Every finding on record at Twin Pines Adult Care Center

Based on observation, interview, and record review, facility staff failed to treat three residents (Resident #5, #7, and #8) in a review of ten sampled residents, with respect and in a manner that maintained their dignity. The facility census was 73.Review of the facility's Dignity and Respect policy, undated, showed the following:-Every resident has a right to be treated with dignity and respect;-All staff will speak to and treat all residents with dignity and respect. 1. Review of Resident #8's Face Sheet, undated, showed the following:-The resident was readmitted on [DATE];-The resident was his/her own responsible party;-Diagnoses included dementia, muscle wasting and atrophy (wasting, shrinkage, or decrease in size of body tissues, muscles, or organs, typically resulting in reduced function), anxiety disorder (fear of or apprehension about real or perceived threats). Review of the resident's Care Plan, dated 10/27/24, showed the following:-The resident had a communication problem/potential for a communication problem related to hearing loss;-Allow adequate time to respond. Repeat as necessary. Do not rush;-Face the resident when speaking, make eye contact;-Use simple, brief, consistent word/cues. Use alternate communication tools as needed;-Encourage the resident to verbalize feelings and fears. Clarify misconceptions;-Establish a trusting relationship with the resident;-The resident had decreased mobility due to weakness;-Physical mobility, ambulation, transfer, bed mobility wheelchair mobility, and balance impaired;-The resident was dependent on the staff for bed mobility, toileting, transfers with mechanical lift, and bathing;-He/She was incontinent of bowel;-Provide peri care after each incontinent episode;-He/She used antidepressant and antianxiety medication;-He/She had chronic pain;-He/She was incontinent of bladder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Minimal difficulty with hearing, no hearing aid;-Usually understood. Difficulty communicating some words or finishing thoughts but was able if prompted or given time;-Usually understands. Misses some part/intent of message but comprehends most conversations;-Adequate vision-saw fine detail, such as regular print in newspapers/books;-Moderate cognitive impairment;-No behaviors;-Dependent on staff for toileting hygiene, bathing, bed mobility, and transfers;-Always incontinent of bladder and bowel. Observation on 2/19/26 at 9:00 A.M., showed the following:-Certified Nurse Assistant (CNA) C and CNA D transferred the resident from the wheelchair to the bed using a mechanical lift, but had the resident positioned with his/her head touching the headboard of the bed;-The staff used the reuseable incontinence pad to pull the resident down in the bed;-The top of the resident's incontinence brief did not move with the resident, but stayed with the bottom of the bed, causing the brief between his/her legs to pinch the resident's groin;-The resident yelled out, Stop, you're hurting me!;-Resident D said, hold on, you're fine, then continued to provide care without stopping to make the resident comfortable or acknowledge the resident's discomfort;-Staff completed the resident's peri care and positioned the resident in bed;-CNA D said the resident always complained while standing beside the resident. During an interview on 2/19/26 at 9:30 A.M., Resident #8 said the staff needed to be gentle when moving him/her. During an interview on 2/19/26 at 2:05 P.M., Resident #8's spouse said the following:-CNA D was rough with the resident and was always in a hurry;-A week or two ago, CNA D was rough with the resident during a transfer to the shower chair;-CNA D positioned the resident in the shower chair, while the resident yelled out that CNA D was hurting him/her;-CNA D told the resident to hold on a minute then finished getting him/her positioned in the shower chair;-The resident was mad about what happened;-If it hadn't hurt, the resident wouldn't have yelled out that it hurt;-The staff were unprofessional in front of residents, their family members, and other staff in the dining room recently which was upsetting to the resident;-The resident became upset and anxious easily;-The Director of Quality Assurance Performance Improvement (QAPI) was in the dining room, put his/her hands on his/her hips and told CNA F to get back to work;-CNA F was on a lunch break, eating with the residents, but it didn't matter to the Director of QAPI, because he/she told CNA F to get back to work again;-Another issue occurred when staff were squirting each other with water in the dining room on a different day;-The resident was usually quiet and laid back, but became upset and told staff to stop;-Certified Medication Technician (CMT) I approached the resident, gave him/her a squirter, and told the resident to shoot someone with it but the resident was not happy and did not participate. During an interview on 2/19/26 at 2:25 P.M., CNA D said the following:-He/She knew about the staff squirting each other with water;-It happened on a busy, stressful day when CMT I decided to cheer people up by squirting water. During an interview on 2/19/26 at 9:00 A.M., CNA D said the following:-He/She knew about the incident in the dining room related to a staff member being yelled at in front of the whole dining room;-The incident occurred about a week and half to two weeks ago;-Nursing administration told CNA F to help the other unit, but CNA F didn't want to because he/she had showers to complete on this unit;-CNA F ate lunch in the dining room with the residents, the facility encouraged staff to eat with the residents to engage them in conversations;-The Director of QAPI told CNA F to get back to work because there was too much left to do;-CNA F told the Director of QAPI that he/she had ten minutes left on lunch break, but the Director of QAPI told CNA F to get back to work anyway;-The interaction upset Resident #8 and the spouse;-Residents and family members were in the dining room when it happened, and they looked surprised. 