, 9/12/19, 9/13/19, 9/16/19, 9/17/19, 9/18/19, 9/19/19, or 9/21/19; -No documentation staff completed ordered treatment to the coccyx wound with normal saline, apply calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing change twice daily, on the 3:00 to 6:00 P.M. shift of 9/11/19, 9/21/19. Review of the resident's nurse's notes dated 9/25/19 at 3:44 P.M. showed the following: -A Certified Nurse Assistant (CNA) reported the resident's coccyx wound appeared to deteriorate; -The resident's wound had an area of black necrotic (dead tissue) tissue not previously noted upon the last skin assessment; -Staff spoke to the MDS coordinator who suggested Santyl (a [MEDICATION NAME] agent) calcium alginate; cover with a dry dressing and to change daily; Review of the resident's POS showed an order on 9/25/19 to cleanse the coccyx wound with normal saline, apply Santyl, calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing change twice daily. Review of the resident's TAR showed the following: -No documentation staff entered the order on the TAR on 9/25/19 for staff to cleanse the coccyx wound with normal saline, apply Santyl, calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing, change twice daily; -No documentation staff completed the dressing change as ordered twice daily on 9/25/19, 9/26/19, 9/27/19, 9/28/19 and the morning of 9/29/19. Review of the resident's undated care plan showed no update on the treatment change. Review of the resident's Observation Detail List Report dated 9/2719 at 3:25 P.M. P.M. showed the following: -Cervical spine wound caused by Moisture Associates Skin Damage (MASD). The wound measured 1.5cmL x 0.3cmW x 0.1 cmD open area. The wound bed with yellow slough (dead tissue). Apply skin prep to the wound edges, apply hydrogel and foam dressing daily. No change in treatment plan, physician not notified; -Coccyx Stage II pressure ulcer. The wound measured 8.0cmL x 4.5cmW x 0.5cm D and had an odorous serosanguineous drainage with black eschar on the edges. Staff notified the resident's physician. Review of the resident's nurse's notes dated 9/27/19 at 3:15 P.M. showed the following: - The coccyx Stage II pressure ulcer measured 8.0cmL x 4.5cmW x 0.5 cm D; -The wound had an odorous serosanguineous drainage and black eschar on the edges; -Staff notified the resident's physician on 9/25/19 and treatment was changed to Santyl, calcium alginate and dry dressing daily; -A low air flow mattress was ordered; -The cervical spine wound measured 1.5cm L x 0.3cmW x 0.1cmL. Review of the resident's nurse's notes dated 9/29/19 showed the following: -At 9:35 [NAME]M., the nurse noted the resident's coccyx/buttock wound got worse; -The wound had light brown odorous drainage; -Staff notified the resident's physician and received an order for [REDACTED]. -At 9:40 [NAME]M. staff clarified the treatment order to the resident's coccyx wound. Review of the resident's POS dated 9/29/19 showed the following: -[MEDICATION NAME] 500 mg daily for 10 days; -Cleanse the coccyx wound with normal saline, apply Santyl nickel thick to wound bed, calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing change once daily. Review of the resident's TAR showed the staff did not complete the resident's ordered dressing change of cleanse the coccyx wound with normal saline, apply Santyl nickel thick to wound bed, calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing change once daily on 9/30/19. Review of the resident's POS dated 10/1/19 to 10/6/19 showed the following: -On 9/20/19 cleanse the cervical spine (upper spine) with normal saline, prep the edges of the wound with skin prep, apply Hydrogel to the wound bed, cover with a foam dressing, change daily and as needed -On 9/29/19 cleanse the coccyx (sacral) wound with normal saline, apply Santyl nickel thick to wound bed, calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing change once daily. -[MEDICATION NAME] (an antibiotic) 500 milligrams (mg) tablet once daily for open wound -On 10/2/19 Wound Care Plus (wound care specialist) to evaluate and treat. Review of the resident's TAR dated 10/1/19 to 10/31/19 showed the following; -No documentation staff completed the daily Hydrogel dressing to the resident's upper spine on 10/1/19, 10/2/19; -No documentation staff completed the ordered treatment to the resident's coccyx wound with normal saline, apply nickel thick Santyl to wound bed then apply calcium alginate to wound, skin prep around the wound, and cover the wound with a foam dressing once daily on 10/1/19, 10/2/19 or 10/4/19. Review of the residents Wound Care Plus notes dated 10/2/19 showed the following: -Wound #1 coccyx chronic Stage III pressure injury ulcer and had received status of not healed. The wound measured 5.2cmL x 6.5CMW x 1.4cmL and the wound bed with 76 to 100% slough; -Wound #2 on back is a chronic Stage III pressure injury ulcer, not healed. The wound measured 5.5cmL x 1.7cmW x 0.2cmDwith 26 to 50% slough; -Wound #1 was surgically debrided; -Wound orders for coccyx: Cleanse with normal saline, irrigate or scrub the wound, apply Santyl nickel thick, fill tunneling with calcium alginate rope to fill in dead space but do not pack, cover with a bordered gauze, change daily and as needed; cleanse the wound with normal saline; -Wound orders cervical spine: Cleanse the wound with normal saline irrigate or scrub the wound, apply Santyl nickel thick, use hydrogel as a filler, cover with a bordered gauze. Change the dressing daily; -Plan of care discussed with the Director of Nurses. Review of the resident's POS 10/1/19 to 10/6/19 showed no new orders following the assessment and orders from the Wound Care Plus Nurse Practitioner on 10/2/19. Review of the resident's TAR showed the following: -No documentation staff entered of the Wound Care Plus Nurse Practitioner's wound care orders on 10/2/19; -No documentation staff completed the treatment advised by the Wound Care Plus Nurse Practitioner. Review of the resident's nurse's notes dated 10/6/19 showed the following: -During resident wound treatments, staff noted more blackened areas to the coccyx wound bed and a foul smell; -Staff notified the resident's physician; -The resident was sent to the hospital for an evaluation. Review of the resident's hospital skin assessment evaluation dated 10/6/19 at 12:41 P.M. showed the following: -An unstageable pressure ulcer sacral wound measured 9cmL x 16cmW x 1.5cmD, the wound bed was black, moderate serosanguineous odorous drainage, the wound margins defined, 3cm tunneling at 6:00 to 8:00; -A suspected deep tissue injury at the upper back, the wound bed was black/deep purple; the wound measured 15cmL x 6cmW x 0cmD. Review of the resident's hospital records dated 10/9/19 showed the following: -Following wound debridement, the Stage IV coccyx wound measured 10cmL x 16cmW x 1.5cmD; -Following wound debridement, the Stage IV pressure ulcer at the upper back measured 15cmL x 5cm x 1cmD. During an interview on 10/22/19 at 2:35 P.M., Licensed Practical Nurse (LPN) A said the following: -He/She noticed open spots on the TAR (where staff had not documented treatments completed); -The resident's wound deteriorated; -If the MAR or TAR was blank, that means the medication or treatment was not completed. During an interview on 10/22/19 at 3:05 P.M., LPN B said the following: -The resident's pressure ulcer was facility acquired; -The resident was on an antibiotic because of a wound infection; -If the MAR or TAR was blank it means the treatment not completed or medication administered. During an interview on 10/30/19 at 1:53 P.M., LPN C said the following: -When staff receive a verbal/telephone treatment order, the staff member taking the order was responsible to put the order into the electronic medical record (eMAR) POS; -Staff are to discontinue the previous treatment order and then the system will automatically mark the discontinued treatment order on the TAR; -Staff are to ensure the new order/treatment order was on the TAR. During an interview on 11/5/19 at 10:35 [NAME]M. the Wound Care Plus Nurse Practitioner said the following: -He/She had only assessed the resident's wound one time; -He/she called the wounds chronic because the resident had the wounds since (MONTH) 2019; -The Director of Nursing said the resident had the wounds for a long time; -After he/she assesses the resident's wound, his/her orders and are put into a software program immediately prior to leaving the facility; -The facility has access to the new orders; -Facility staff are responsible to ensure the new orders are placed into the resident's POS and TAR; -He/she said the resident did not have failure to thrive or any other underlying health condition. During an interview on 10/29/19 at 2:05 P.M. and 11/4/19 at 3:33 P.M., the resident's physician said the following: -He expected staff to transcribe verbal orders onto the POS when received; -He expected staff to transcribe the orders onto the TAR when received; -He expected staff to implement treatments as ordered when received; -He expected staff to care plan resident treatments; -He would expect staff to follow the Wound Care Plus NP ordered when received; -The decline in the resident's wounds could have be caused by staff not completing dressing changes and not following physician orders. During an interview on 10/30/19 at 3:51 [NAME]M., the Director of Nursing said the following: -She expected licensed staff to ensure orders are placed in the eMAR and ensure the treatment changes ordered by the physician were placed on the TAR and the care plan; -She expected staff to complete treatments as ordered; -If there was any question, staff should check the orders or call the physician for clarification. During an interview on 11/5/19 at 8:33 [NAME]M., the administrator said the following: -He expected staff to ensure new orders are placed in POS when received; -He expected staff to ensure new orders are placed on the MAR and TAR when received; -He expected staff to update the resident's care plan with new treatment orders when received; -If any doubt in the order, he expected staff to call the physician to clarify. MO 5

Based on observation, interview, and record review, the facility failed to provide necessary care and services for two residents (Residents #5 and #7), in a review of eight sampled residents, to maintain or improve his/her highest practicable physical and mental well-being, by failing to monitor and document bowel movements and administer medications as appropriate to prevent constipation. The resident developed a fecal impaction (hardened stool that cannot pass through the rectum or colon with a normal bowel movement) on 1/28/19 and 2/11/19, which required manual intervention to remove. The facility failed to appropriately monitor, assess, and provide treatment as indicated by professional standards for one resident (Resident #5) following his/her return to the facility from the emergency room for treatment of [REDACTED]. The facility census was 104. 1. Review of the facility's policy on Resident Change in Condition (Observing, Recording and Reporting), dated (MONTH) (YEAR), showed the following: -Purpose: To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; -After a resident has a change in physical or mental function, observe and monitor for changes in consciousness, pain, bleeding, vital signs including temperature, generalized weakness, difficulty breathing, flushing, or cyanosis; -Monitor the resident's condition frequently until stable; -Notify physician of condition change, need for treatment orders and/or medication order changes. 2. Review of the facility's policy, Medication Administration, dated (MONTH) (YEAR), showed the following: -Purpose: Medications are given to benefit a resident's health as ordered by the physician; -Important: If the resident refuses medication, indicate failure to administer medication on the medication record by circling initials and make a notation on the back of the medication record (include date, time, and what occurred, initials and title); -Record the medication given on the medication sheet. 3. During an interview on 2/20/19, the administrator said the facility did not have a policy on bowel monitoring. 4. Review of Resident #5's care plan, dated 9/13/18, showed the following: -The resident was at risk for pain related to falls; -Administer medications as ordered; -Monitor and record the effectiveness and report adverse effects. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 9/18/18, showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Required limited assistance of one staff for bed mobility, transfers, walking, dressing, and toilet use; -Always incontinent of bowel and bladder; -Received opioid medication four out of seven days. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -Senna S (stool softener plus laxative) 8.6 milligrams (mg)/50 mg, two tabs daily; -[MEDICATION NAME] (medication that prevents nausea and vomiting) 8 mg every eight hours as needed (PRN) for nausea; -[MEDICATION NAME] (laxative) suppository per rectum every three days PRN if no bowel movement; -Milk of Magnesia (laxative) 30 milliliters (ml) daily PRN for constipation; -Senna S 8.6 mg/50 mg, one to two tabs daily PRN for constipation; -[MEDICATION NAME]/[MEDICATION NAME] (narcotic pain medication that can cause constipation) 5/325 mg, one to two tabs every eight hours PRN for pain. Review of the resident's Medication Administration Record [REDACTED] -Staff administered the [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg PRN once a day for pain on 1/1/19, 1/3/19, 1/5/19, and 1/10/19; -On 1/12/19, staff administered [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg two times. There was no evidence staff administered the once daily dose of Senna S, and no evidence to show why staff did not administer the medication. -Staff administered the [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg PRN twice a day for pain on 1/13/19 and 1/14/19; -Staff administered the [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg PRN once a day for pain on 1/16/19 and 1/17/19; -On 1/17/19, there was no evidence staff administered the once daily dose of Senna S, and no evidence to show why staff did not administer the medication. -Staff administered the [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg PRN once a day for pain on 1/18/19 through 1/20/19; -Staff administered the [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg PRN twice a day for pain on 1/21/19 and 1/22/19. Review of the resident's documented bowel movements for (MONTH) 2019 showed the resident had one documented medium bowel movement for the month on 1/27/19 at 9:08 P.M. Review of the resident's nurse's note, dated 1/28/19 at 3:22 P.M., showed the resident was impacted and required staff to digitally remove a small amount of hard stool. Staff administered Milk of Magnesia and Senna PRN. Review of the resident's MAR for (MONTH) 2019 showed the following: -No evidence staff administered the PRN Senna or Milk of Magnesia on 1/28/19 (as indicated in the nurses notes); -No evidence staff administered the once daily dose of Senna A on 1/31/19. There was no documentation to show why staff did not administer the medication. -There was no documentation staff administered any PRN laxatives in (MONTH) 2019. Review of the resident's POS for (MONTH) 2019 showed the following: -Hospice resident; -Senna S 8.6 mg/50 mg, two tabs daily; -[MEDICATION NAME] 8 mg every eight hours PRN for nausea; -[MEDICATION NAME] suppository per rectum every three days PRN if no bowel movement; -Milk of Magnesia 30 ml daily PRN for constipation; -Senna S 8.6 mg/50 mg, one to two tabs daily PRN for constipation; -[MEDICATION NAME]/[MEDICATION NAME] 5/325 mg, one to two tabs every eight hours PRN for pain. Review of the resident's MAR for 2/1/19 through 2/11/19 showed the following: -No evidence staff administered the once daily dose of Senna S on 2/2/19 and 2/3/19. There was no documentation to explain why the medication was not administered; -Staff administered the [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg PRN once a day for pain on 2/9/19 and 2/10/19; -No documentation staff administered PRN laxatives from 2/1/19 through 2/11/19. Review of the resident's documented bowel movements from 2/1/19 through 2/11/19 showed the resident had one large bowel movement on 2/10/19 at 9:13 A.M. (The resident's last documented bowel movement was on 1/27/19.) Review of the resident's nurses notes showed no documentation regarding the resident's condition on 2/11/19. Review of the resident's nurse's notes showed on 2/12/19 at 6:00 A.M., the certified nurse aide (CNA) reported to the nurse the resident had a large amount of emesis with blood and blood clots. The CNA showed the nurse a blanket with a large amount of bloody emesis with blood clots. Staff contacted the on call nurse practitioner and received orders to send to resident to the emergency room . The resident was transferred to the hospital at 6:30 A.M. Review of the resident's emergency room discharge report, dated 2/12/19, showed the following: -Chief complaint: Vomiting blood; -Reported by accompanying family, the resident was impacted at the nursing home yesterday and the stool was manually removed; -Emergency Department Course: The resident presented to the emergency room after multiple episodes of vomiting with blood. The resident's blood counts were low but not critical. The resident was discharged back to the nursing home; -Start taking [MEDICATION NAME] 4 mg by mouth every six hours as needed for nausea/vomiting; -Follow up with the primary care physician. Review of the resident's medical record showed no documentation of the resident's condition upon his/her return from the hospital or throughout the day shift on 2/12/19. During an interview on 2/19/19 at 2:42 P.M., CNA C said he/she worked with the resident on the day shift on 2/12/19. The resident returned from the hospital around 1:30 P.M. on 2/12/19. The resident had almost continuous vomiting on 2/12/19. CNA C informed the charge nurse (Licensed Practical Nurse (LPN) B) about the resident's condition. The charge nurse was well aware of the resident's continued nausea and vomiting. During an interview on 2/19/19 at 3:12 P.M., hospice Registered Nurse (RN) A said he/she arrived at the facility on 2/12/19 at 3:00 P.M. LPN B was walking out the door when hospice RN A walked in. LPN B said the resident needed a suppository for the vomiting because he/she was not taking anything by mouth. Hospice RN A contacted the physician and got orders for the [MEDICATION NAME] suppository (medication to treat severe nausea and vomiting). The resident's family member picked up the suppositories from the pharmacy and brought them into the facility on [DATE]. Hospice RN A administered the first suppository at about 4:00 P.M. on 2/12/19. Hospice RN A instructed staff to give the next dose at 9:00 P.M. in an attempt to get the resident's vomiting under control. Review of the resident's POS for (MONTH) 2019 showed on 2/12/19 at 4:16 P.M., an order was received for [MEDICATION NAME] suppository 25 mg per rectum every four hours PRN for nausea and vomiting (received by hospice Registered Nurse (RN) A). Review of the resident's MAR indicated [REDACTED].M. Staff did not document any results of the PRN [MEDICATION NAME]. Review of the resident's medical record showed no documentation of the resident's condition throughout the evening and night on 2/12/19. Review of the resident's MAR for (MONTH) showed staff administered the PRN [MEDICATION NAME] suppository on 2/12/19 at 10:00 P.M. Staff did not document any result of the PRN [MEDICATION NAME]. Review of the resident's nurse's note, dated 2/13/19 at 5:04 A.M., showed the resident slept through the night with no emesis noted. During a telephone interview on 2/20/19 at 11:43 A.M., CNA [NAME] said he/she worked with the resident on the day shift on 2/13/19. The resident was groggy and didn't feel well. The resident refused fluids. The resident vomited dark, what looked coffee grounds, at about 1:30 P.M. on 2/13/19. It was a large amount and CNA [NAME] had to change the resident's clothes and bed linen. CNA [NAME] reported this to LPN B just shortly after 1:30 P.M. CNA [NAME] did not observe LPN B ever