2. Review of Resident 7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, complete by facility staff, dated 11/23/25, showed the following:-Cognitively intact;-Understands others;-Made self-understood;-No behaviors. Review of the resident's Care Plan, dated 9/15/25, showed the following:-The resident had an impaired communication/a potential for communication impairment due to hearing deficit;-Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternate communication tools as needed. During an interview on 2/13/26 at 2:50 P.M. and 2/19/26 at 8:55 A.M. the resident said the following:-The staff didn't treat the resident with respect;-At night, the staff played music loud enough to keep him/her awake;-The night shift staff told him/her it couldn't be turned down because other residents enjoyed it;-The resident couldn't remember the night staff member's name;-He/She told the nurse on the next shift after it happened. 4. During an interview on 2/24/26 at 9:36 A.M., the Director of Nursing said the following:-Her expectation was for staff to treat all residents with dignity and respect;-The facility was the residents' home and staff should treat it as such;-Her expectation was nursing administration disciplined staff members away from residents, families, and visitors;-She was unaware the night shift was playing music at night;-She was unaware the staff were squirting each other with water in front of residents;-Her expectation was staff to not be rushed when caring for residents and to not be unnecessarily rough. No one had reported anything about that to her. During an interview on 2/24/26 at 1:22 P.M., the Administrator said the following:-His expectation was for staff to treat all residents with dignity and respect and not be rough when providing care;-The staff should treat the residents like a loved one. #2744230

Based on observation, interview, and record review, the facility failed to provide each resident with meals served at an appetizing temperature for four residents (Residents #2, 3, 4, and 7) out of ten sampled residents. The facility census was 73. Review of the facility's Monitoring Food Temperatures for Meal Service policy, dated 2016, showed the following:-Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures;-Food temperatures of hot foods on a room tray at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident;-Any complaint regarding food temperatures by residents will be documented on the Food Temperature Log;-Complaints will be investigated by conducting a test tray for that meal to determine if foods are remaining above 120 degrees Fahrenheit;-The investigation is recommended to be completed with 72 hours of the complaint. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, complete by facility staff, dated 11/23/25, showed the following:-The resident was cognitively intact;-Setup assistance required from the staff with eating. Review of the resident's Care Plan, updated 2/26/25, showed the following:-The resident's meal trays were to be the first served;- Before taking the tray to him/her, the meal trays were to be heated in the microwave for 30 seconds to one minute;-He/She required set up assistance for eating. Review of the resident's Physician Orders, dated February 2026, showed regular diet, regular texture, and regular consistency (started 11/27/25). During an interview on 2/13/26 at 2:50 P.M., the resident said the following:-The facility had a problem with the food being cold;-There was a staff member that microwaved the food before serving it because the staff member knew the resident did not like cold food;-Sometimes when the resident was in the bathroom, the staff brought in the meal tray, took the cover off the food and walked away;-By the time he/she was done in the restroom and back to her chair, the food was already cold. 2. Review of Resident #2's annual MDS, dated [DATE], showed the following:-The resident was cognitively intact;-Setup assistance required from the staff with eating. Review of the resident's Care Plan, updated 1/26/26, showed the following:-The resident preferred to eat in his/her room;-He/She required assist with tray set up by one staff member. Review of the resident's Physician Orders, dated February 2026, showed regular diet, regular texture, regular consistency, and small portions per his/her request (started 11/11/23). During interview on 2/13/26 at 10:15 A.M., the resident said the following:-He/She ate meals in his/her room;-He/She ordered soup off the menu several times throughout the week, and it was always cold. 3. Review of Resident #3's Care Plan, dated 4/14/25, showed the following:-Provide the resident with as much control as possible in routines, food preferences, etc.;-Provide, serve diet: no added salt, regular texture, as ordered;-The resident required setup assistance by staff to eat. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident had moderate cognitive impairment;-Setup assistance required from the staff with eating. Review of the resident's Physician Orders, dated February 2026, showed no added salt diet, regular texture, and regular consistency (started 12/27/24). During interview on 2/13/26 at 10:30 A.M., the resident said the following:-The food was frequently cold when served;-That morning, the eggs were too cold to eat. 4. Review of Resident #4's quarterly MDS, dated [DATE], showed the following:-The resident had moderate cognitive impairment;-Setup assistance required from the staff with eating. Review of the resident's Care Plan, updated 1/19/26, showed the following:-Monitor and encourage good consumption of food and fluids. Offer substitutions as needed or requested;-Provide the resident with as much control as possible in routines, food preferences, etc.;-Serve diet: low concentrated sweets, regular consistency;-He/She required set up assistance by one staff to eat. Review of the resident's Physician Orders, dated February 2026, showed low concentrated sweet diet, regular texture, and regular consistency. During interview on 2/13/26 at 10:40 A.M., the resident said the following:-He/She ate in the dining room;-Sometimes the food was cold. 5. During an interview on 2/13/26 at 11:42 A.M., Certified Nurse Aide (CNA) C said the following:-The residents complained about the temperature of the food being too cold;-He/She knew Resident #7 frequently complained of his/her food being cold; therefore, CNA C microwaved the resident's food prior to taking it to the resident's room;-The process of delivering meal trays had changed;-In the past, the kitchen plated the food, covered it, then gave it to nursing staff to take to the resident;-Now the kitchen plated the food, covered it, and placed it in a cart for the staff to deliver to the resident rooms;-If nursing staff was busy, the food sat until someone was available to pass out the trays. During interview on 2/13/26 at 11:42 A.M., CNA D said the following:-Nursing staff was supposed to clock in at 6:45 A.M., and received report from the off going staff;-The kitchen staff had the breakfast trays plated and in the cart at 7:00 A.M.,-It took longer than 15 minutes to get everything done with the off going staff and getting the remainder of residents ready for the day;-By the time the nursing staff were available to pass out trays, the food was room temperature. During interview on 2/13/26 at 11:55 A.M., Licensed Practical Nurse (LPN) E saidresidents complained about the food being cold. Observation of the test tray, the last tray served after all the resident had been served on 2/13/26 at 12:45 P.M., showed the following: - The fried chicken thigh was 116 degrees Fahrenheit;-The green beans were 112 degrees Fahrenheit. During interview on 2/18/26 at 8:02 A.M., the Dietary Manager said the following:-His expectation was the kitchen staff checked the temperature of the food before it left the kitchen and again before the trays were served to residents;-He was not aware of any resident complaints about cold food;-His expectation was the food was maintained at the temperature per policy at a minimum of 120 degrees Fahrenheit by the time the resident received the meal tray. During interview on 2/24/26 at 1:22 P.M., the Administrator said the following:-His expectation was the residents' food reached and were maintained at the temperature per the regulations;-If the food was not at the correct temperature, then there needed to be an investigation to determine why food temperatures were not appropriate. #2722550

Based on interview and record review, the facility failed to notify the responsible party when one resident (Resident #9) of ten sampled residents, had medication changes and transfer to a hospital. The facility census was 73.Review of the facility's Notification of Changes Policy, dated 5/2021, showed the following:-It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority;-Notification is provided to residents and/or the resident representative(s) to promote the resident's right to make choices about care and treatment and to keep them informed of the resident's current health status. Review of the facility's Procedure for Notification of Changes for Resident policy, updated 2017, showed the following:-The nurse will immediately notify the resident and/or the resident representative(s) for a decision to transfer or discharge the resident from the facility;-The nurse will notify the resident and/or resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician;-Educate the resident and/or resident representative about the risks and benefits of the proposed treatment change and provide an opportunity for the resident to make an informed choice of the treatment or alternate that they prefer. Review of Resident #9's Face Sheet, undated, showed the following:-The resident was admitted to the facility on [DATE];-He/She was his/her own responsible party;-The staff listed emergency contact #1 with phone number;-The staff listed emergency contact #2 with phone number;-Diagnoses included dementia (general, umbrella term for a decline in mental abilities-including memory, thinking, reasoning, and language-severe enough to interfere with daily life), and rheumatoid arthritis (chronic disorder where the immune system mistakenly attacks the lining of joints, causing painful inflammation, stiffness, and swelling). Review of the resident's Physician Orders, dated 10/15/25, showed the following:-Colchicine (medication to treat gout) 0.6 milligrams (mg) give one tablet by mouth two times a day related to pericardial effusion (buildup of excess fluid in the sac surrounding the heart, which can compress the heart and restrict its ability to function properly);-Methotrexate (medication to treat rheumatoid arthritis) 2.5 mg give one tablet by mouth every 24 hours as needed for rheumatoid arthritis flare up. Review of the resident's Physician Orders, dated 10/17/25, showed to hold the colchicine 0.6 mg. Review of the resident's Physician Orders, dated 10/20/25, showed to resume the colchicine 0.6 mg two times a day. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/20/25, showed the resident was cognitively intact. Review of the resident's Physician Orders, dated 10/24/25, showed the physician ordered colchicine 0.6 mg give one tablet by mouth one time a day related to pericardial effusion. Review of the resident's Physician Orders, dated 10/25/25, showed the physician discontinued the order for colchicine 0.6 mg daily. Review of the resident's Nurse Notes showed no documentation the nurse notified the resident or emergency contact when the colchicine was restarted on 10/17/25 or when the directions changed on 10/24/25. Review of the resident's Physician Orders, dated 12/5/25, showed methotrexate 2.5 mg give one tablet by mouth one time a day for rheumatoid arthritis. Review of the resident's Nurse Notes showed no documentation the nurse notified the resident or emergency contact when the methotrexate order was changed from as needed to scheduled daily. Review of the resident's Transfer Form, dated 1/14/26, showed the facility transferred the resident to the hospital for abnormal vital signs (low/high blood pressure, high respiratory rate). Review of the resident's Nurse Notes showed no documentation the nurse notified the resident's emergency contact when the facility transferred the resident to the hospital by ambulance. During an interview on 2/18/26 at 10:48 A.M., the resident's emergency contact #1 said the following:-The facility did not contact him/her the methotrexate order was changed from as needed to once a day;-The family asked the nursing staff several times for the medication colchicine to be discontinued, but the facility continued to administer it, even though it was causing the resident nausea and vomiting;-The facility didn't call any family members about sending the resident to the hospital on 1/14/26;-He/She requested staff contact him/her when the resident had any changes, because the resident previously forgotten what was discussed. During an interview on 2/19/26 at 8:49 A.M., Licensed Practical Nurse (LPN) H said the following:-The resident's family member #2 was very involved in the resident's care;-LPN H thought he/she called the resident's family regarding the resident being transferred to the hospital. It should have been documented in the nurse notes;-The nurses were supposed to call the resident's family when sending a resident to the hospital and when there was a significant change in physical or mental status;-If a family member had a problem with a resident's medication, the nurse was supposed to contact the physician and follow up with the family member. During an interview on 2/20/26 at 12:48 P.M., the resident's emergency contact #2 said the following:-On 1/14/26, the facility sent the resident to the hospital but did not contact any of the family;-A friend saw the resident going into the hospital's emergency department and called family member #1 to ask what was happening to the resident;-That was how the family found out the resident was in the hospital. Review of the resident's Nurse Notes showed no documentation of the resident or family being notified when colchicine medication was started or when the instruction was changed. No documentation of the resident or family being notified when the methotrexate was changed from as needed to scheduled daily. There was no documentation staff notified the resident's family when the resident transferred to the hospital. During an interview on 2/24/26 at 1:22 P.M., the Director of Nursing said the following:-Her expectation was the nurse notify the resident's family when the resident was sent to the emergency department;-Since the resident was his/her own responsible party, the nursing staff was not required to notify the family when a medication hanged, unless the family requested to be informed. 2725731

Based on interview, record review, and policy review, the facility failed to have a grievance procedure with an identified person to lead investigations, a system to inform residents of their right to file a grievance, and documentation to show the results of grievance investigations for six of six residents (Resident (R) 1, R21, R28, R38, R48, and R56) interviewed in the resident group interview. The failure had the potential to affect all residents who resided at the facility to be informed of their right to file a grievance and for the facility to resolve any grievance the residents may have. Findings include: Review of the facility's undated policy titled, Grievance Policy, indicated, Objective of Grievance Policy: The objective of the grievance policy is to ensure the facility makes prompt efforts to resolve grievances a resident may have. The intent of the grievance process is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution. The grievance policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and Performance Improvement Program (QAPI) .Procedure: A. The