go into the room on 2/13/19 or assess the resident after CNA [NAME] had reported the resident had vomited. During an interview on 2/19/18 at 2:50 P.M., LPN B said he/she was in the resident's room on 2/13/19 at 8:00 A.M. to administer morning medications. The resident refused his/her medications at that time but had no complaints and seemed fine. LPN B said he/she did not go back into the resident's room after 8:00 A.M., but was up and down the resident's hall and the resident appeared to be okay. LPN B said on 2/13/19 at about 2:00 P.M., the aide reported to him/her the resident vomited. LPN B passed the information on to the oncoming nurse and is not aware of what happened after that. LPN B said he/she did not administer the [MEDICATION NAME] suppository to the resident because he/she did not realize the [MEDICATION NAME] suppositories were available to give to the resident. During an interview on 2/19/19 at 4:00 P.M., CNA G said he/she worked the evening shift on 2/13/19. The resident was throwing up constantly. The resident vomited twice in one hour at the start of the shift and he/she reported this to the charge nurse, LPN I. CNA G cleaned the resident up. A while later, the resident's family member arrived, about 3:30 P.M. and found the resident had vomited. The family member was upset the resident had not been given any medication to control the vomiting. Review of the resident's medical record showed no documentation of the resident's condition throughout the day, including episodes of vomiting, on 2/13/19. During a telephone interview on 2/20/19 at 10:37 A.M., LPN I said he/she worked with the resident on the evening shift on 2/13/19. LPN I said he/she was told in report the family didn't want anything done for the resident because he/she was a hospice resident. On 2/13/19, the resident was continually drooling a dark, mucous-like substance. The family reported the resident was throwing up. LPN I said he/she administered the [MEDICATION NAME] suppository at 3:45 P.M. after a family member requested it be given due to finding vomit on the resident's bed. Review of the resident's MAR for (MONTH) showed staff administered the PRN [MEDICATION NAME] suppository on 2/13/19 at 3:45 P.M. Staff did not document any result of the PRN [MEDICATION NAME]. (Review showed no evidence staff administered the [MEDICATION NAME] suppositories between 10:00 P.M. on 2/12/19 and 3:45 P.M. on 2/13/19. Staff reported the resident had episodes of vomiting at 1:30 P.M. and at the beginning of the evening shift. Staff did not administer [MEDICATION NAME] suppository until 3:45 P.M. when family requested the medication be given.) Review of the resident's nurse's notes showed no documentation why staff administered the PRN [MEDICATION NAME] on 2/13/19 at 3:45 P.M. During a telephone interview on 2/20/19 at 8:15 A.M., the resident's family member said he/she was at the facility on 2/11/19 at 2:30 P.M. and the resident was very agitated. Staff assisted the resident to the bathroom and the resident tried to move his/her bowels and could not. LPN H removed the impaction of stool from the resident and his/her mood improved a great deal. On 2/12/19, staff sent the resident to the emergency room due to vomiting blood. The resident returned to the facility on [DATE] at 1:30 P.M. The hospital sent the resident back to the facility on a medication he/she already had ordered. The hospice nurse spoke with the physician and got an order for [REDACTED].M., another family member arrived and found the resident covered in vomit. The family member had to find a staff member for help. He/she arrived at the facility about 4:10 P.M. on 2/13/19 and the resident was continually vomiting. He/she asked staff why the [MEDICATION NAME] suppository had not been given to the resident. No one had an answer for him/her. The charge nurse shrugged his/her shoulders and walked away. During an interview on 2/19/19 at 4:20 P.M., the administrator said on the evening of 2/13/19, the resident's family reported another family member had come to the facility earlier and found the resident covered in vomit. The family member said the resident had medication in place for vomiting and questioned why it wasn't given. The family member said staff told him/her the resident had vomited all day. The administrator called LPN B at home and asked why the medication wasn't given; LPN B responded it was just a little bit of vomit and the CNA did not tell him/her about it until 2:00 P.M. The administrator did not know anything about the resident being impacted until he/she read about it in the emergency room report. During an interview on 2/14/19 at 2:15 P.M., RN D said he/she was aware the resident was impacted a few days ago. He/she had heard this from another nurse in the facility but could not recall who. RN D did not know why there was no documentation of the resident being impacted which required the nurse to remove the stool manually. There should have been a note about that event, as well as a nursing note when the resident returned from the emergency roiagnom on [DATE] and documentation if the resident continued to vomit. During a telephone interview on 2/20/19 at 11:43 A.M., CNA [NAME] said the resident had been constipated several times in the past. The previous Sunday (2/10/19) or Monday (2/11/19), the resident was impacted and LPN H had to manually assist the resident to remove the stool. The resident was much better after the stool was removed. During an interview on 2/19/18 at 2:50 P.M., LPN B said he/she did not have any knowledge of the resident ever being constipated or impacted. The nurse aides documented residents' bowel movements in the computer. LPN B said he/she was not sure if anyone tracked or checked the documentation. LPN B did not ever review the bowel charting completed by the aides. During an interview on 2/19/19 at 3:12 P.M., hospice RN A said the resident transferred to the emergency roiagnom on [DATE] due to vomiting a large amount of bright red blood. The day or two before the resident was sent to the emergency room , the resident was impacted of stool which staff at the nursing home had to manually remove. The same thing had occurred the previous week. The resident became very anxious, worked up, and agitated whenever he/she was constipated. Once the stool was removed, the resident was always much calmer. During a telephone interview on 2/20/19 at 11:25 A.M., the administrator said staff should have documented an assessment when the resident returned from the emergency room (on 2/12/19). The administrator would expect staff to document any medication given and document the effectiveness of any PRN medication given. If a resident was impacted of stool, staff should contact the physician for further instructions. During a telephone interview on 3/5/19 at 10:45 A.M., the resident's physician said he would expect staff to monitor residents' bowel movements and to contact him/her to get something in place if a resident was having problems with constipation prior to developing a fecal impaction. Resident #5's fecal impaction could have contributed to him/her vomiting blood. The vomiting could have been the result of a [MEDICAL CONDITION] or [MEDICAL CONDITION] problem, which a fecal impaction could exacerbate. The resident's physician would have expected staff to monitor the resident and assess him/her at least every three or four hours and would expect staff to administer the ordered medication if the resident continued to vomit. Vomiting is very uncomfortable and staff should have been diligent to keep the resident's vomiting under control in order to reduce his/her discomfort. 5. Review of Resident #7's care plan, last revised 11/30/18, showed the following: -Pain related to rib fractures; -Evaluate effectiveness of pain management and adjust if adverse side effects emerge; -The resident had self-care deficits with all activities of daily living; -One person assist with toileting. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was moderately impaired; -Required physical assistance from one person with toileting; -Received opioid medications (medication for pain that can cause constipation) seven out of seven days; -Always continent of bowel. Review of the resident's Physician order [REDACTED]. -Senna S 8.6 mg/50 mg, one tab daily; -[MEDICATION NAME]/[MEDICATION NAME] (opioid pain medication that can cause constipation) 5/325 mg, one tab three times a day; -Milk of Magnesia (MOM) 30 ml daily PRN for constipation; -Fleets enema 133 ml, insert one enema rectally as needed if no bowel movement in three days and no result from MOM; -Polyethylene [MEDICATION NAME] (laxative) 17 grams in eight ounces of liquid once daily PRN. Review of the resident's documented bowel movements from 1/1/19 through 1/31/19 showed the following: -On 1/10/19 at 7:37 P.M., the resident had a small bowel movement; -On 1/30/19 at 3:31 A.M., the resident had a medium bowel movement; -There were no additional bowel movements documented for the month. Review of the resident's MAR for (MONTH) 2019 showed staff did not administer any PRN laxatives. Review of the resident's POS for (MONTH) 2019 showed the following: -Senna S 8.6 mg/50 mg, one tab daily; -[MEDICATION NAME]/[MEDICATION NAME] 5/325 mg, one tab three times a day; -Milk of Magnesia 30 ml daily PRN for constipation; -Fleets enema 133 ml, insert one enema rectally as needed if no bowel movement in three days and no result from Milk of Magnesia; -Polyethylene [MEDICATION NAME] (laxative) 17 grams in eight ounces of liquid once daily PRN. Review of the resident's documented bowel movements from 2/1/19 through 2/19/19 showed the following: -On 2/10/19 at 9:22 A.M., the resident had a small bowel movement; -On 2/13/19 at 11:15 A.M., the resident had a medium bowel movement; -On 2/18/19 at 9:24 A.M., the resident had a medium bowel movement. -There were no additional bowel movements documented for this period. Review of the resident's MAR for (MONTH) 2019 showed staff did not administer any PRN laxatives. 6. During an interview on 2/19/19 at 3:50 P.M., LPN F said the aides report to the nurse if a resident hasn't had a bowel movement in three days. Some residents can say if they are or are not constipated. The aides charted residents' bowel movements in the computer. LPN F did not review the CNA charting for bowel movements. 7. During an interview on 2/19/19 at 4:20 P.M., the administrator said the aides documented residents' bowel movements in the computer. Nurses should check this documentation daily to see who has not had a bowel movement in three days. If a resident has not had a bowel movement in three days, staff should administer a laxative or stool softener if one was in place, and if not, call the physician for further instructions. Complaint #MO 2

Based on interview and record review, the facility failed to assess and monitor one resident's (Resident #6) condition following increased complaints of leg pain, in a review of six sampled residents. The resident was seen by the physician on 6/28/18, who informed staff to monitor the resident's leg. The resident presented with increased pain, swelling and bruising to his/her left leg. Nursing staff failed to monitor the condition of the resident's leg until 7/2/18, when an order was received for an x-ray. The resident continued with increased pain between 7/2/18 and 7/5/18 (as indicated by the medication administration record), however, there was no documented assessment of the resident's leg on 7/4/18. Staff documented the resident received as needed [MEDICATION NAME] (narcotic pain medication) two times on 7/4/18 for pain greater than an eight on a scale of zero to ten. On 7/5/18, staff noted the resident had extensive bruising to the left leg and increased pain. The resident was sent to the hospital, where an x-ray showed a left proximal femoral (thigh bone) shaft fracture. The facility census was 103. 1. Review of the facility's Condition Change Policy, dated (MONTH) (YEAR), showed the following: -Purpose; to observe, record and report any condition change to the attending physician so that proper treatment can be implemented; -After all resident falls, injuries or changes in physical or mental function, monitor the following: -Observe swelling and discoloration, if present, chart size, site and amount and color; -Observe for pain; -Observe for abduction, shortening or improper positron of extremities; -Notify resident's responsible party; -Monitor the resident's condition change, need for treatment orders and/or medication order changes. -Notify physician of condition change, need for treatment orders and/or medication order changes. Review of the facility's Notification of Physician policy, undated, showed the following: -Purpose: to ensure proper and timely notification of physician regarding resident's care; -Upon admission, upon any identified change of condition as directed by physician's protocol, and when deemed necessary by nursing staff; -Policy: Facility will immediately inform the resident, consult with the resident's physician and if known, notify the resident's legal representative or interested family member when there is: -An accident resulting in injury to the resident and has potential in requiring physician intervention; -A significant change in resident's physical, mental or psychosocial status; -A need to alter treatment significantly; -A decision to transfer or discharge the resident from the facility. 2. Review of Resident #6's care plan, last revised on 4/25/18, showed the following: -The resident had a history of [REDACTED].>-The resident will not exhibit any nonverbal signs of pain (e.g., crying guarding, moaning, restlessness, grimacing, diaphoresis or withdrawal); -Administer medications as ordered, evaluate, record, report effectiveness and any adverse side effects; -Assess effects of pain on the resident (sleep disturbance, activity disturbance, self-care disturbance, appetite disturbance, psychosocial disturbance, role/ relationship disturbance, etc.); -Evaluate effectiveness of pain management interventions, adjust if ineffective or adverse side effects emerge; Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 4/22/18 showed the following: -Severe cognitive impairment; -Required extensive assistance of one staff member with bed mobility, transfers, locomotion on and off unit, dressing and toilet use; -During the last five days the resident had been on scheduled pain medication; -During the last five days the resident had not received as needed (PRN) pain medications -During the last five days, the resident had not received non-medication interventions for pain; -Pain interview showed no presence of pain. Review of the resident's physician order [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (a narcotic to treat severe pain) patch 25 microgram (mcg)/hour, apply one patch topically and change every 72 hours; -[MEDICATION NAME]-[MEDICATION NAME] (a narcotic used to treat pain) 7.5 mg /325 mg every six hours as needed for pain. Review of the resident's (MONTH) (YEAR) PRN medications log showed the following: -On 6/27/18 at 4:00 P.M., the resident received [MEDICATION NAME] 7.5 milligrams (mg)/325 mg one tablet, for leg pain rated a nine on a scale of zero to ten; -On 6/27/18 at 10:00 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for leg pain rated an eight on a scale of zero to ten. Review of the resident's nurse's notes showed no documentation of an assessment being completed of the resident's left lower extremity on 6/27/18. Review of the resident's (MONTH) (YEAR) PRN medications log showed on 6/28/18 at 5:00 A.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet. The resident was grasping left lower extremity and was resistive to care, saying It hurts. During interview on 7/9/18 at 8:15 A.M., Registered Nurse (RN) G said on 6/28/18, he/she had the physician take a look at the resident's left knee as the resident was having considerable pain in the left knee and holding it up towards his/her chest. There was no bruising, just pain. The physician said an x-ray had been done of the hip. RN G thought all was good, but did not know at the time that the most recent x-ray was in April. The physician said to monitor the resident's leg; he/she thought the physician meant to monitor the leg for the day. Review of the resident's nurse's notes showed no documentation the resident was having considerable pain in his/her left leg on 6/28/18, evidence of the physician's assessment of the resident, or directions from the physician to continue to monitor the resident's left leg. Review of the resident's (MONTH) (YEAR) PRN medications log showed on 6/29/18 at 7:30 A.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for complaints of left leg pain. Review of the resident's nurse's notes showed no documentation of an assessment being completed of the resident's left lower extremity on 6/29/18 when the resident continued to have complaints of left leg pain. During interview on 7/6/18 at 2:10 P.M., Certified Nurse Assistant (CNA) H said the resident was still having pain on 6/29/18; he/she told Licensed Practical Nurse (LPN) E and LPN E gave the resident pain medication. No bruising was noted to the resident's left leg until 6/30/18. Review of the resident's (MONTH) (YEAR) PRN medications log showed the following: -On 6/30/18 at 3:00 A.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for complaints of left leg pain; -On 6/30/18 at 9:00 A.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for complaints of left lower extremity pain (RN G's initials); -On 6/30/18 at 3:00 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for complaints of left lower extremity pain (RN G's initials). During interview on 7/6/18 at 2:50 P.M. and 7/20/18 at 11:46 A.M., CNA C said the following: -On 6/30/18, the resident was yelling out in pain, and there was bruising started on the resident's left knee. He/she knew something was wrong as he/she had cared for the resident for over four years; -The resident wasn't himself/herself; -He/she had to prop something under the resident's leg because otherwise the resident's leg would swing outward; -The resident's thigh area was doubled in size; -The resident had complained of pain before but never to this extent; -He/she called the nurse (unable to recall which nurse), outside the unit and told him/her the resident was having pain in his/her leg; -The resident was given something for pain and it helped because the resident stopped yelling out in pain. During interview on 7/9/18 at 8:15 A.M., RN G said he/she didn't get any information about the resident's knee in report on 6/30/18. If the CNAs would have come to him/her with a concerns about the resident, he/she would have checked it out. (Review of the PRN medication log showed RN G's initial next to the administration of the PRN [MEDICATION NAME] at 9:00 A.M. and 3:00 P.M. on 6/30/18 for left extremity pain.) Review of the resident's nurse's notes showed no documentation of an assessment being completed of the resident's left lower extremity on 6/29/18 when the resident continued to have complaints of left leg pain. Review also showed no documentation of an assessment being completed of the resident's left lower extremity on 7/1/18. Review of the resident's physician order [REDACTED]. -[MEDICATION NAME] (a narcotic to treat severe pain) patch 25 microgram (mcg)/hour, apply one patch topically and change every 72 hours; -[MEDICATION NAME]-[MEDICATION NAME] (a narcotic used to treat pain) 7.5 mg /325 mg every six hours as needed for pain. Review of the resident's (MONTH) (YEAR) PRN medications log showed the following: -On 7/2/18 at 12:30 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for complaints of left lower extremity pain, rated eight on a scale of zero to ten; -On 7/2/18 at 7:00 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for pain rated eight on a scale of zero to ten. During interview on 7/6/18 at 10:55 A.M., CNA A said the following: -The resident's left leg was turning in on 6/29/18. By 7/2/18, when he/she came back to work after being off a few days, it was turning in badly; the resident couldn't straighten it out at all; -If staff even touched the resident's leg, the resident would say, Oh, its killing me! -He/she tried to put the resident's feet on the foot pedals but it caused excruciating pain; -The pain medication was not controlling the resident's pain; CNA A was constantly telling LPN D the resident was still in pain. During interview on 7/6/18 at 2:35 P.M., Nurse Aide (NA) B said the following: -On 7/2/18, he/she told LPN D to look at the resident's leg, the bruising was more noticeable; -The resident's pain was in his/her left thigh more than the knee, and the resident's leg was turned in and bent funny; it was like it was double jointed; -The resident swore up and down staff was killing him/her when staff did anything; he/she was in severe pain. During interview on 7/6/18 at 11:00 A.M., Licensed Practical Nurse (LPN) D said the following: -He/she worked a 12-hour shift on 7/1/18 and he/she did not receive anything in report that there was any issues with the resident's knee; -At the end of his/her shift on 7/2/18, an aide came to him/her and asked if someone could look at the resident's knee; -He/she pulled the resident's pant leg up and looked at the knee and saw bruising and swelling; -He/she passed it on to the medication nurse for 3-11 shift to notify the charge nurse as it was the end of his/her shift; -He/she had not been assessing the resident's knee prior to this as he/she was unaware of any issues that had been going on. (Review of the facility staffing sheets showed LPN D worked a day shift as charge nurse to the 300 and 400 hall (the unit where the resident's room was located) on 6/28/18, 6/29/18, 7/1/18 and 7/2/18.) During interview on 7/6/18 at 2:30 P.M., LPN E said the following: -He/she was told on 7/2/18 that the resident had pain and swelling to his/her left knee; -The resident had weird bruising; purple dots on the top of the knee; -He/she thought the leg had already been x-rayed; -He/she got to looking in the resident's medical record around 10:20 P.M. and saw it had not been x-rayed so he/she passed the information to LPN F in report that night; -He/she would have let the physician know a lot quicker if he/she would have known there had not been an x-ray completed. Review of the resident's nurse's notes, dated 7/3/18 at 3:55 A.M., showed the 3-11 shift nurse (LPN E) reported to this nurse (LPN F) the resident's left knee was swollen. The resident's left knee was swollen and bruised. A physician order [REDACTED]. The resident complained of pain when moved. The resident was medicated with [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]). During interview on 7/11/18 at 5:45 A.M. and 7/20/18 at 8:30 A.M., LPN F said the following: -He/she worked on 6/30/18 and no one mentioned there was any issues with the resident's left knee; -He/she would not necessarily look at the knee or assess it unless it was reported to him/her specifically that there was an issue; -He/she relied on the CNAs to let him/her know of any concerns with the residents on the unit; -LPN E told him/her in report on 7/2/18 (prior to his/her 11-7 shift) that he/she found out before shift change there was an issue with the resident's knee; -After he/she received report, he/she assessed the resident's knee; -The resident was already in bed, positioned on his/her left side. LPN F pulled the covers back and grabbed the resident's left heel and the resident grimaced and said, It hurts; -He/she didn't assess the resident's hip or do anything else; he/she knew something was wrong; -The resident's knee was bruised and looked like a cantaloupe; -The resident did not want LPN F touching it; -He/she obtained an order for [REDACTED].>-Radiology did not show up before his/her shift was over. Review of the resident's (MONTH) (YEAR) PRN medications log showed the following: -On 7/3/18 at 4:00 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for pain rated a nine on a scale of zero to ten; -On 7/3/18 at 9:00 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for pain rated a seven on a scale of zero to ten. Review of resident's nurse's notes, dated 7/3/18 at 10:12 P.M., showed the following: -Knee x-ray done, awaiting report; -[MEDICATION NAME] was given, resident up in wheelchair for supper, tolerated well; -Left knee remains swollen and bruised. Review of the resident's (MONTH) (YEAR) PRN medications log showed the following: -On 7/4/18 at 3:00 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for pain rated a nine on a scale of zero to ten; -On 7/4/18 at 9:00 P.M., the resident received [MEDICATION NAME] 7.5 mg/325 mg one tablet, for pain rated an eight on a scale of zero to ten. During interview on 7/19/18 at 12:30 P.M. and 7/20/18 at 8:20 A.M., LPN E said the following: -He/she administered the resident's [MEDICATION NAME] on the evening shift of 7/2/18, 7/3/18 and 7/4/18; -He/she may not always ask the resident where the pain was located prior to administering a PRN; -He/she did not necessarily ask the resident to elaborate or check the specific area that the resident was complaining of; -He/she often just wrote down pain and the level on 0-10 scale; -He/she often assumed it was probably in the same spot, as last time. -The resident had a lot of pain in his/her back due to scoliosis, he/she thought he/she gave the [MEDICATION NAME] for that and maybe left knee pain. Review of the resident's nurse's notes, dated 7/4/18 at 8:16 P.M., showed the x-ray results were received. The results showed no acute fracture, arthritic changes were seen. Review of the resident's nurse's notes showed no documentation of an assessment being completed of the resident's left lower extremity on 7/4/18. Review of the nurse's note, dated 7/5/18 at 11:53 A.M., showed the following: -On 7/2/18, the resident was noted to have slight bruising around the left knee cap as reported by the night nurse; -The area was painful and an x-ray to left knee was ordered and was done on 7/3/18; -The x-ray results showed no acute fracture or dislocation; -Today, upon assessment, the resident has extensive bruising to the left leg and has increased pain; -New orders were received to send the resident to the emergency room (ER) for additional x-ray; -Resident is known to propel self in wheelchair and at times staff observe the resident get his/her feet tangled in the wheels. Review of the emergency department provider notes, dated 7/5/18 at 11:52 A.M., showed the following: -Chief complaint: left leg injury; -Time since incident: two days; -Injury: yes; -Mechanism of injury: crush; -Leg location: left upper leg; -Pain details: -Quality: unable to specify: -Onset quality: sudden; -Duration: two days; -Timing: constant; -Chronicity: New; -Physical Exam: -Elderly and demented; curled up in fetal position; -Left hip tenderness; -Left hip swelling with tenderness; swelling extends down to the left lower leg, but does not include the foot; -Left foot is cool to touch and equal through the opposite side; -Large ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising); -Responds only to pain; no response to other stimulus; -Final result: -Findings: mildly comminuted fracture (when a bone is broken into several parts, it is usually due to high impact injury to the bone such as a fall, accident or some other trauma) of the proximal (situated nearer to the center of the body or point of attachment) left femur, appears to be proximal shaft, just below the trochanters (any of two bony protuberances by which muscles are attached to the upper part of the thigh bone); -There is marked superior displacement, moderate medial (situated in the middle) angulation (abnormal bend or cure and angular position), also likely some rotational malalignment (rotation deformity); -Impression proximal left femoral shaft fracture. During interview on 7/5/18 at 3:45 P.M., the Director of Nursing (DON) said the following: -The resident was known to get his/her leg caught up in his/her wheelchair; -On 6/22/18 and 6/28/18, the resident was seen by the physician; there was no pain or bruising at that time; -He/she would expect staff to let the physician know if there was swelling or bruising in the knee; -He/she would expect staff to monitor the resident after the physician said for staff to continue to monitor; -He/she was not aware if the staff noted the swelling and bruising before 7/5/18; -He/she looked at the resident's leg on 7/5/18 and instructed staff to send the resident to the ER; he/she knew there was an issue. During interview on 6/28/18 at 3:46 P.M., the resident's physician said the following: -He/she was at the facility on 6/28/18 and was told the resident was having pain in his/her knee; -He/she assessed the knee and there was no bruising or [MEDICAL CONDITION]; -He/she instructed the staff to continue to monitor the leg; -If staff started to see swelling, bruising or increased pain, he/she would have expected to have been notified and he/she would have ordered an x-ray. Complaint MO 4

Based on observation, interview, and record review, the facility failed to implement interventions for residents the facility assessed as being at risk for weight loss. The facility failed to consistently offer physician ordered supplements and failed to provide prompt and necessary assistance at meal times for three residents with a history of weight loss (Residents #6, #10 and #13), in a review of 21 sampled residents. The facility identified six residents with weight loss. The facility census was 119. 1. Review of the facility's policy on nutrition from the Nursing Guidelines Manual, dated March 2012, showed the following: -Purpose: The facility will provide nutrition as determined by the physician and in cooperation with the dietician for all residents according to State and Federal guidelines, and will not hold nutrition to hasten or prompt death; -Guidelines: 1. Residents will be provided meals three times a day at facility determined times; 2. Diet ordered by a physician will be followed (see dietary manual for additional information on specific diets). If a resident does not like the meal offered, they will be given an alternative choice; 3. Staff will feed all residents who are unable to feed themselves; 4. Residents will be assessed for adaptive devices to promote the highest level of independence. Residents with swallowing problems will be provided with nutrition as directed by the physician in accordance with state and federal guidelines and under the direction of a dietician; 5. Residents will be offered bedtime snacks unless contraindicated; 6. At no time will the facility withhold nutrition to promote or hasten death. If a resident, family, or physician request withholding fluids or foods, that resident will be discharged from the facility; 7. If a resident is admitted without the facility being informed of the family or resident's request for withholding fluids or nutrition, that resident will be given fluids and nutrition until the resident can be transferred to another facility. Review of the facility's assistance with meals policy, dated March 2012, showed the following: -Purpose: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident; -Guidelines for dining room residents: All residents will be encouraged to eat in the dining room. Nursing staff and/or feeding assistants will serve resident trays and will help residents who require assistance with eating. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. For example: Not standing over residents while assisting them with meals. Keeping interactions with other staff to a minimum while assisting resident's with meals. Avoiding the use of labels when referring to residents (e.g."feeders"). Avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident. -Residents Confined to Bed: The dietary department will deliver food carts to appropriate areas. The nursing staff will prepare residents for eating. The nursing staff and/or feeding assistants will take food trays into residents' rooms. Nursing staff and/or feeding assistants will pick up residents' food trays after each meal and will notify the dietary staff to pick up the carts; -Residents Requiring Full Assistance: Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. Nursing staff and/or feeding assistants will feed those residents needing full assistance. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: 1. Not standing over residents while assisting them with meals; 2. Keeping interactions with other staff to a minimum while assisting resident's with meals; 3. Avoiding the use of labels when referring to residents (e.g."feeders"). 2. Review of Resident #6's vital sign and weight flow sheet showed the resident's weight on 5/20/14 was 125 pounds. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/27/14, showed the following: -[DIAGNOSES REDACTED]. -Ability to make daily decisions was moderately impaired; -Required extensive assistance of one staff member for eating; -Height was 64 inches; -Weight was 121 pounds; -No nutritional approaches were utilized. Review of the resident's vital sign and weight flow sheet showed the following: -On 5/28/14, the resident's weight was 120.6 pounds; -On 6/5/14, the resident's weight was 121.4 pounds; -On 6/14/14, the resident's weight was 115 pounds; -On 6/18/14, the resident's weight was 109.6 pounds with an intervention to add 90 cubic centimeters (cc) of med pass supplement (a liquid supplement that provides additional calories and protein) twice a day; -On 6/23/14, the resident's weight was 114.2 pounds. (The resident had a significant weight loss of 5.3 percent in one month.) Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Ability to make daily decisions was moderately impaired; -Required limited assistance of one staff member for eating; -Height was 64 inches; -Weight was 116 pounds; -No nutritional approaches were utilized. Review of the resident's care plan, with a problem start date of 7/15/14, showed the following: -The resident was at risk for weight loss; -Approaches: Offer bedtime snacks. The resident liked ice cream, but not chocolate. Monitor and record intake of food. Monitor and record weight monthly and as needed. Offer substitutes if the resident has a problem with the food that is served. Provide set up help, cueing, physical help and assistance for meals. Review of the resident's nutritional assessment, signed by the dietician on 7/29/14, showed the following: -No skin concerns; -The resident continued to feed himself/herself with staff assistance. The resident ate between 80% and 90% of meals. The resident received health shakes and snacks; -The dietician's plan was to discontinue the resident's health shakes and start the med pass supplement. The resident's weight was more stable and weekly weights were no longer required. Review of the resident's dietician progress note, dated 10/29/14, showed the resident's weight was down to 113.4 pounds. Recommendation was to increase the med pass supplement to 120 cc three times a day. Review of the resident's physician order sheet showed an order, dated 10/31/14, for 120 cc of med pass supplement to be given by mouth three times a day at 8:00 A.M., 12:00 P.M., and 4:00 P.M. and to chart the percentage consumed. Review of the resident's physician order sheet for November 2014 showed an order for [REDACTED].M., 12:00 P.M., and 4:00 P.M. and to chart the percentage consumed. Review of the resident's medication administration record (MAR) for November 2014 showed the following: -an order for [REDACTED].M. and 4:00 P.M. Chart the percentage consumed (order was for 120 cc three times a day); -The med pass supplement was documented as given twice a day at 8:00 A.M. and 4:00 P.M.; -The resident refused the supplement one time on 11/18/14 at 8:00 A.M. (The November MAR did not reflect the physician order for [REDACTED].) Review of the resident's MAR for December 2014 showed the following: -an order for [REDACTED].M., 12:00 P.M., and 4:00 P.M. and to chart the percentage consumed; -The resident refused the supplement 15 times of the 93 times it was offered; -The resident consumed 50% to 100% of the supplement 78 of the 93 times it was offered. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Ability to make daily decisions was moderately impaired; -Required supervision and set up help only with eating; -Height was 64 inches; -Weight was 115 pounds; -The resident had weight loss that was not physician prescribed. Review of the resident's care plan, last reviewed on 1/9/15, showed the following updates, in addition to those in place on 7/15/14: -The resident's weight was 115.2 pounds, down ten percent in 180 days; -Regular diet and increase the med pass supplement to 120 cc three times a day from 90 cc two times a day. Review of the resident's nutritional flow sheet (the sheet used by CNA's to document the percent of meals consumed) for 1/1/15 through 1/28/14 showed the following: -No documentation from 1/1/15 through 1/8/15; -On 1/19/15, 1/20/15, and 1/21/15, the resident refused both lunch and supper; -On 1/22/15, the resident refused supper; -On 1/23/15 and 1/24/15, the resident refused both breakfast and lunch; -On 1/26/15, the resident consumed five percent of breakfast and 25% lunch and supper; -On 1/27/15, the resident consumed 25% of breakfast and refused both lunch and supper; -On 1/28/15, the resident refused all three meals. Further review of the resident's nutritional flow sheet for 1/1/15 through 1/28/15 showed the following: -an order for [REDACTED].M., 12:00 P.M., and 4:00 P.M. and to chart the percentage consumed (this had been on the resident's MAR previously); -No documentation of the 8:00 A.M., 12:00 P.M., or 4:00 P.M. med pass supplement from 1/1/15 through 1/8/15; -No documentation of the 4:00 P.M. med pass supplement from 1/12/15 through 1/16/15; -No documentation of the 12:00 P.M. med pass supplement on 1/16/15 and 1/18/15; -No documentation of the 4:00 P.M. med pass supplement on 1/19/15; -No documentation of the 4:00 P.M. med pass supplement from 1/25/15 through 1/28/15. Review of the resident's dietician progress note, dated 1/27/15 (no time), showed the resident's weight was 115.8 pounds. The recommendation was to discontinue the med pass supplement because the resident was not drinking it. Offer the resident grilled cheese and soup as these items were better consumed. Observation of the resident on 1/27/15 showed the following: -At 12:17 P.M., the resident sat in a wheelchair in the dining room and received a lunch tray that included a pork chop and broccoli; -At 12:23 P.M., the resident fed himself/herself one bite of food and laid his/her head on the dining room table; -At 12:25 P.M., the resident remained with his/her head on the dining room table and both eyes closed; -At 12:33 P.M., the resident remained with his/her head on the dining room table and both eyes closed; -At 12:37 P.M., staff told the resident to wake up and eat. The resident raised his/her head and then laid it back down on the table; -At 12:42 P.M., staff told the resident to eat. The resident said he/she was not hungry. A staff member wheeled the resident out of the dining room and into the television room; -At 12:45 P.M., the resident sat in a wheelchair in the television room with his/her head in his/her lap; -At 12:50 P.M., staff wheeled the resident to his/her room and assisted him/her to bed; -At 5:20 P.M., the resident sat in a wheelchair in the dining room with his/her head on the dining room table. The resident had received a meal tray of blueberry pancakes. The resident had not eaten any of the meal. Staff gave the resident a cup of coffee. The resident did not raise his/her head from the table; -At 5:30 P.M., the resident remained with his her head on the dining room table and both eyes closed. The resident had not consumed any food or beverage. A staff member told the resident to eat and drink. The resident said he/she was tired. Staff did not offer the resident an alternate to the meal or a grilled cheese and soup as directed by the dietician; -At 5:42 P.M., staff wheeled the resident out of the dining room into the television room. The resident had not consumed any food or beverage. Review of the resident's physician order sheet for January 2015 showed an order for [REDACTED].M., 12:00 P.M., and 4:00 P.M. and to chart the percentage consumed. Review of the resident's MAR for January 2015, on 1/28/15 at 7:20 A.M., showed no order for the med pass supplement for the entire month. Observation