facility will promote the grievance process throughout the organization .B. Grievance Official: The facility will train and designate an individual who is responsible for: a. Overseeing the grievance process in conjunction with facility administration, b. Receive and track all grievances through to their conclusion .f. Complete written grievance resolutions/decisions to the resident involved .C. Resident and Resident Representative Notification: The facility will inform residents orally and in writing of their right to make complaints and grievances and the process to do so during admission, readmission and the care planning process .E. A grievance concern can be expressed orally to the grievance official or facility staff or in writing using a grievance form which will be located adjacent to the bill of rights posting located throughout the facility at each nursing station and outside the social service office. F. Grievances may be given to any staff member who will forward the grievance to the grievance office, or they may file the grievances anonymously in the designated box located outside the nursing administration office. G. Response: Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority .H. Resolution. The grievance official will complete a written response within seven working days to the resident or resident representative .I. The grievance officer will maintain a log of all grievances for a period of three years .J. QAPI: The facility will track, trend, and analyze the grievance process and findings for trends, performance gaps and opportunities for individual education, system, and systemic improvement.'' During the initial observational tour of the facility on 10/08/24 between 9:30 AM-11:30 AM, there were no grievance forms observed on any of the facility's four neighborhoods. There was a black box observed on the wall, labeled grievance, after entering through the main door of the facility. Further observations on 10/09/24 at 7:45 AM, 10/10/24 at 7:30 AM, and 10/11/24 at 7:45 AM revealed there were no grievance forms observed in the different neighborhoods and/or next to the grievance box which was on the wall after entering the facility. During an interview on 10/08/24 at 2:09 PM, the Administrator was asked to provide the grievance log for the previous six months for review. The Administrator denied having such a log or having documentation of grievance investigations or their results. The Administrator said, We all attend the monthly resident council meetings and handle concerns immediately. We just hired a QA (Quality Assurance) staff member to handle the grievance process. A Resident Group interview was held on 10/10/24 at 11:00 AM with six alert and oriented residents chosen by the facility (Resident (R) 1, R21, R28, R38, R48, and R56) who regularly attended the monthly Resident Council meetings. The residents were asked if they knew how to file a grievance. None of the six residents knew of a process to file a grievance. None of the residents knew of the newly hired QA staff member. Review of six months of Resident Council meeting minutes revealed no discussions about grievances, the right to file a grievance, or the right to have a conclusion to the grievance investigation. During an interview on 10/11/24 at 7:52 AM, the QA staff member said she was New to position, just over a month. The QA denied having received prior grievance concerns, upon hire, for investigation or anything new since being hired to investigate. During an interview on 10/11/24 at 1:30 PM, the MDSC indicated if a resident and/or family expressed a concern during a care conference, then she took notes and informed either the DON or the Administrator and sometimes both. The MDSC stated she would go to the department that the concern was about and let them know. The MDSC confirmed she did not write any concerns identified down on the facility's grievance form. 25232

Based on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was labeled and dated with an open date to ensure opened food items were discarded in a timely manner. This had the potential to increase the spread of foodborne illnesses for 72 out of 72 residents that receive meals from the kitchen. Findings include: Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen), 2016 Edition, revealed Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. (1) See Date Marking Guidelines in this section for exceptions to dating individual dry storage food items . c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration . f. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers . During the follow up observation of the kitchen with the DM (Dietary Manager) on 10/09/24 at 9:40 AM, in the cooler there were a one gallon container of sweet and sour sauce, a one gallon container of salad dressing, and a five pound container of strawberry halves that had been opened and not labeled to indicate the open date of each item. Also, the dry food storage contained three boxes of cereal that were open and not dated with the open date. During an interview on 10/09/24 at 9:50 AM, the dietary aide (DA)1 stated they were supposed to date items when opened to ensure they get rid of food that had been in the refrigerator too long. During an interview on 10/09/24 at 10:00 AM, the DM stated the staff should have put an open date on the food items. The DM said he/she was working on getting everyone to put an open date and an out date on the things they open so residents don't get outdated food.