of the resident on 1/28/15 showed the following: -At 6:17 A.M., the resident lay in bed with both eyes closed; -Between 7:10 A.M. and 8:40 A.M., the resident remained in bed with both eyes closed. No meal tray had been delivered to the resident's room; Review of the resident's physician order sheet for January 2015 on 1/28/15 at 7:30 A.M. showed no order to discontinue the med pass supplement as recommended by the dietician on 1/27/15. During an interview on 1/28/15 at 8:50 A.M., Certified Nurse Assistant (CNA) B said the resident never did eat or drink anything that morning because he/she had refused to get out of bed and come to the dining room. Residents could be offered meal trays in their rooms, but the resident said he/she did not want anything. Further observation of the resident on 1/28/15 showed the following: -Between 12:30 P.M. and 12:40 P.M., the resident sat in his/her wheelchair in the hallway outside of the dining room. The resident had not eaten any lunch and said he/she was hungry; -At 12:40 P.M., Licensed Practical Nurse (LPN) P attempted to wheel the resident into the dining room and the resident refused. LPN P told the resident he/she was not going to argue with him/her. The resident again said he/she was hungry but not for chicken and dumplings. LPN P offered to get the resident an alternative. The resident said he/she would not eat it in the dining room; -From 12:40 P.M. until 1:10 P.M., the resident remained in the wheelchair in the hallway outside of the dining room. No food or drink had been offered to the resident; -At 1:10 P.M., the resident wheeled himself/herself into the dining room and sat at a table. Most of the residents had finished eating and had left the dining room. No food or drink was offered to the resident. No staff were present in the dining room; -At 1:15 P.M., the resident remained in the dining room with his/her head in his/her lap. No food or drink was offered to the resident. No staff were present in the dining room; -At 1:27 P.M., staff wheeled the resident out of the dining room and into the television room. No food or drink was offered to the resident. During an interview on 1/28/15 at 12:40 P.M., Certified Medication Technician (CMT) GG said he/she didn't think the resident had an order to receive supplements. The resident did receive health shakes provided by the kitchen and came with the resident's meals. CNA's chart how much the resident consumes at each meal, including the amount of health shake consumed in the meal consumption book. The resident was not offered a health shake today because he/she had refused to come to the dining room. If a resident didn't like the meal that was served, staff could request an alternate meal from the kitchen. An alternate meal was not requested for the resident today because he/she had refused to eat and would not come into the dining room. Observation on 1/29/15 at 9:32 A.M. showed the resident's family member wheeled him/her into the dining room from the television room in the wheelchair. The resident's family member gave the resident a donut and a container of milk. The family member said the resident can be picky about his/her food but really liked donuts, milk, and hamburgers. The resident ate all of the donut and milk provided by the family member. The family member said he/she tries to come to see the resident once a week and brings him/her a donut and milk. The family member said the resident always eats the donut and milk he/she brings. Observation on 1/29/15 at 5:30 P.M. showed the resident sat in the hallway in his/her wheelchair outside the dining room. The resident had not eaten. LPN CC sat in the television room of the special care unit with another staff member. No residents were present in the television room. Residents were sitting in the dining room and had been served their evening meals. During an interview on 1/29/15 at 5:30 P.M., LPN CC said the resident had not eaten anything that evening. Staff had offered to bring the resident a tray but the resident said he/she was not hungry. During an interview on 1/30/15 at 12:15 P.M., LPN J said the med pass supplement was kept on the special care unit medication cart and the nurse gave it to residents who had a order for it. The med pas supplement was documented on the resident's MAR. If there was no med pass supplement on the medication cart, it could be obtained in the special care unit medication room. LPN J said the kitchen provided health shakes and they were given with meals. The CNA's documented the resident's consumption of the health shakes on the resident's consumption record in the meal book. Observation on 1/30/15 at 12:15 P.M. with LPN J showed there was no med pass supplement available on the special care unit medication cart or in the special care unit medication room. During an interview on 1/30/15 at 2:00 P.M., the Director of Nursing (DON) said the medication nurse was responsible for giving the med pass supplement . The nurse should document the med pass supplement on the resident's MAR and include the amount consumed. Health shakes come from the kitchen and are given with meals. The CNA's document the health shakes on the resident's food intake record. There had been a problem with January's paperwork from the pharmacy and some residents' med pass supplement had been placed on the food intake record instead of the MAR. 3. Review of Resident #13's vital sign and weight flow sheet showed the following: -On 5/4/14, the resident's weight was 120.8 pounds; -On 6/5/14, the resident's weight was 119 pounds; -On 7/5/14, the resident's weight was 118 pounds. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required supervision and set up help with eating; -Height was 65 inches; -Weight was 118 pounds. Review of the resident's vital sign and weight flow sheet showed the following: -On 8/5/14, the resident's weight was 117.4 pounds; -On 9/5/14, the resident's weight was 108 pounds. (The resident had a significant weight loss of 8.0 percent in one month.) Review of the resident's dietician progress note, dated 9/25/14, showed the resident's weight was 108 pounds, which was an eight percent loss in 30 days. The resident received health shakes and a recommendation was made for a regular diet with snacks three times a day. Review of the resident's physician order sheet (POS) for October 2014 showed an order for [REDACTED]. Review of the resident's nurse's note, dated 10/23/14 at 9:00 A.M., showed the interdisciplinary team (IDT) met and discussed the resident's weight loss. Health shakes and snacks were to be given. The physician was faxed to see if the resident's anti depressant and anti anxiety medication could be stopped. The physician was also asked about pain medication due to the resident's complaints of leg pain. Review of the resident's nurse's note, dated 10/28/14 at 9:00 A.M., showed the IDT met and discussed the resident's weight loss. The physician added pain medication and a blood pressure medication was decreased for the resident. Review of the resident's dietician progress note, dated 10/29/14 showed the resident weighed 98 pounds. The resident's weight was down 6% in 30 days, down 14% in 90 days, and down 16% in 180 days. A recommendation was made to change health shakes three times a day to one carton of boost supplement twice a day. Review of the resident's physician order sheet (POS) for October 2014 showed an order dated 10/31/14 for med pass supplement 240 cc by mouth three times a day, chart the percent consumed. Review of the resident's POS for November 2014 showed an order dated 10/31/14 for med pass supplement 240 cc by mouth three times a day, chart the percent consumed. Review of the resident's MAR from November 2014 showed an order for [REDACTED]. (The MAR did not reflect the order received on 10/31/14 for med pass 240 cc three times a day). Documentation on the MAR showed the resident consistently consumed the 120 cc of med pass supplement that was offered. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required supervision and set up help with eating; -Height was 65 inches; -Weight was 98 pounds; -The resident had a weight loss that was not physician prescribed. (The resident had a 16.5 percent weight loss in three months.) Review of the resident's care plan, last reviewed on 11/3/14, showed the following: -The resident was at risk for weight loss and his/her weight was down 5% in 30 days and down 10% in 180 days; -Approach: Administer medications and monitor for side effects. Regular diet. Monitor and record food intake. Monitor lab work. Monitor and record weight monthly. Report abnormal labs. Provide med pass supplement, health shakes and snacks three times a day Review of the resident's vital sign and weight flow sheet showed the following: -On 11/7/14, the resident weighed 98.4 pounds; -On 11/25/14, the resident weighed 97.2 pounds. Review of the resident's dietician progress note, dated 11/26/14, showed the resident's weight was down 16% in 90 days and down 19% in 180 days. Increased calories had been provided with snacks and the med pass supplement. No new recommendations were made. Review of the resident's vital sign and weight flow sheet showed the resident's weight on 12/24/14 was 99.6 pounds. Review of the resident's dietician progress note, dated 12/29/14, showed the resident's weight was down 9% in 90 days and down 17% in 180 days. Increased calories had been provided with snacks and the med pass supplement. No new recommendations were made. Review of the resident's POS for January 2015 showed an order for [REDACTED]. -Snacks three times a day, chart the percent consumed; -Med pass supplement 240 cc by mouth three times a day, chart the percent consumed. Review of the resident's nutritional flow sheet for January 2015 showed the following: -No documentation of meal intake from 1/1/15 through 1/8/15; -No documentation the med pass supplement was offered or consumed form 1/1/15 through 1/8/15; -No documentation the med pass supplement was offered or consumed at 5:00 P.M. on 1/14, 1/15, 1/25, 1/26, 1/27, and 1/28; -No documentation snacks were offered. Observation on 1/26/15 showed the following: -At 5:10 P.M., during the supper meal, the resident was in room in bed with both eyes closed; -At 6:15 P.M., the resident remained in bed. Staff reported the resident had not been feeling well and did not get up for supper and did not eat or drink anything. Review of the resident's nutritional flow sheet for 1/26/15 showed the following: -The resident consumed 0% of the morning meal; -The resident consumed 25% of the noon meal; -The resident refused to eat the evening meal. Observation and interview on 1/27/15 at 8:27 A.M. showed the resident was in bed with both eyes closed. CNA A said the resident had not been feeling well for the past two days and did not get up that morning for breakfast. Staff had not offered the resident a meal tray in his/her room, but had been assisting the resident with fluids. Observation on 1/27/15 showed the following: -At 12:24 P.M., the resident was up in the dining room in the wheelchair feeding himself/herself; -At 12:35 P.M., staff provided the resident with chicken noodle soup and CNA A assisted the resident to eat; -At 5:23 P.M., the resident was in the dining room in the wheelchair and had received his/her evening meal tray. A staff member sat next to the resident in a chair and had his/her cell phone in both hands in his/her lap. The resident was not eating or drinking; -At 5:26 P.M., the resident ate part of a banana on his/her own without staff assistance. Observation on 1/29/15 at 5:33 P.M. showed the resident in the dining room of the special care unit in his/her wheelchair. The resident had received his/her meal tray. The resident's hot dog stuck out of his/her glass of ice water. The resident was not eating or drinking. One staff member was present in the dining room assisting another resident. No staff were assisting or encouraging the resident to eat. LPN CC sat in the television room on the special care unit with another staff member. No residents were present in the television room at that time. 4. Review of Resident #10's vital sign and weight flow sheet showed on 7/3/14, the resident weighed 127 pounds. Review of the resident's dietitian progress notes showed the following: -On 8/29/14, health shakes with lunch and supper; -On 9/25/14, resident snacks to three times daily for additional calories. Review of the resident's vital signs and weight flow sheet dated 10/5/14, showed the resident weighed 112 pounds. (The resident had a significant weight loss of 11.8 percent in a three month period.) Review of the resident's nurses notes showed on 10/23/14 at 9:00 A.M., the Interdisciplinary Team (IDT) met and discussed weight loss for the resident. The notes showed the following: -Health shakes two times daily; -The resident liked pancakes; -Encourage to go to the dining room; -Use calm, reassuring approach, can be difficult to cooperate. Review of the resident's dietitian progress note, dated 10/30/14, showed the resident would continue with shakes and snacks to increase calories. Review of the resident's vital sign and weight flow sheet showed on 11/3/14, the resident weighed 105.4 pounds. (The resident had a significant weight loss of 5.9 percent in one month.) Review of the resident's nurses notes, dated 11/6/14 at 9:00 A.M., showed the IDT met and added super cereal with breakfast. Review of the dietitian progress notes, dated 11/26/14, showed the resident's weight was down despite increased calories provided and measures recently started. No lab available. No medication changes. Review of the resident's vital sign and weight flow sheet showed on 12/3/14, the resident weighed 99.8 pounds. (The resident had a significant weight loss of 5.3 percent in one month.) Review of the resident's care plan, dated 12/26/14, for nutritional status showed the following: -Problem: Weight loss 5 percent for 30 days. Weight loss 22 percent for 180 days; -Long term goal: Resident will maintain current body weight of 99-105 pounds; -Approaches: Health shakes with supper. Super cereal with breakfast. Snacks three times daily. Monitor/record weight weekly. Notify physician and family of significant weight change and offer the resident a snack when resident leaves 25 percent or more of food. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Rejected care daily; -Setup help only with eating; -Height: 63 inches, Weight: 99 pounds; -Therapeutic diet. Review of the resident's dietitian progress note showed no entry for December 2014. Review of the dietitian progress note, dated 1/26/15, showed the following: -Resident already receiving increased calories with snacks, super cereal and health shakes; -Recommendation for Boost VHC (a very high calorie supplement drink), 60 milliliters, three times daily for additional calories. Review of the record showed no evidence the recommendation for Boost VHC was initiated. Record review of the resident's Physician Order Sheet (POS), dated 1/1/15 through 1/31/15 showed the following: -[DIAGNOSES REDACTED]. -Regular diet; -Super cereal with breakfast (ordered 11/22/14); -Snacks three times daily (chart percent consumed) (ordered 11/22/14) -Health shakes at bedtime (ordered 9/23/14). Review of the resident's nutritional flow sheet, dated 1/1/15 through 1/31/15, showed the following: -Breakfast intake was blank on 1/20/15, zero consumed on 1/9, 1/12, and 1/18 and the resident refused on 1/27/15; -Lunch intake was blank on 1/19 and 1/25/15; -Supper intake was zero on 1/25 and 1/26/15 and the resident refused on 1/9/15; -Supplemental (health shakes) one with lunch and supper. Chart percent consumed. Staff documented for lunch on 1/12,1/15-1/17, 1/19-1/24, 1/26, 1/28-1/31, zero percent charted for consumption. For supper on 1/12 through 1/18/15, zero percent charted and from 1/19 through 1/31/15 the sheet is blank. Observation on 1/27/15 showed the following: -At 12:20 P.M., the resident sat in his/her wheelchair in the dining room with a glass of iced tea; -At 12:38 P.M., the resident was gone from his/her table. His/her plate contained a pork chop, broccoli, corn bread, lemonade, and a pink health shake. -At 1:00 P.M., the resident was not in the dining room. His/her plate of food remained on the table; -At 1:10 P.M., the resident sat on the side of his/her bed in his/her room and did not return to the dining room. The resident's food plate or any other food items were not brought to the resident's room; -At 5:15 P.M., the resident sat in his/her wheelchair in the dining room where he/she had pancakes and lemonade. The resident took one to three bites of the pancake. No supplement health shake was on the resident's tray. Observation on 1/29/15 showed the following: -At 9:30 A.M., the resident sat on the side of his/her bed with his/her breakfast tray on the over the bed table. The tray contained a small juice glass (empty), a full cup of coffee, and a plate containing two biscuits with gravy which appeared to have one or two bites missing. No super cereal noted on the tray as ordered with breakfast; -At 11:45 A.M., the breakfast tray remained in the resident's room. The resident did not consume anymore of the food on his/her tray; -At 1:50 P.M., staff removed the lunch tray which was untouched. The tray had beans, corn bread, apple pie and lemonade. Foil remained over the top of the lemonade glass. There were no other drinks on the tray. The resident lay on his/her side in his/her bed. During interview on 1/29/15 at 9:30 A.M., LPN P said he/she passed supplement drinks to a lot of residents (iced boost was on top of the medication cart). He/she said the supplement was listed on the MAR and he/she recorded the percent consumed. During interview on 1/29/15 at 1:50 P.M., CNA O when a resident refused a meal, staff would let the nurse know. He/she said CNA's must make two attempts to get the resident to eat. During interview on 1/30/15 at 9:10 A.M., CNA N said the resident would not wake up for breakfast but he/she did drink his/her juice on 1/29/15. Staff would tell the charge nurse so he/she would get the resident a shake. 5. Review of the Registered Dietician's consultation reports showed the following recommendations were made to the facility: -July 2014: Make sure snacks are passed on a daily basis as this is part of the menu (bedtime snacks are included in each diet) and to follow orders and interventions; -August 2014: Make sure all snacks are passed as this is an intervention for weight loss and wound healing; -September 2014: Be sure all supplements are passed as this is an intervention for weight loss and wound healing; -November 2014: Staff in the special care unit report that needed items are not provided (ice cream and health shakes). Make sure all special items are provided as this is an intervention for weight loss; -December 2014: Multiple complaints reported from the special care unit about not receiving snacks. Be sure snacks are provided for those with orders because this is an intervention for weight loss and wound healing. 6. During an interview on 1/30/15 at 2:00 P.M., the Director of Nursing (DON) said the facility weighed residents weekly for four weeks after admission and then monthly. If staff observe a resident eating less or if a resident's monthly weight goes down, that resident will be weighed weekly and monitored until stable. The DON said some interventions the facility utilized to prevent weight loss were monitoring the residents' medications and lab work, and offering residents additional food and supplements. The DON said snacks come fro