Based on record review and interview, the facility failed to ensure that five of five employee files reviewed had the required Quality Assurance and Performance Improvement (QAPI) training. This failure had the potential to have a negative impact on staff for their unawareness about how to bring concerns to QAPI and in return this could impact the 72 residents currently residing at the facility. Findings include: Review of Certified Nursing Assistant (CNA)1's personnel file indicated CNA1's Date of Hire (DOH) was 08/16/23 and there was no evidence of CNA1 receiving the required QAPI training. Review of CNA6's personnel file indicated CNA6's DOH was 08/10/23 and there was no evidence of CNA6 receiving the required QAPI training. Review of CNA7's personnel file indicated CNA7's DOH was 03/15/23 and there was no evidence of CNA7 receiving the required QAPI training. Review of Environmental Services (ES) personnel file indicated ES's DOH was 03/12/87 and there was no evidence of ES receiving the required QAPI training. Review of Nursing Supervisor's (NS) personnel file indicated NS's DOH was 09/18/02 and there was no evidence of NS receiving the required QAPI training. During an interview on 10/11/24 at 9:30 AM, the Director of Nursing (DON) confirmed that there was no QAPI training for the facility staff.

Based on record review, interview, and policy review, the facility failed to ensure that three of five employee files (Certified Nursing Assistant (CNA) 6, CNA7, and CNA1) reviewed had a background check prior to hire. This had the potential to have staff hired that have an unknown history of abuse. Findings include: Review of facility's undated policy titled, New Employee Background Check Policy, indicated, To ensure the safety and well-being of residents by conducting thorough background checks on all prospective employees, contractors, and volunteers before they are hired or engaged by the facility .Procedure: 1. Initiating Background Checks: Human Resources (HR) will request a criminal background check for all prospective employees using the appropriate state and federal systems .2. Reviewing Background Check Results: Upon receipt of the background check results, HR will review the information to determine if the prospective employee is eligible for hire. If the background check reveals disqualifying information, HR will ensure the individual does not have contact with residents. 1. Review of Certified Nursing Assistant (CNA) 6's employee file indicated her date of hire (DOH) was 08/10/23. Further review indicated that CNA6's background check was started 08/14/23, four days after her hire date and was not completed until 09/11/23. Review of CNA6's Punch Data, dated 08/10/23 through 09/11/23, indicated CNA6 worked the following dates: 08/10/23, 08/11/23, 08/12/23, 08/13/23, 08/17/23, 08/24/23, 08/25/23, 08/26/23, 08/27/23, 08/31/23, 09/03/23, 09/04/23, 09/07/23, 09/08/23, 09/09/23, and 09/10/23. 2. Review of CNA7's employee file indicated her DOH was 03/15/23. Further review indicated CNA7's background check was submitted on 03/15/23; however, it was not completed until 03/29/23, 14 days after her hire date. Review of CNA7's Punch Data, dated 03/15/23 through 03/29/23, indicated that CNA7 worked the following dates: 03/15/23, 03/17/23, 03/18/23, 03/19/23, 03/21/23, 03/22/23, 03/24/23, 03/28/23, and 03/29/23. 3. Review of CNA1's employee file indicated her DOH was 08/16/23. Further review indicated CNA1's background check was submitted on 08/18/23, two days after her hire date and not completed until 09/15/23. Review of CNA1's Punch Data, dated 08/16/23 through 09/15/23, indicated that CNA1 worked the following dates: 08/16/23, 08/18/23, 08/21/23, 08/22/23, 08/25/23, 08/26/23, 08/27/23, 08/28/23, 08/30/23, 08/31/23, 09/01/23, 09/04/23, 09/05/23, 09/06/23, 09/08/23, 09/09/23, 09/10/23, 09/11/23, 09/13/23, and 09/15/23. During an interview on 10/11/24 at 11:00 AM, the Administrator confirmed that background checks were late and stated they should have been conducted prior to hire date. During an interview on 10/11/24 at 11:22 AM, the Infection Preventionist (IP) confirmed background checks were not fully completed on the employees above prior to the start of their first shift.