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents, and failed to consistently evaluate and analyze the risks for accidents, develop meaningful interventions to reduce the potential for accidents, and implement interventions to prevent accidents as identified on the residents' plan of care for eight residents (Residents #1, #5, #7, #10, #13, #15, #18, and #22), in a review of 24 sampled residents, and three additional residents (Residents #32, #39, and #41). The facility's failure resulted in actual harm for two residents (Resident #15 and #41). The facility census was 119. 1. Review of the facility's Fall Prevention Manual, dated June 2006, showed the following: -Overview: Falls are a serious health risk for older persons. Much can be done to prevent falls. Because of the high incidence of falls in the elderly, skilled nursing facilities (SNF) have an important role to play in preventing falls. SNF are in a unique position to identify patient risks and to coordinate fall prevention and fall reduction program. Moreover, falls can be prevented and their severity reduced without an increased use of restraints; -Clinical Background: Most falls are a result of a complex interaction of environmental, medical, and physical factors. Therefore, one intervention alone is less likely to be successful as a combination of interventions. This incorporates a patient fall risk assessment, care planning, and an exercise component; -Assessment: Assessment is the cornerstone of a fall prevention program. Literature supports that a fall risk assessment that incorporates a focused history, environmental and physical risks to persons has a positive impact on reduction in fall rates, deaths from falls, and hospitalization rates among residents in long term care facilities. Studies suggest that a fall risk assessment should be conducted upon admission to the nursing home, on a regular basis, and post fall. Individualized safety assessments positively affect fall rates in a nursing home environment. Risk factor lists are a valid toll for effectively assessing fall-prone elderly; -Care Planning: Research shows that care planning by an interdisciplinary team (IDT) soon after admission-with revisions as conditions change-is the most effective way to provide individualized care. Risk factors identified in the risk assessment should be the basis for an individualized care plan. Once individualized risks for falls are identified, care planning is effective in preventing falls and thus, allows rehabilitative programs to be more effective; -Exercise: A recent study conducted does suggest that regular exercise shows promise for improving fall-related outcomes for elderly nursing home residents. 2. Review of the Fall log provided by the facility for the last 90 days, showed the following: -43 Residents with falls; -22 with more than one fall in the last 90 days; -One resident with six falls; -Two residents with five falls; -One resident with four falls; -Six residents with three falls. 3. Observation of the facility on 2/3/15 at 10:20 A.M., showed the facility with 37 residents on the falling leaf program. During an interview on 1/30/15 at 1:50 P.M., the DON said residents on the falling leaf program had a picture of a leaf posted on the outside of their rooms on the door frame. Residents on the falling leaf program were not to be left alone in the bathroom or while in their wheelchairs unattended. Some residents on the falling leaf program were able to transfer themselves and get up their own. These residents required more frequent monitoring by staff. These interventions were communicated to direct staff in the resident's care plan and the care plan should provide more specific instructions regarding the resident's falling leaf program. During an interview on 2/3/15 at 4:45 P.M., the DON said she had not seen the policy on the falling leaf program. The facility was unable to provide the policy for the falling leaf program at the time of the survey. Review of the Falling Leaf Program, undated, provided by the administrator on 2/19/15, showed the following: -All new admissions will automatically be placed on the falling leaf program for the first two weeks in facility. Bed alarm and wheelchair alarms will be placed for first week of admission if resident scores low risk on the fall assessment and is stable will remove after first week. -Residents will be placed on falling leaf if they have two or more falls in 90 day period. -Residents will be taken off falling leaf program if they have no falls in 90 days. -Residents on falling leaf should not be left in room unattended unless in bed. -Falling leaf will be placed on resident's door. 4. Review of Resident #15's Physician order [REDACTED]. -admitted was 1/26/15; -[DIAGNOSES REDACTED]. Review of the resident's admission care plan, dated 1/26/15, showed the following: -Required assistance of one staff member for bathing, dressing, hygiene, grooming, toileting, walking, and eating.; -Falls/Safety Risk: Resident will remain free of injuries and falls; -Keep call bell in reach; -Encourage use of the call light; -Instruct resident on safety measures; -Physical therapy referral; -Assess resident's footwear for proper fit and non skid soles. Review of the resident's fall risk assessment, dated 1/26/15, showed a score of 21 (a score of 10 or above indicated high risk for falls). Observation on 1/26/15 at 5:15 P.M. showed the resident walked on his/her own past the 100/200 unit nurse's station and into the main dining room. The resident stumbled and fell face first onto the floor. Staff responded to the resident and asked where his/her wheelchair was and said the resident should have been in his/her wheelchair. Staff rolled the resident over to his/her back and a half dollar sized, purple, raised area was observed above the resident's right eye. Observation on 1/26/15 at 5:55 P.M. showed the resident sat in a wheelchair behind the 300 unit nurse's station. Staff assisted the resident to eat and held an ice pack to the resident's forehead. Another staff member placed a tab alarm on the resident and the wheelchair. Review of the resident's nurse's note, dated 1/27/15 at 9:00 A.M., showed the interdisciplinary team met regarding the resident's fall. A tab alarm was applied as well as a fall mat and the falling leaf program. Review of the resident's nurse's note, dated 1/28/15 at 11:40 P.M., showed the resident slid out of bed. Staff assessed a decreased level of consciousness. The physician was contacted and an order was received to transfer the resident to the emergency room if his/her condition worsened. The resident was barely able to respond to staff and was transferred to the emergency room by ambulance at 12:55 A.M. Review of the resident's post fall investigation report, dated 1/28/15, showed the following: -The resident fell in his/her room at 11:40 P.M.; -The fall was not witnessed; -The resident needed to use the bathroom; -The resident did not have on proper footwear; -The bed alarm had been removed; -The resident's call light came on when staff entered his/her room; -The resident was weak, but had no complaints of pain; -The resident was found sitting on the fall mat next to his/her bed. During an interview on 1/29/15 at 11:25 A.M., the Director of Nursing (DON) said she was aware the resident had been transferred to the hospital but was not aware the resident had fallen the night before on 1/28/15. The DON said when the resident fell on [DATE], he/she had walked all the way from his/her room to the main dining room of the facility. The DON didn't know how staff members missed seeing the resident walking on his/her own prior to the fall. Review of the resident's emergency department progress notes, dated 1/29/15 at 2:49 P.M., showed the following: -Clinical indication for emergency room visit: A fall two days ago, with another fall today, hematomas (localized swelling filled with blood, caused by a break in the wall of a blood vessel) to the face, and found unresponsive in the nursing home; -Assessment and Plan: status [REDACTED]. The subdural hematoma (a collection of blood in the space between the outer and middle layers of the covering of the brain, most often the result of a blow to the head) and the subarachnoid hemorrhage (an abnormal and very dangerous condition in which blood collects beneath the membrane that covers the brain. This area, called the subarachnoid space, normally contains cerebrospinal fluid. The accumulation of blood in this area can lead to stroke, seizures, and other complications) were believed to be post traumatic in nature. The resident's aspirin was held. There was no indication for urgent surgery, as the risks of surgery would outweigh the benefit. The resident would be followed closely with a series of neurological exams and be admitted to the hospital. During an interview on 1/29/15 at 5:30 P.M., LPN CC said he/she was familiar with the resident. The resident had lived in the facility prior to this admission and had a history of [REDACTED]. LPN CC had not received any update form the emergency room regarding the resident's condition. During an interview on 1/30/15 at 6:12 A.M., LPN BB said he/she was the charge nurse on duty the following shift after the resident fell in the dining room on 1/26/15. The resident was in bed that night after the fall. Around 3:00 A.M. on 1/27/15, the resident removed his/her alarm and got up out of bed. LPN BB observed the resident standing in the doorway of his/her room and was able to reach the resident before he/she fell . The resident expressed a need to use the bathroom. LPN BB assisted the resident to the bathroom and back to bed. LPN BB said he/she was also the charge nurse on duty on 1/28/15 at 11:40 P.M. when the resident fell a second time. The resident's call light came on and a CNA entered the room and found the resident on the floor on the fall mat next to the bed. LPN BB assessed the resident and assisted the resident back to bed. LPN BB said the resident had a regular mattress with a fall mat beside the bed at the time of the fall. The resident was weak but didn't have any complaints of pain or limitations in body movements. The resident's initial neurological examination was normal. After the resident was put back in bed he/she became lethargic. LPN BB contacted the physician and received an order to send the resident to the emergency room if his/her condition worsened. LPN BB placed oxygen on the resident. The resident remained lethargic, was no longer speaking, and began hitting the bed with his/her right arm repeatedly. The resident would not respond or open his/her eyes. LPN BB contacted emergency services and the resident was sent to the emergency room by ambulance. LPN BB said the resident had lived in the facility approximately three or four months ago. LPN BB said the resident would try to get up on his/her own and was at risk of falling at that time as well. LPN BB said he/she had received a call from the hospital and was told the resident's situation did not look good. 5. Record review of Resident #41's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/14, showed the following: -Cognitively intact; -No rejection of care; -Independent with bed mobility, transfers, walk in room and corridor, locomotion on and off the unit, and toilet use; -Steady at all times with walking, moving on and off the toilet, and moving surface-to-surface; -Not steady, but able to stabilize without staff assistance with moving from seated to standing position and turning around; -No functional limitations in range of motion; -Had no mobility devices; -Always continent of bladder and bowel; -Had no falls since last assessment (6/26/14). Review of the resident's Fall Risk Evaluation, dated 9/15/14, showed the following: -The resident had one to two falls in the past three months (MDS showed no falls); -The resident's total score was 10 (10 or above represents High Risk). Review of the resident's care plan, dated 9/15/14, showed the following: -Problem: The resident as risk for falls related to diagnosis, medications, history of falls, cognitive, and history of seizures; -Goal: The resident will remain free from injury; -Approaches: Encourage the resident to assume a standing position slowly. Medications per physician orders [REDACTED]. Report to the physician any falls. Keep the bed in the lowest position with brakes locked. Keep personal items and frequently used items within reach. Provide proper, well-maintained footwear. Provide an environment free of clutter. Teach the resident safety measures to stand slowly. Up as needed with wheeled walker. Decreased blood pressure medications. Scooped mattress (special mattress with raised edges and open area in middle section). Guards put on the bed frame to hold the mattress in place. Record review of the resident's nurse's notes, dated 11/28/14 at 2:40 P.M., showed the resident was found on the floor on his/her back between the beds in the room. The resident said he/she lost his/her balance and fell by the air condition unit and then crawled to the call light. He/she denied pain, had full range of motion in all extremities. Neurocheck within normal limits. Physician notified. Resident responsible for self. Further review of the resident's record showed no documentation staff evaluated the root cause for the fall and implemented or added any new interventions to the care plan. Record review of the resident's nurse's notes, dated 12/4/14 at 12:00 P.M., showed the resident returned from physician's office and stated he/she had fallen. The resident had a small abrasion to his/her chin/lip and left knee. The physician's office sent a report of the incident back with the resident. Neurochecks started. Record review of the resident's nurse's notes, dated 12/4/14 at 10:20 P.M., showed the resident had slight bruising and deviation to his/her septum (part of nose). Physician notified and order for an x-ray obtained. Record review of the resident's nurse's notes, dated 12/5/14 at 3:50 P.M., showed the x-ray of the resident's nose was negative. Further review of the resident's record showed no documentation staff evaluated the root cause for the fall and implemented or added new interventions to the care plan. Record review of the resident's nurse's notes, dated 12/10/14 at 2:20 P.M., showed the resident was found lying on the floor by his/her bed. Range of motion within normal limits. Neurocheck within normal limits. No injury noted. Assisted the resident up with a gait belt and two staff. Physician and family notified. Record review of the resident's nurse's notes, dated 12/11/14 at 9:00 A.M., showed the interdisciplinary team (IDT) had a meeting for fall. No antianxiety medication was given prior to fall, the resident lost his/her balance. Adding to falling leaf program. Review of the care plan showed the care plan was updated with the falling leaf. Record review of the resident's nurse's notes, dated 12/12/14 at 9:30 A.M., showed the resident was found lying on the floor beside his/her bed. The resident said he/she hit his/her head on the night stand. The resident did not use the call light for assistance. Educated the resident to use the call light for assistance. Neurochecks started. Physician notified. Record review of the resident's nurse's notes, dated 12/12/14 at 1:00 P.M., showed the resident complained of pain to his/her buttocks, no bruising or swelling noted. Staff gave the resident Tylenol (analgesic). Further review of the resident's record showed no documentation staff evaluated the root cause for the fall and implemented/added any new interventions to the care plan. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No rejection of care; -Independent with bed mobility, transfer, walk in room and corridor, locomotion on the unit, and toilet use; -Needed supervision with locomotion off the unit, dressing, and personal hygiene; -Steady at all times with moving from seated to standing, walking, and turning around; -Not steady, but able to stabilize without staff assistance for moving on and off the toilet and surface-to-surface; -Had no functional limitation in range of motion; -Used walker for mobility; -Always continent of bladder and bowel; -Had fall since last assessment (9/15/14); -Had two or more non-injury (no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall); -Had no injury falls (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall- related injury that causes the resident to complain of pain); -Had no major injury falls (bone fracture, joint dislocation, closed head injuries with altered consciousness, subdural hematoma). Review of the resident's fall care plan showed the care plan was reviewed on 12/14/14 with no new interventions or revisions added. Record review of the resident's nurse's notes, dated 1/30/15 at 8:00 P.M., showed the resident in his/her room at 6:45 P.M. trying to sit down on his/her mattress. The resident missed the mattress and slid to the floor. Initial assessment revealed no injuries, now the resident complains of his/her right arm and leg hurting. Full range of motion. The resident was assisted into a wheelchair. PRN (as needed) pain medications administered. Physician notified. Record review of the resident's nurse's notes, dated 2/2/15 at 9:00 A.M., showed the IDT had a meeting on falls. Family was notified of a fall on 2/1/15 at 7:30 P.M. The resident said he/she did not have his/her walker in front of him/her at the time of the slip from bed. The resident has a scoop mattress. Discussed rearranging the room to get in and out on the window side of the room, the resident to discuss in room and rearrange to better able transfers. (Review of the nurses note showed the resident missed the mattress when he/she was trying to sit down.) During an interview on 2/3/15 at 11:00 A.M., the resident said the following: -He/she was trying to get into his/her bed the other night and fell on to his/her right side, causing right shoulder and hip pain; -Staff did not assess him/her. He/she got himself/herself up since there were no staff around to assist him/her and then he/she turned on the call light. He/she informed staff at that time that he/she had fallen and was having pain in his/her right shoulder and hip. He/she was given Tylenol; -He/she continued to have pain in the right shoulder and right ankle. Staff informed him/her that they would put a grab bar on his/her bed to assist him/her to get in and out of bed; -No staff had rearranged his/her room; -He/she had not been out of bed much since this fall due to the pain; -He/she had received pain medication earlier that day. Observation on 2/3/15 at 11:00 A.M., showed the resident sat on his/her bed. He/she had a scooped mattress. The resident's call light was on the floor on the left side of his/her bed and not within the resident's reach. The resident did not have grab bars on the bed. 6. Record review of Resident #32's Fall Risk Evaluation, dated 9/5/14, showed the resident scored 14 (10 or above represents high risk). Review of the resident's nurse's notes, dated 11/2/14 at 6:30 A.M., showed staff heard the resident yelling from the shower room. The resident lay on his/her left side on the floor. The resident said he/she got up by himself/herself from the toilet and his/her chair went out from underneath him/her. The resident was reminded to ask for help and not get up by himself/herself. Range of Motion (ROM) and skin assessment performed. The resident was able to move all extremities without difficulty. No redness or bruising noted at this time. Physician and family notified. Review of the resident's nurse's notes, dated 11/2/14 at 8:30 P.M., showed the resident was yelling. An aide went into the resident room. The resident was on the floor by the bathroom door. The resident had gotten off the toilet and reached for his/her wheelchair, the wheelchair started rolling and he/she went after it, out of the bathroom. When the wheelchair stopped, he/she fell back and hit his/her back on the handle of the bathroom door and slid down to the floor. Review of the resident's nurse's notes, dated 11/3/14 at 9:15 A.M., showed the Interdisciplinary team (IDT) met and reviewed falls from 11/2/14. Will put automatic locks on the resident's wheelchair since the wheelchair moved both times on him/her. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Had no rejection of care; -Dependent on two staff for transfer; -Required extensive assist of two staff for toilet use and bathing; -Required extensive assist of one staff for dressing and personal hygiene; -Required limited assist of one staff for bed mobility and locomotion on and off the unit; -Was not steady, only able to stabilize with staff assistance moving surface-to-surface; -Moving from seated to standing position, walking, turning around, and moving on and off toilet did not occur; -Had functional limitation in range of motion on one side upper extremity; -Had functional limitation in range of motion on both lower extremity; -Used a wheelchair for mobility; -Was frequently incontinent of bladder; -Had fallen since last assessment (8/27/14); -Had one fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain). Review of the resident's care plan, last reviewed 11/28/14, showed the following: -Problem: Resident requires extensive assist with transfers, non-ambulatory at risk for further decline. Goal: The resident will tolerate transfers to wheelchair with assist. Approaches: Keep call light within reach. Monitor/record/report to presence of pain/intolerance during transfers. Provide assist of two staff and mechanical list for transfers; -Problem: The resident is at risk for falls related to mobility, medications, diagnosis, and incontinence. Goal: The resident will remain free from injury. Approaches: Assure the resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Use mechanical lift for all transfers. Provide the resident an environment free of clutter. Provide toileting assistance before and after meals; -Problem: Self care deficits, at risk for further decline related to memory deficit, mobility, medications, and diagnosis. Goal: The resident will continue to feed self all meals. Approaches: Assist two with all transfers. The resident up in wheelchair propelled by staff; -Staff failed to care plan the automatic locks for the wheelchair (per IDT 11/3/14). Review of the resident's nurse's notes, dated 1/28/15, showed the following: -At 2:15 P.M., the resident returned from activities outing to a restaurant. The activities director reported the resident was wheeling himself/herself down the wheelchair ramp and the wind pushed the wheelchair over the edge where the concrete and asphalt met, causing the wheelchair to flip over on its side. The resident hit his/her right side of his/her head caused discoloration, ice was applied. Range of motion within normal limits, neurochecks within normal limits, pupils equal and reactive. Physician notified. Family called and no answer, left message non-emergency to return call; -At 3:00 P.M., the resident's family returned call and updated to all the above and also informed that when the Certified Nurse Assistants (CNA)s went to lay the resident down at 3:00 P.M., the resident was not responding to staff. The evening shift nurse went into the resident's room and assessed the resident; -At 3:15 P.M., called to the resident's room due to the resident being non-responsive. The resident only responded by grunting. Pupils equal and reactive to light. Oxygen saturation 53% (normal = 90-100%), oxygen applied at two liters per nasal cannula. Skin warm. The resident was leaning forward in his/her wheelchair, unable to keep balance in chair. Two CNAs transferred the resident into the bed. The resident had bruising and swelling on the right side of his/her forehead, the swelling was going down to the right temple area; -At 3:30 P.M., oxygen saturation was 58% with oxygen on at two liters. The resident answered by grunting. Local ambulance at the facility to transport the resident to an outlying hospital. During an interview on 1/29/15 at 3:40 P.M., the Activities Director said the following: -The resident was coming out of the restaurant, self-propelling in his/her wheelchair down the the handicap ramp toward the parking lot. The Activities Director was by the van getting the lift down for the resident. She heard a man holler "ma'am" and she turned to find the resident on top of a parking lot stone. She hollered for the activity assistant and about that time, an employee from the restaurant, came out to assist. Another person in the parking lot asked if needed help and she informed that person it would be great. The activity assistant and activity director did range of motion and looked the resident over, they saw no injury. The Activity Director, the activity assistant, the restaurant employee and the bystander in the parking lot chair lifted the resident into his/her wheelchair and it was at that time that they noticed the resident had a raised area to the right side of the resident's forehead. The employee from the restaurant went into the restaurant to get a bag of ice while the activity director and assistant got the resident loaded into the van. The employee came back out with the bag of ice and activity director applied it to the resident's right side of his/her forehead and had the resident hold it there. She then drove the van back to the facility which was an approximately 20 minutes away. She talked to the resident the entire ride back to the facility. The resident just kept saying, "I am fine;" -He/she now realized he/she should not have moved the resident, and should have called the ambulance; -Once back to the facility, he/she brought the resident in first, then grabbed the ADON and informed her what had happened. On the way to the resident's room, he/she saw the resident's charge nurse and informed him/her of the incident also and then left the resident with the nurses. Staff failed to assess the resident before moving him/her as directed by the facility policy and failed to follow the resident's care plan and assist the resident with his/her wheelchair. Record review of the resident's outlying hospital record, dated 1/29/15, showed the following: -Arrival complaint Diagnosis: [REDACTED]. Hematoma (collection of blood within the tissue) to the right temporal. On Coumadin (anticoagulant); -CT scan non-contrast of head results: Right frontal 2.5 centimeter (cm) scalp hematoma; -Admitting for further evaluation and treatment; -The resident's family was informed of the resident's possible [DIAGNOSES REDACTED]. Record review of the resident's medical record showed the resident was readmitted to the facility on [DATE]. Observation and interview on 1/29/15 at 4:15 P.M., showed the resident in his/her bed and family member at his/her bedside. The family member rolled the resident's wheelchair back and forth, the resident was not in the wheelchair. (The wheelchair should lock when the resident was not in it.) The family member said he/she thought the wheelchair was to lock when the resident was not in it. During an interview on 1/30/15 at 6:20 A.M., the resident said the following: -He/she came out of the restaurant and propelled himself/herself in his/her wheelchair; -Staff was by the van getting the lift down; -It was windy and as he/she came down the handicap ramp, the wind blew him/her to where the concrete ramp and the asphalt come together. When his/her wheelchair hit that, he/she fell forward out of the wheelchair; -The next thing he/she remembered was waking up to the activity staff above him/her and things from then were a little "foggy." Observation and interview on 1/30/15 at 8:20 A.M., showed therapy assistant and CNA N assisted the resident to bed. Therapy assistant placed a gait belt around the resident's waist, then put a walker in front of the resident's wheelchair and had the resident grab a hold of the walker then stand. The resident stood with stand by assist only and pivoted onto the left side of the resident's bed. CNA N then moved the resident's wheelchair back and was able to do without difficulty. CNA N moved the wheelchair in a back and forth motion and the wheelchair moved freely. The wheelchair was missing the left piece of the automatic lock on the wheelchair. CNA N said the automatic lock did not work on the resident's wheelchair and it was supposed to. Observation and interview on 2/3/15 at 11:25 A.M., showed the following: -The resident was still in the same wheelchair with the piece of the automatic lock on the left still missing; -The resident said the wheelchair did not automatically lock when he/she stood, he/she had to put on the actual wheelchair locks. 7. Review of Resident #5's admission MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Required extensive assistance from one staff member for bed mobility, transfers, walking, dressing, eating, toilet use, transfers, and personal hygiene; -Frequently incontinent of bladder; -At risk for pressure ulcers; -Balance was not steady; -One fall without injury since admission. Review of the resident's nurse's note, dated 9/26/14 at 4:00 P.M., showed the nurse was at the nurse's station and heard a crash and shouts for help. The resident was found on the floor of his/her room on his/her right side. The resident obtained a small skin tear to the right outer wrist. Review of the resident's nurse's note, dated 9/29/14 at 9:00 A.M., showed interdisciplinary team (IDT) met regarding the resident's fall. The resident was placed on the falling leaf program and the toileting program. Review of the resident's nurse's note, dated 11/5/14 at 11:30 P.M., the resident was found on the floor in an upright position in front of the bathroom. The floor was wet with urine. The resident obtained skin tears to both arms. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Required extensive assistance of one staff member for personal hygiene and toilet use; -Required limited assistance of one staff member for transfers; -Did not reject care; -Balance was not steady; -Two falls without injury since the previous assessment on 9/1/14; -One fall with injury since the last assessment on 9/1/14. Review of the resident's care plan, dated 11/21/14, showed the following: -Problem: Resident is limited in ability to maintain activities of daily living. Goal: Resident will continue to feed self meals. Approach: Monitor for the presence of pain during grooming and personal hygiene. Praise resident for neat appearance. Provide assistance for facial hair. Provide assistance for grooming hair. Provide a non-distracting environment for grooming and personal hygiene; -Problem: Resident experiences bladder incontinence. Goal: Resident will improve current level of bladder continence. Approach: Adapt environment to maximize independence. Administer medications as ordered. Encourage fluids. Ensure adequate bowel elimination. Keep call light in reach. Provide incontinence care after each incontinent episode. Provide assistance of one staff member for toileting before and after meals, at bedtime, and as needed. Report an

This deficiency was uncorrected. For previous examples, refer to Statement of Deficiencies dated 3/14/12. Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to residents to prevent two residents (Residents #24 and #12) at risk for falls from repeated falls, and to prevent accidental injuries during transfers between surfaces for three residents (Residents #18, #19 and #22) of 23 sampled residents. The facility census was 112. 1. Review of Resident #24's Fall Risk Evaluation dated 04/28/12, showed the following: Level of consciousness/mental status -Disoriented times three at all times; -Score of two; History of falls (past 3 months) -No falls; -Score of zero; Ambulation/elimination status -Ambulatory and incontinent; -Score of four; Vision Status -Adequate (with or without glasses); -Medications that cause lethargy or confusion: takes one to two of these medications currently and/or within the last 7 days; Gait/Balance-Normal -Score of two; Predisposing Diseases -One or two present; -Score of two; Total score of ten; Score of ten or above represented HIGH RISK. Review of the Physician order [REDACTED]. -Alzheimer's Disease; -Congestive heart failure (CHF), -Coronary artery disease (CAD); -Anemia (may cause weakness, fatigue, and dizziness). Review of the nurse's notes dated 05/01/12, showed the following: - At 11:15 P.M., the nurse was called to the resident's room; -The resident was found on the floor next to the dresser; -The resident was bleeding from top of the head and left arm; -At 11:30 P.M. the physician was notified and ordered triple antibiotic ointment (TAO) to area on top of the head and to monitor the bleeding. Review of the resident's care plan dated 04/28/12, showed staff did not review or add interventions such as increased supervison after the fall on 05/01/12 to prevent additional falls. Review of the nurse's notes dated 05/02/12, showed the following: -At 10:15 P.M. the resident was found on his/her back with head up against the rocking chair; -He/she received a skin tear to the left forearm; -He/she received a laceration to the left side of skull; -He/she received a puncture wound to back of head on the left side; -He/she had a hematoma (bruise) to left ear with a skin tear; -At 10:35 P.M. the physician ordered to send the resident to emergency room . Review of the CT Scan of the spine dated 05/02/12, showed the following: -History of trauma to neck; -Findings included a bony dicontinuity seen in left C4 (Cervical spine) transverse process that suggested that this was an acute fracture. Review of the nurse's notes dated 05/03/12, showed the following: -At 1:45 A.M. the resident returned to the facility by ambulance; -The resident received six staples to area left side of the head; -The resident received six staples to area toward top of the head; -The resident had a CT scan done, that showed a closed cervical fracture without spinal cord injury. During interview on 05/03/12 at 8:25 A.M., RN V said the following: -The MDS coordinator was in charge of the care plans; -Unsure if care plan was in the chart; -The DON (Director of Nursing) was responsible for falls; -After the resident is evaluated to be a fall risk the DON places a leaf on the door; -The resident usually has to have at least two falls before the leaf is placed; -All at risk residents for fall should be on the care card in the resident's closet; -Was unsure if the resident had a care card in the closet. Observation on 05/03/12 at 8:40 A.M., showed the resident did not have a leaf on his/her door. During interview on 05/03/12 at 8:50 A.M., RN HH said the following: -Inside of the residents closet there should be a care card; -A leaf is desginated on the door to alert staff of a fall risk. During interview on 05/03/12 at 9:10 A.M., CNA CC said the following: -The facility had falling leaf program; -If leaf is placed on the outside of the door indicates the resident is a fall risk. Observation on 05/03/12 at 9:20 A.M., CNA W showed the resident did not have a Care Card in the room in his/her closet. During interview on 05/03/12 at 9:30 A.M., the Administrator said the following: -Fall assessment is not necessarily looked at upon admission; -The facility has a falling star program; -Leaves are placed on the door for residents who are at risk for falls; -The MDS coordinator and the DON were responsible for placing the leaves on the doors; -Unsure if one was placed on Resident #24's door. Review of the May, 2012, Physician order [REDACTED]. (milligrams) one tablet by mouth at bedtime. During interview on 05/03/12 at 9:50 A.M., LPN D said the following: -The resident experienced a fall on 05/01/12 at approximately 11:00 P.M.; -The resident experienced a second fall on 05/02/12; -The resident was in his/her bed on 05/02/12 at 8:30 P.M., Ambien was given at that time; -The resident had tried to kick, hit, and get out of the bed; -At approximately 10:15 P.M. CNA R and CNA S heard a crash, found the resident on the floor on his/her back with his/her head against the rocking chair in the television room; -The fall was unwitnessed; -The resident had busted his/her head open and was bleeding; -Assessed the resident and notified physician; -Physician discontinued Ambien; -Order was received to transfer the resident to emergency room . During inteview on 05/03/12 at 10:33 A.M., the resident's spouse said he/she started the Ambien prescription on approximately 04/13/12. During interview on 05/03/12 at 12:15 P.M., CNA R said the following: -Was reported to him/her the resident fell on [DATE]; -CNA R laid the resident down on 05/02/12 in his/her bed; -Reported the resident had gotten up and walked to the television room; -The resident was unsteady when he/she ambulated; -The resident required assistance of one with walking; -The resident almost tripped over his/her foot the night before; -He/she was not in the television room when the resident fell ; -He/she assisted another resident that was unclothed in the hall; -Found the resident on the floor in the television room with his/her head against the rocking chair; -Reported to LPN D the resident had fallen and busted his/her head open and was bleeding a lot; -LPN D assessed the resident; -There usually is a care plan in the resident's room and a leaf on the door to identify a resident who is a fall risk; -Was unable to find a care plan in the resident's closet and there was not a leaf on the door to identify Resident #24 was a fall risk; -The resident had no mats on the floor; -He/she said check on the residents at least every two hours. Observation on 05/03/12 at 12:20 P.M. showed the Director of Nursing (DON) measured the following: -Skin tear to the back of left elbow measured 1.0 cm x 0.5 cm; -Skin tear to left elbow measured 6 cm x 3 cm; -Skin tear to left side of wrist 0.3 cm x 0.3 cm; -Skin tear to left side of hand 3 cm x 1 cm; -Laceration of right side of head 4 cm x 0.5 cm closed with 6 staples; -Laceration left side of head 3 cm x 0.5 cm closed with 6 staples; -Back of the head (puncture wound by the neck) 0.2 cm x 0.2 cm; -Skin tear to left pinky finger 1.3 cm x 0.8 cm. During interview on 05/03/12 at 2:00 P.M., the DON said the following: -After a resident has fallen, should immediately put measures in place to reduce further falls; -Charge nurse is expected to fill out incident report and document about the fall; -MDS coordinator or herself document on the care plan. During interview on 05/03/12 at 2:45 P.M., CNA S said the following: -The resident was supposed to have care plan inside of his/her wardrobe; -When looked inside the wardrobe, there was none; -Was unable to find the care plan in the chart or the chart that night; -Was his/her first time to care for the resident; -There were not mats in his/her room prior to his/her fall; -During change of shift was reported the resident had fallen on 05/01/12; -On 05/02/12, attempted to lay the resident down for bed; -The resident received his/her medicine (sleeping pill) around 8:00 P.M.; -The resident was in television room; -He/she told CNA R he/she was going to the bathroom; -CNA S left the television room to assist a resident in the hall that undressed; -When returned from the bathroom was talking with CNA R in the hall and when talking heard a thump; -Ran to the resident with assist of CNA R; -The resident lay between the chairs on his/her back; -The resident's head was bleeding; -The charge nurse was notified and went to assess; -The charge nurse had told him/her to keep an eye on the resident after having sleeping pill; -The ambulance was called and when the ambulance arrived the resident was assisted by three to get to the cot. During interview on 05/14/12 at 2:00 P.M., the resident's Physician said the following: -Would have expected the staff to place an alarm; -Ultimately one on one with the resident would have been best; -Would have expected staff to document, care plan, and educate staff; -Move closer to the nurses staff if room available; -Ambien could have contributed to the fall. During interview on 05/18/12 at 11:30 A.M., the Physical Therapist said the following: -The resident was on hospice; -Order was not received for Physical therapy; -No evaluation completed. During interview on 05/18/12 at 1:05 P.M., the MDS Coordinator said the following: -The charge nurse is responsible for the admission care plan; -Charge nurse can update care plan with new orders; -She reviews care plan quarterly and with a significant change. Review of the Lippincott Nursing 2012 drug handbook showed the following: Indications and dosages for the medication Ambien: -Short term management of insomnia; -For elderly patients Ambien (Hypnotic) 5 mg.(milligram) immediately before bedtime; Adverse Reactions -Central Nervous System; -Amnesia; -Dizziness; -Lethargy; -Light headedness; -Nervousness. 