Based on record review, interview, and policy review, the facility failed to ensure three of three residents (Resident (R) 21, R41, and R2) reviewed for hospitalization out of a total sample of 22 and their representatives were given a written notice of transfer to the hospital. In addition, the Ombudsman was not notified of the monthly hospitalization s. This failure created the potential for residents or their responsible party not to have the information needed to understand their transfer to the hospital. Findings include: Review of the facility's policy titled Transfer and Discharge from the Facility Policy, dated 2017, indicated, It is the policy of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident unless a transfer or discharge from the facility is: A. Necessary for the resident's welfare and the resident's needs cannot be met in the facility .The resident and representative will receive timely notification, adequate preparation, orientation and information to make the transfer as orderly and safe as possible. The notice still contains information about the transfer and information about the resident's appeal rights. The facility will assist the residents to obtain, complete and submit an appeal form at the president's request. The resident will not be discharged during the appeal process. If the transfer is due to an emergency, the notice will be issued as soon as practicable. The facility forwards a copy of all discharge notices to the Office of the State Long-Term Ombudsman and required state agencies 1. Review of R21's undated ''Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated that R21 was readmitted to the facility on [DATE]. a. Review of R21's Progress Note, dated 08/03/24, located under Notes tab in the EMR indicated [R21's Name] very anxious, tearful, and states that she is having difficulty remembering staff names and is confused .On call physician contacted and order given to transfer out R21.'' b. Review of R21's Progress Note, dated 09/28/24, located under Notes tab in the EMR indicated Spoke with [name of physician] who is on-call regarding R21 not feeling right, something is off .tremors gradually intensifying throughout the day .Nurse and R21 decided it would be best to get checked out at emergency department (ED).'' Review of the Miscellaneous tab in the EMR indicated no evidence of a written transfer hospital notification. 2. Review of R41's undated Face Sheet, located under the Profile tab in the EMR indicated R41 was admitted to the facility on [DATE]. Review of R41's facility provided Transfer Form, dated 08/17/24 indicated [R41's Name] tested positive for Coronavirus disease (COVID) this morning. R41 complained feeling chilled, noted full body tremors. R41 was sent to the emergency room (ER). Review of the Miscellaneous tab in the EMR indicated no evidence of a written transfer hospital notification. During an interview on 10/09/24 at 1:20 PM, the Ombudsman stated there had not been a monthly hospitalization list sent from the facility since January 2024. During an interview on 10/10/24 at 9:01 AM, the Director of Nursing (DON) confirmed R21 nor R41 received a written transfer notice for hospitalization s. In addition, the DON confirmed the Ombudsman was not notified of hospitalization s. During an interview on 10/10/24 at 9:30 AM, the Administrator confirmed the Ombudsman had not been notified of hospital transfers, and there was no written transfer notice given to either the resident and/or resident representative. The Administrator stated he was aware of the regulations. 3. Review of R2's Admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, type II diabetes mellitus, and unspecified dementia. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/24 and located in the MDS tab of the EMR, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired. Review of R2's Census located under the Clinical tab in the EMR, identified R2 was transferred to the hospital on 06/14/24 and readmitted to the facility on [DATE]. Review of R2's Nursing Note, dated 06/14/24 at 6:12 PM, located in the Progress Notes tab of the EMR, revealed Resident was eating supper when staff approached him after noticing he was acting sleepy/lethargic. Resident was unresponsive to verbal and tactile stimuli and proceeded to became very pale and slump in his wheelchair. Sternal rub performed to attempt to arouse the patient, and after 10 seconds resident woke up, coughing on food that he had pocketed into his mouth. Resident was awake and responsive at this point, but very confused. He proceeded to make animals noises at staff, growling and barking, and attempting to grope staff inappropriately. VS [vitals] were obtained at this time and were as follows: B/p [blood pressure]: 167/80, 95% on RA [oxygen on room air], HR-71 [heart rate], R-18 [respirations], T-97.6*F. [temperature] On call [physician] contacted and notified of resident's status and orders given to transfer to ED [emergency department] for further evaluation and treatment. Review of R2's Progress Notes and Misc tabs of the EMR revealed no documented evidence a written transfer notice was provided to the resident and/or the resident representative at the time of the transfer or soon after the transfer to the hospital on 06/14/24. During an interview with the DON and the Administrator on 10/10/24 at 1:50 PM, both confirmed the facility did not provide transfer/discharge notices to residents, resident representatives, or the Ombudsman. 25232