2. Review of Resident #24's Resident Admission collection sheet dated 04/28/12, showed the following: -General Skin condition dry and intact; -No problem skin areas documented on diagram; -No comments listed for skin condition; -Transferred independently; -Full weight bearing; -Ambulated independently; -Bladder incontinence; -Assistance needed for grooming, dressing and bathing. Review of the resident's care plan dated 04/28/12, showed the following: Falls/Safety Risk/Elopement Risk -Keep call bell in reach; -Encourage use of call light; -If unable to use call light, nursing assistant will assess resident every 30-60 minutes; -Instruct the resident on safety measures; -Assess resident's footwear for proper fit and non-skid soles; Cognitive Loss -Orient as needed to person, place, and time; -Introduce self; -Approach in a calm manner; -Explain what you intend to do while providing care; -Anticipate needs and observe for non-verbal cues; Activities of daily living -Bathing/hygiene one assist; -Dressing/grooming one assist; -Toileting one assist. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 03/12/12, showed the following: -Brief Interview for Mental Status (BIMS) score was one out of 15; -Zero to seven is severe cognitive impairment; -Required extensive assist of one with ambulation and transfers. Review of the care plan dated 03/13/12, showed the following: Problem -The resident has socially inappropriate/disruptive behavioral symptoms; -He/she yells out at times; -He/she has repetitive speech; -He/she wanders into the wrong rooms; Goal -He/she will be redirected; -He/she will be in safe environment; Approach -Administer as needed medications (PRN); -Monitor and record effectiveness; -Report any adverse effects; -Assess whether the behavior endangers the resident and/or others, intervene as necessary; -Avoid over-stimulation (noise, crowding, and other physically aggressive residents). -Maintain a calm environment and approach to the resident; -Maintain a calm, slow, understandable approach with the resident; -Obtain a psych consult/psychosocial therapy; -Place resident in specially designed therapeutic unit; -Praise the resident when behavior is appropriate; -When resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs (pain, hunger, toileting, too hot/cold, etc.). Review of the nurse 's notes dated 04/28/12, showed the following: -At 4:00 P.M. Resident #3 was upset with his/her new roommate (Resident #24); -He/she cursed at the resident and pushed him/her down; -The DON (Director of nursing) was notified of the incident; -At 4:30 P.M. his/her physician was notified of the resident ' s agitation; -The physician gave the order to send the resident to the local emergency room for evaluation. Review of the nurse's notes dated 04/29/12, showed the following: -At 5:00 A.M. the resident returned to the facility with new medication order; -Depakote (mood stabilizer) 125 mg (milligram) twice daily. Review of the nurse's notes dated 04/28/12, showed the following: -At 11:30 A.M. Resident #24 was admitted to the facility; -At 4:00 P.M. the nurse was called to see Resident #24; -The resident was in confrontation with Resident #3; -Resident #3 pushed Resident #24 onto the floor; -Resident #24 received a skin tear to left side of hand by the little finger size of pencil eraser; -He/she had a skin tear to upper and lower left arm; -He/she had abrasion to left side of face. During interview on 05/01/12 at 2:45 P.M., CNA II said the following: -Resident #24 had altercation with him/her on 04/28/12; -The resident punched him/her in the face two times; -Resident #3 witnessed him/her being hit by Resident #24; -He/she took Resident #3 to lay down and reassured the resident he/she was okay; -He/she took Resident #24 to the television room; -He/she then left the unit for awhile. During interview on 05/16/12 at 1:45 P.M., CNA LL said the following: -An altercation occured on 04/28/12 at approximately 3:30 P.M. between Resident #24 and Resident #3; -Had taken Resident #3 to the bathroom and was leaving the room when the resident stopped at the door frame; -Resident #24 was in the hall walking by and Resident #3 pushed Resident #24 on his/her back; -Resident #24 fell very hard onto the floor and hit his/her head; -Resident #24 had a rug burn to the left side of head and a skin tear to his/her left arm below the elbow; -He/she hollered for help in the unit; -The other CNA had left the floor for awhile; -Someone from the 300 hall came to assist; -Resident #24 was assessed by the charge nurse; -Resident #24 and #3 were separated to decrease chance of further altercations 2. Review of Resident #12's Occupational Therapist (OT) notes dated 12/05/11, showed the following: -Resident likes to self propel with use of his/her tilt inspace with chair independently throughout the facility with left upper extremity (left arm); -Resident is able to reposition self in wheel chair but is not always aware of when he/she is too close to the edge of the wheel chair; -Resident constantly changes position in the wheel chair and is observed scooting his/her bottom forward to the edge of the wheel chair seat purposefully; -Do not recommend tilting chair back due to agitating the resident and because he/she enjoys self propelling self throughout facility; -Resident would benefit from anti-thrust or pommel cushion to prevent him/her from sliding forward, but still allowing him/her to propel him/herself. Review of resident #12's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/24/12, showed the following: -Diagnoses: [REDACTED]. -Speech unclear, slurred or mumbled words; -Brief Interview for Mental Status unable to be completed due to resident rarely or never understood; -Not cognitively intact; -Bed mobility with extensive assistance of two people; -Transfers with extensive assistance of two people (hoyer lift in care plan); -Cannot walk; -Locomotion on the unit or sufficiency once in wheel chair with limited assistance of one person assist; -Locomotion off of the unit and how resident sufficiency once in the wheel chair with assistance of one; -Toilet with extensive assistance of two people; -Frequently incontinent of urine; -Frequently incontinent of bowel; -Restraints not used. Review of the resident's care plan dated 04/23/12, showed the following: -Resident has self care deficit related to mental retardation and weakness; -Hoyer lift with transfers; -Up in wheel chair per hoyer lift and turn and reposition every two hours; -Eyeglasses on when up; -Resident has difficulty making self understood related to dementia and mental retardation; -Resident has a history of falling related to poor safety awareness; -Mat on floor next to bed; -Encourage resident to assume a standing position slowly; -Wheelchair alarm; -Give resident verbal reminders not to ambulate/transfer without assistance; -Keep call light in reach at all times; -Observe frequently and place in supervised area when out of bed; -Prepare wheel chair prior to assisting resident to edge of bed; -Do not let go of resident once assisted to edge of bed (9/23/11); -Toilet before and/or after meals; -Monitor for items resident drops on the floor and may attempt to pick up; -Ensure wheel chair is not in fully forward position and recline slightly (11/28/11); -Fall on 04/26/12, fell out of wheel chair, ensure wheel chair is in back tilt. Review of the resident's Care Card (undated), showed the following: -Assist of two for pivot transfer; -Lay down per one assist; -Assist of one person for toilet use; -Wheel chair for ambulation; -(Fall risk not indicated on Care Card). Review of the resident's nurse's notes dated 03/12/12 at 11:40 A.M., showed the following: -Resident found lying on the floor on his/her back near the table in the main dining room; -fell forward out of wheel chair landing on his/her face then rolled over onto his/her back; -Glasses broken and abrasion to left side of forehead; -Resident had no complaint of pain when asked if head hurt; -Resident verbally answers to yes/no questions; -Vital signs: 97.7, 91% oxygen saturation on room air, pulse 90, blood pressure 110/80, pupils round and reactive to light and accommodation, hand grips equal; -Physician notified at 12:15 P.M.; -Family notified; -Neuro (neurological) checks performed. Review of the resident's nurse's notes dated 03/17/12 at 3:00 A.M., showed the following: -Vital signs: blood pressure 96/60 with normal range of 120/80, temperature 97.2 with the normal range of 98.6, respirations 18 with normal range of 12-20 breaths per minute, pulse 94 with normal range 60-100 bpm (beats per minute); -Observed witting on floor next to bed; -Roommate said resident rolled out of bed feet first; -One centimeter abrasion to left inner ankle; -Physician and guardian notified. Review of the resident's nurse's notes dated 04/26/12 at 8:30 A.M., showed the following: -Resident sitting up in wheelchair at the doorway to his/her room; -Resident leaned forward landing face first onto the floor in the doorway; -Resident turned over onto back; -Abrasion noted to tip of nose and across entire forehead; -Abrasions cleansed with normal saline and prescribed ointment applied to abrasions; -Family notified; -Physician notified. Review of the resident's nurse's notes dated 04/27/12 at 9:00 A.M., showed the following: -IDT team note: Resident fell out of wheelchair onto the floor in his/her doorway; -Will obtain OT evaluation for positioning in wheelchair related to fall. Review of the resident's physician order [REDACTED]. -Up in wheel chair with alarm (date of original order unknown per DON); -OT to evaluate and treat one time for wheel chair positioning. Observation of dining services on 04/30/12 at 6:00 P.M., showed the following: -Resident sitting up in wheelchair in the main dining room; -Wheelchair reclined to where feet could not touch floor and seat belt applied; - Had a large abrasion across entire forehead which was oozing yellow drainage; -Had a smaller abrasion to the tip of his/her nose; -When asked if his/her name was the given name for Resident #12, the resident said "No"; -When asked if he/she lived at the facility, he/she said "No"; -When the resident was asked if he/she was going to eat by facility staff the resident said "No"; -The resident said no to every question asked, even if "no" was not the appropriate response to the question; -Resident's roommate said facility staff leaves the resident in his/her wheelchair in the middle of the room unattended for hours. Observation on 05/02/12 at 8:30 A.M., showed the following: -Sitting up in wheelchair with wheelchair tilted backward in the middle of his/her room with seat belt applied; -Wheelchair brakes on; -No wheelchair alarm in place; -No call light accessible to resident for use; -Strong urine odor. Observation on 05/02/12 at 10:10 A.M., showed the following: -Resident sitting up in wheelchair with wheelchair tilted backward in the middle of his/her room with a seat belt applied; -Wheelchair brakes on; -No alarm noted to wheelchair; -Strong urine odor; -No call light accessible to resident for use; -Staff did not reposition resident. Observation on 05/02/12 at 10:30 A.M., showed the following: -Sitting up in wheelchair with wheelchair tilted backward in the middle of his/her room with a seat belt applied; -No wheelchair alarm attached; -Wheelchair brakes on; -Seat belt on; -Strong urine odor; -Call light out of reach for resident use; -CNA S said it was the resident's shower day and that was why he/she was sitting up in wheelchair unattended and not lying in bed. Observation on 05/02/12 at 10:45 A.M., showed the following: -Resident sitting up in wheelchair with wheelchair tilted backward to where feet could not touch floor; -No wheelchair alarm attached; -Seat belt on; -Strong urine odor; -Call light out of reach; -Brakes on. Observation on 05/02/12 at 11:15 A.M., showed the following: -Staff getting resident up with gait belt and two person assistance manually; -Resident unable to bear weight; -Resident very unsteady; -Staff did not follow care plan directing the use of a hoyer lift. During interview on 05/09/12 at 9:28 A.M., the Administrator said the following: -The "Fall Champion" is the Director of Nursing (DON); -The Fall Champion job description is included in the Fall Protocol -The MDS Coordinator updates and oversees the care cards. During interview on 05/10/12 at 8:45 A.M., the DON said the following: -He/she is the " Fall Champion " which is a "new hat" he/she is wearing; -Did not know he/she was the Fall Champion before the resident fell on [DATE]; -Is a new employee and just learning all of his/her responsibilities; -Would expect nursing staff to understand the criteria in severity and possible complications related to a head injury; -Would expect nursing staff to complete neurochecks as indicated in the facility Fall Protocol. During interview on 05/18/12 at 1:45 P.M., the DON said the following: -The resident fell on [DATE]; -The DON was on shift at the time of the fall; -The resident was sitting in his/her wheelchair right before the fall; -The resident's wheelchair should have been tilted backward and was not. During interview on 05/10/12 at 1:50 P.M., the OT said the following: -Use of cushions and other types of wheelchairs were unsuccessful for the resident; -Recommended to tilt the wheelchair back far enough so that feet do not touch the ground; -Tilting of the wheelchair was to prevent the resident from falling when standing up; -Finished the OT evaluation on 04/26/12; -Did not recommend or order the use of a safety belt across the resident's waist. Review of the resident's OT notes dated 04/27/12, showed the following: -Recently seen by OT for wheelchair positioning; -Good positioning unless agitated and attempts to move wheelchair or get out of wheelchair; -Recently trialed standard wheelchair with pommel cushion; -Pommel cushion unsuccessful; -Not appropriate for seat belt due to strength; -Recommend slight tilt back in wheelchair. During interview on 05/18/12 at 11:45 A.M., the OT said the following: -Resident could no longer propel since 04/27/12; -Resident had declined in functionability since 04/27/12; -Resident could not perform range of motion independently; -Resident could not follow commands; -Resident did not have the mental capacity to release seat belt; -OT did not recommend a seat belt at any time. Review of the facility's fall program, revised on January 2011, showed the following: -Facility will appoint a Fall Champion to assist in the oversight and monitoring of the facility's fall prevention program; -During admission, the fall risk assessment must be done within four hours of admission; -Anyone scoring a ten or more on the Fall Risk Assessment will be considered at risk for at least two weeks; -Any resident scoring ten or more but does not exhibit high risk behaviors and does not fall within this two week timeframe may come off the Falling Star Program; -The new admission will be reviewed at the morning "stand up" meeting to alert the management team that a resident is a fall risk. At this time, determination will be made that the appropriate preventative fall measures are in place or that additional preventative measures need to be taken. The Fall Champion will be responsible for ensuring that a "Falling Star" has been placed on the resident's name plate and that any equipment such as wheelchairs or walkers have stars as well; -Remember signs of an effective Falling Star Program is that all team members are involved and preventative measures are put into place right away upon first assessment of risk; -Daily, every event will be taken each day to morning stand up meeting along with the resident's chart for review by the IDT team after the primary portion of the stand up meeting is done. Review the resident's event- review the nursing notes, neuro check information and interventions that have been placed and the surrounding circumstances that occurred prior to the fall. Document the IDT note right in the Nurses notes as to what happened and what was in place, what is being placed and any other information pertinent to preventing the next fall. At this time the Care Plan and Residents ' Care Card will be updated. Write FALL RISK in capital letters on the top of the Care Card and highlight in yellow to bring attention to this risk. The CNAs (certified nursing assistants) are the first line of defense and should be the first to know that a resident is a fall risk and that there are things in place to prevent falls; -Weekly, the Fall Champion will monitor the Falling Star Program and the "Stars" weekly during rounds; -The facility's IDT will meet weekly and discuss the facility's falls and the interventions put into place and their effectiveness; -The Fall Champion will collaborate with the MDS Coordinator to ensure that the resident's care plan is updated as necessary; -The Fall Champion will be responsible for overall in servicing on fall prevention and Interventions; -The Fall Champion will be responsible for keeping a current list of any alarms being utilized. This list should be updated daily as the need to add or delete arises. The Restorative aide should be assigned to check alarm placement and functionality daily; -The Fall Champion will bring the event report, the post fall assessment and the resident's chart to the next stand up meeting for post fall analysis and discussion. Documentation of interventions tried and what new interventions were put into place will be done at this time. Before leaving stand up, a thorough chart review must be completed, this includes review of the nursing documentation of the event, nurses notes and neuro check documentation, current labs, new labs needed, recent medication changes, any therapy or restorative notes and review of interventions in place, the success and failures of interventions. Update the care plan at this time. The Fall Risk Assessment will also need to be updated at this time. All residents with two or more falls will be referred to therapy. Any resident with three or more falls will have a root cause analysis completed with the IDT team at the weekly At Risk Meeting; -The Fall Champion in collaboration with the IDT/Fall Team will ensure that each resident's care plan is updated as necessary; -The Fall Champion will keep a log of all residents' falls and residents' fall risk scores for ongoing review and will review this log and all residents with falls weekly; -A Falls Team Worksheet will be completed weekly during these meetings to help monitor what interventions have been tried and what have been successful and not so successful; -The Fall Champion will set up a Tupperware container in each medication room and place three working fall alarms in each for quick nursing response and interventions for any falls; -The Fall Champion will develop a list of those residents who are on the falling star program and also a list of all residents and their interventions that are to be in place; -The Restorative Aide will check alarms daily for functionality using the " Daily Alarm checklist" ; -The Fall Champion and the Director of Nursing (DON) will be responsible for reporting fall rates to the home ' s QA (quality assurance) Committee Meetings and on the DON report monthly. 3. Review of Resident #18's MDS dated [DATE], showed the following: -Severely impaired cognition and unable to make decisions; -Had inattention that fluctuated and disorganized thinking; -Had verbal behaviors that occurred one to three days and other behaviors occurred daily; -Rejected care four to six days out of the week; -Required extensive assistance of two staff with transfers; -[DIAGNOSES REDACTED]. Review of the resident's care plan dated 04/25/12, showed the following: Problem: -Self care deficit in transfers related to advanced dementia and weakness; -Approaches included two person pivot transfer. Problem: -Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by yelling out and resists care at times; -Goal: Resident will have no adverse response to resisting care and yelling out; Approach included: -Assess whether the behavior endangers the resident and/or others. Intervene if necessary; -Avoid over-stimulation (e.g. noise, crowding, other physically aggressive residents); -Maintain a calm, slow, understandable approach with the resident; -Place resident in a room near the nurse's station; -When resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs (e.g. pain, hunger, toileting, too hot/cold, etc.; (The care plan did not address resident refusals) Observation on 05/02/12 at 9:12 A.M. showed the following: -The resident was in the broda (reclining wheelchair) chair in his/her room; -CNA F and CNA G placed gait belt around the resident; -The resident began to get upset with the aides and used vulgar language toward CNA G, and began to talk constantly; -CNA G talked to the resident and told him/her they would transfer him/her to the wheelchair to go to the beauty shop; -The resident said, "No..[***] and kept talking and mumbling incoherently; -The resident's mouth was open and the resident began moaning as the gait belt moved up on his/her upper chest; -The resident's legs were both bent at the knees; -CNA G said, "Relax" and CNA F said "Get his/her hair done" as they lifted the resident from the bed to the wheelchair; -The resident's knees were both bent and did not touch the floor. During interview on 05/02/12 at 9:15 A.M., CNA G said the following: -It took two people to transfer the resident since they were trying to do therapy with the resident's legs; -The resident did not bear weight; -Some days, it was "more easier" when they worked with the resident's legs and sometimes he/she would keep his/her legs down and not bent. Observation on 05/02/12 at 11:50 A.M., showed CNA F carried mechanical lift pad to the resident's room. During interview on 05/02/12 at 11:50 A.M., CNA F said they planned to do a hoyer (mechanical) lift transfer since knees buckled ea

Based on observation, interview and record review, the facility failed to ensure a consistent system of communication was employed to address residents at risk for falls on the facility special care unit, that there was sufficient staff on the special care unit to address resident's safety needs, and staff recognized safety hazards which may contribute to falls. This included two of four sampled residents (Resident #1 and #2), who either sustained falls with injury or observation showed were at high risk for falls. Seventeen residents resided on the eighteen bed unit. The facility census was 104. 1. Review of Resident #1's nurse's notes dated 12/29/11 at 1000 (10:00 A.M.) showed staff overheard two residents speaking to one another then cussing, walked out of the nursing office on the Alzheimer's unit, (the nursing office on the unit is located at the end of the unit hall and staff inside the office have no visibility of the unit except for what is happening directly across the hall from the unit). Residents in hallway and observed Resident #1 on the floor laying on his/her left side, resident crying out in pain. Review of the resident's fall risk evaluation dated 1/3/12 showed the resident scored 16 indicating the resident was high risk for falls, with a history of falls indicated on the assessment. Review of the resident's significant change minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 1/10/12 showed the facility assessed the following: -The resident had moderate cognitive impairment with memory problems, trouble concentrating and delusions; -Required extensive assistance of two or more persons to transfer; -The resident walked in his/her room only once or twice with two or more persons to physically assist; -Had limitation in range of motion of both lower extremities; -Balance problem walking and seated to stand; -Sustained falls in the last month, and had a history of [REDACTED]. -[DIAGNOSES REDACTED]. Review of the resident's care plan dated 1/13/12 showed the following: -Identified risk of falls related to poor safety awareness and limited mobility related to hip fracture, noted a fall dated 2/15/12 with right wrist fracture in addition to the hip fracture; -Included approaches to keep the bed in the lowest position, keep call light in reach, verbal reminders not to ambulate, transfer without assistance, hipsters and PT as ordered. -The care plan did not include intervention including personal safety alarms for the bed or chair. Review of the resident's nurses notes dated 1/29/12 through 3/8/12 showed the following: -On 1/29/12 at 3:00 P.M., late entry, resident found sitting on the floor in front of the wheelchair with cushion between him/her and the chair, physician notified and family aware; -On 2/1/12 10:20 A.M. this nurse heard resident call out. Noted resident laying on back on floor next to bed, complaints of pain to left hip, stated she needed to use the restroom, physician contacted. Staff assessed the resident with an unsteady gait, a surgical wound, bladder incontinence, disoriented, with inattention and disorganized thinking; -On 2/15/12 at 3:45 P.M. observed resident on the floor in the TV room. Complaints of the right wrist hurting, ROM (range of motion), very limited; -On 2/15/12 at 7:15 P.M. x-ray obtained and at 8:25 P.M. results showed fracture of the right wrist; -On 2/16/12 at 9:15 A.M. IDT (interdisciplinary team) note: Reviewed fall and right wrist fracture. Has a history of falls and fractures, fall risk score = 14 (high risk). Plan of care review and updated; -On 3/8/12 at 10:00 P.M. resident had therapy before dinner, after the resident wanted to go to bed. Shortly after resident was yelling, found on the floor with slacks and brief down. Resident stated he/she needed to go to the bathroom. Physician contacted and family wanted x-ray of left hip; -On 3/8/12 9:15 A.M. IDT noted: Reviewed 3/8/12 fall, has history of falls with fracture. Plan of care reviewed and updated. Bed alarm applied. Review of the resident's physician orders [REDACTED]. Review of the resident's Certified Nurse Aide (CNA) care card (undated) showed the resident to use a wheelchair alarm, hipsters and as of 3/9/12 a bed alarm. Observation of the resident on 3/2/12 from 11:45 A.M. until 2:45 P.M. showed the following: -At 11:40 A.M. entered the unit and observed eight residents in the common sitting area including Resident #1 with no staff visible on the unit in the hall, common area or dining room; -Resident #1 noted sitting in his/her wheelchair in the common area calling out, " Somebody help me please, somebody out there help me", the resident was noted with no personal alarm in use. The resident shifted his/her weight in the chair and with his/her hands on the wheelchair arms attempted to push up and turn his/her body to look out over the half wall separating the common area from the hallway; -At 11:45 A.M. resident up in his/her wheelchair with no foot pedals; -Resident with a wrist immobilizer on his/her right arm; -No personal alarm in use; -CNA A said the resident could not propel his/herself in the wheelchair, (but had no foot pedals); -At 2:45 the resident in his/her bed with bed in a low position on back resting with no personal alarm in use. 2. Review of Resident #2's Functional Assessment for persons with Alzheimer's disease dated 12/13/11 showed the resident with lack of safety awareness, can sometimes get lost in familiar surroundings and has difficulty with complex tasks (ADL's). Review of the resident's last fall risk evaluation dated 12/13/11 showed the facility assessed the resident with a score of eight which did not represent high risk for falls. Review of the resident's care plan updated 12/13/11 showed the following: -Resident is at risk for falling due to medications including an antidepressant and anti anxiety medication; -Staff should assure the floor is free of glare, liquids, and foreign objects; -Provide resident an environment free of clutter and keep the call light in reach at all times. Review of the resident's nurses notes dated 12/27/11 at 1015 (10:15 A.M.), showed the resident observed laying on left side in bathroom floor. Upper thigh reddened, no bruising or swelling noted. Review of the resident's physician orders [REDACTED]. Observation of the resident on 3/2/12 from 11:43 A.M. through 3:15 P.M. showed the following: -At 11:43 A.M. two CNA's on the SCU attending to eight residents in the common area to assist residents to the dining room; -At 11:43 A.M. CNA A left the eight residents and ran down the unit hall to intervene when the resident was noted in the hallway with his/her knees buckling to assist the resident before the resident fell . CNA A assisted the resident to walk to the dining room. The resident ambulated with a shuffling gait and leaned forward, staff directed resident to pick of his/her feet; -At 2:30 P.M. the resident was observed walking down the unit hall pushing Resident #4 in his/her wheelchair. As Resident #2 pushed the wheelchair, the resident struggled using a shuffling gait and leaned forward. Resident #2 was audibly breathing very hard and fast. The resident's gray pants were noted to be very long, covering the top of his/her feet and dragging behind him/her on the floor as the resident attempted to walk and push the chair. The facility activity director was with Resident #2, in front of Resident #4 in the wheelchair encouraging Resident #2; -At 3:15 P.M. CNA B took the resident to his/her room to use the bathroom as the resident walked on his/her pants in a shuffling gait. CNA B said the resident tried very hard when walking, becomes more and more intense and leaned forward more and more. The resident attempted to sit on the corner of the bed, backing up without looking. CNA B physically redirected the resident to sit on the bed. During interview on 3/2/12 at 1:20 P.M. CNA A and CNA C said there were several residents on the SCU who required total care, including Resident #1 and two other residents who required transfers with the Hoyer lift. There were several residents who were fall risk including Resident #1 and Resident #2. CNA A said they tried to get the residents who required Hoyer lifts done when the Registered Nurse (RN) was on the unit. CNA A said he/she could not guarantee the two aides would not be in a room together and no one would be out supervising residents in the hall or other common areas. During interview on 3/2/12 at 12:30 P.M. RN A said the following: -He/She worked as the charge nurse on a portion of the 300 hall and the SCU; -Most, if not all, residents on the SCU were fall risks; -Some residents on the SCU were full care, it was almost impossible to watch everyone; -He/She was on the unit to give medications and at other times when he/she could be, he/she tried to schedule his/her time on the unit to coincide with the time when the aides needed to transfer the two Hoyer lift residents, so someone would be out on the hall to supervise; -Since Resident #2 has been off medications the resident shuffled more and was more anxious; -A personal alarm was not currently used for Resident #1, and had not been for several days, she was told this was against regulation; -RN A had staff put an alarm on the resident while up in his/her wheelchair at 1:30 P.M. During interview on 3/9/12 at 10:45 A.M. the facility MDS/Care Plan Coordinator said the following: -The facility was trying to reduce some of the alarms; -Did not feel the alarm was effective for Resident #1 and it was taken off, she directed staff to put the alarm back on, she was not sure whose decision it had been initially to remove the alarm; -If a resident has a fall it was discussed with the interdisciplinary team, (DON, Dietary, MDS/Care Plans, Social Service), follow up generally included one person from the team letting someone know what the discussion and plan were; -If there are no further injuries from falls assume the plan is working; -No one in particular is designated to follow up, may talk with the aides during the quarterly review process. During interview on 3/9/12 at 1:05 P.M. the director of nurse (DON) said the following: -The IDT does follow up regarding falls each week; -If there are no falls assume the interventions in place are working; -The MDS/Care plan coordinator said she noted Resident #2 more unsteady this past week, no falls noted as having been prevented by staff recently, she would expect staff to report these as well as actual falls; -Felt two CNA's and a nurse to float would be sufficient staff on the SCU; -Expected at least two on the unit at all times; -This week some residents from the SCU have been moved to the general population because these residents required heavier care; -She would not expect Resident #2 to be pushing another resident in his/her wheel chair as observed by the surveyor on 3/2/12. During interview on 3/9/12 at 12:50 P.M. the administrator said the following: -When asked how long the pin alarm had not been used for Resident #1, she said the MDS/ Care Plan coordinator thought it was about 24 hours; -When asked why the alarm was not used the administrator said staff were not responding to the alarms, the alarms became like "background noise " to staff, they looked at it that maybe the alarms were not effective; -Thought Resident #1 had bed alarm prior, the facility met with family and they did not feel the resident needed anything for the bed, but needed it more for the wheelchair, but last night the resident got up out of bed and fell again. Complaint # MO and MO

Based on observation, interview and record review the facility failed to provide the necessary care and services for one resident, (Resident #1), of three sampled residents to ensure the resident maintained his/her highest practicable level of well being in accordance with the resident's assessment and plan of care. The resident presented with an above the knee amputation with exposed bone and was assessed with [REDACTED]. The facility failed to provide interventions for pain management when the resident experienced significant pain during these dressing changes. The census was 102. 1. Review of the resident's discharge Minimum Data Set (MDS) a federally mandated assessment instrument required to be completed by facility staff dated 12/4/11 showed: - The resident was cognitively intact; - The resident had scheduled and as needed (PRN) pain medication; - The resident had occasional pain that interfered with sleep and activities; - The resident rated the pain at a six on a zero to ten pain scale. Review of the resident's December 2011 physician's orders [REDACTED]. - The resident was readmitted to the facility from the hospital on [DATE]; -[DIAGNOSES REDACTED]. - Orders for [MEDICATION NAME] (an opiate [MEDICATION NAME]) CR 40 milligrams (mg) every six hours and [MEDICATION NAME] (an opiate [MEDICATION NAME])10 mg every two hours as needed for pain; - Above the knee amputation (right leg), cleanse stump with normal saline and apply [MEDICATION NAME] (an ointment that stimulates blood vessel activity), cover with Vaseline gauze and [MEDICATION NAME], change daily and as needed. Review of the resident's pressure ulcer care plan dated 10/25/11 and reviewed on 12/1/11 instructed facility staff to administer [MEDICATION NAME] ([MEDICATION NAME]) prior to treatment (dressing changes) and as needed. Review of the resident's pain evaluation dated 12/10/11 showed the facility assessed the resident as follows: -When asked if the resident had pain in the last five days the resident replied yes and the pain was continuous; -Pain described as aching and throbbing with anxiety associated with the pain; -Pain was increased by wound dressing changes; -Pain in stump noted as almost constant; -Pain in stump rated as an eight on a scale of one to ten and a two one hour after medication; -Pain relieved by medication; -Pain management intervention is necessary, refer to the plan of care. Observation of the resident on 12/14/11 at 11:00 A.M. showed the following: - The resident in bed on his/her back; - Licensed practical nurse (LPN) A started to remove the dressing from the resident's stump above the right knee: - The resident started yelling out, the resident said, "It's hurting!", the resident was groaning, thrashing and screaming, "It hurts!". LPN A continued to finish removing the dressing; - After LPN A removed the dressing he/she said he/she was going to find out if the resident had anything for breakthrough pain; - The resident continued to moan and groan; - At 11:10 A.M. LPN A administered [MEDICATION NAME] to the resident; - Immediately after administering the [MEDICATION NAME] LPN A washed his/her hands and started cleaning the bone protruding from the stump above the resident's right knee; - The resident immediately started yelling out and continued to yell loudly, "I hurt!", the resident was thrashing and trying to pull away from LPN A; - The surveyor stopped the dressing change procedure. Observation on 12/14/11 at 11:45 A.M. showed LPN A entered the resident's room to complete the dressing change initiated on 12/14/11 at 11:00 A.M. LPN A washed his/her hands and put on gloves. The resident laid quietly in his/her bed. LPN A poured normal saline over the bone protruding from the stump of the right leg, the resident grimaced, frowned and yelled out. When LPN A finished pouring the normal saline over the bone the resident calmed down. LPN A took a 4 by 4 gauze and wiped the resident's stump and the resident yelled, "No! No!" and swatted at LPN A. LPN A applied the [MEDICATION NAME] and petroleum gauze to the wound. The administrator entered the room and asked the resident if he/she was in pain and the resident answered "Yes." During interview on 12/14/11 at 11:15 A.M. LPN A said on this current admission the resident did not have orders to premedicate before dressing changes. LPN A said before the resident went to the hospital he/she gave the resident [MEDICATION NAME] and waited one hour before doing his/her dressing changes. LPN A said if he/she did the dressing changes quick the resident would quit moaning and yelling. LPN A said he/she was sure the resident was in pain when the dressing change was done. LPN A said the resident did not yell out until he/she touched the stump and the bone protruding from the stump. LPN A said yelling, moaning and jerking away were indications of pain. LPN A said it took about 30 minutes for the [MEDICATION NAME] to work and he/she was not sure why he/she did not wait for the [MEDICATION NAME] to take effect before he/she started cleaning the wound. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 12/14/11 with no documentation of any PRN [MEDICATION NAME] until 11:00 A.M., (observation showed LPN A administered the PRN [MEDICATION NAME] 10 mg at 11:10 A.M.). At the time of the observation of the dressing change at 11:00 A.M. it had been five hours since the resident received [MEDICATION NAME] for pain control. Review of Mosby's nursing drug reference 2010 showed [MEDICATION NAME]'s onset of pain control as 15-30 minutes with a peak in one hour and duration of three to four hours. During interview on 12/15/11 at 11:30 A.M. LPN B said he/she tried to schedule the dressing changes after the resident had received his/her routine pain medication. LPN B said the dressing changes were extremely uncomfortable for the resident, they hurt him/her a lot. LPN B said it really hurt the resident when he/she removed the dressing from the stump. LPN B said he/she did not give the resident any of the PRN [MEDICATION NAME] for pain control. During interview on 12/14/11 at 11:25 A.M. the resident said the stump and the bone protruding from the stump hurt really bad when it was touched. The resident said it was always painful but much worse when it was touched. The resident said it did help some when staff gave him/her medication prior to dressing changes. During interview on 12/15/11 at 10:00 A.M. the resident's physician said the resident's pain was controlled when he/she was in the hospital and he/she was not aware the pain was not controlled since the resident returned to the facility. The physician said if a resident was showing signs/symptoms of pain such as yelling out during a dressing change then the dressing change should be stopped and the resident given pain medication. Staff should wait for the medication to take effect before doing a dressing change. The resident's physician said if the resident was still having pain after receiving pain medication he/she should be notified, he/she was always available. The physician said if the dressing changes were causing the resident pain then the resident should be premedicated prior to dressing changes. During interview on 12/14/11 at 11:40 A.M. the administrator said the resident was alert and oriented. She would expect staff to stop a dressing change if the resident was in pain and administer pain medication and would also expect staff to wait for the pain medication to take effect before doing a dressing change.