Based on record review, interview, and policy review, the facility failed to ensure three of three residents (Resident (R) 21, R41, and R2) reviewed for hospitalization out of a total sample of 22 residents were given a written copy of a bed hold notice within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties not to have the information needed to safeguard their return to the facility. Findings include: Review of facility's policy titled, Bed Hold and Return to Facility Policy and Procedure, dated 2017, indicated, It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer . Residents and their representatives will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave . Nursing and social work staff are educated about the resident's bed hold and return rights to ensure that required information is provided at the time the resident leaves the facility .Procedure: A. Bed Hold and Return Notice upon transfer: The facility will provide the resident and resident representative with a written notice which specifies the duration of the bed-hold policy at the time of transfer for hospitalization or therapeutic leave. This notice specifies the following information: a. The state bed-hold policy during which the resident is permitted to return and resume residence in the nursing facility. The facility's policies regarding bed-hold periods permitting resident to return: in the event of absence of the resident from [name of the facility] by reason of residents transfer to a hospital or other facility to receive medical care, resident may retain his/her room at [name of the facility] provided that resident/resident representative pays the daily charge for the room, [name of the facility] does not guarantee or assure that a room will be available to resident to resident at [name of the facility] any time thereafter. Medicare and [name of healthcare insurance] make no payment for holding beds, therefore, it is necessary for charge to be in pain privately. If you choose not to reserve the bed, [name of the facility] will admit the resident to the first available appropriate bed. The Social Service department will contact the resident/resident representative when this issue arises. 1. Review of undated R21's ''Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated R21 was readmitted to the facility on [DATE]. a. Review of R21's Progress Note, dated 08/03/24, located under Notes tab in the EMR, indicated [R21's Name] very anxious, tearful, and states that she is having difficulty remembering staff names and is confused .On call physician contacted and order given to transfer out R21.'' b. Review of R21's Progress Note, dated 09/28/24, located under tab Notes in the EMR, indicated Spoke with [name of physician] who is on-call regarding [R21's Name] not feeling right, something is off .tremors gradually intensifying throughout the day .Nurse and [R21's Name] decided it would be best to get checked out at emergency department (ED).'' Review of the Miscellaneous tab in the EMR indicated no evidence of a written bed hold notification. 2. Review of R41's undated Face Sheet, located under the Profile tab in the EMR, indicated that R41 was admitted to the facility on [DATE]. Review of R41's facility provided Transfer Form, dated 08/17/24 indicated [R41's Name] tested positive for Coronavirus disease (COVID) this morning. [R41's Name] complained feeling chilled, noted full body tremors. [R41's Name] was sent to the emergency room (ER). Review of the Miscellaneous tab in the EMR indicated no evidence of a written bed hold notification. During an interview on 10/10/24 at 9:01 AM, the Director of Nursing (DON) confirmed R21 nor R41 received a written bed hold notice. The DON stated every resident was allowed back to the facility. During an interview on 10/10/24 at 9:30 AM, the Administrator confirmed the residents and/or resident representatives were not given a written bed hold notice. 3. Review of R2's Admission Record, located under the Profile tab in the EMR revealed R2 was admitted to the facility on [DATE]. Review of R2's Census located under the Clinical tab in the EMR, identified R2 was transferred to the hospital on 06/14/24 and readmitted to the facility on [DATE]. Review of R2's Nursing Note, dated 06/14/24 at 6:12 PM, located in the Progress Notes tab of the EMR, revealed Resident was eating supper when staff approached him after noticing he was acting sleepy/lethargic. Resident was unresponsive to verbal and tactile stimuli and proceeded to became very pale and slump in his wheelchair. [A] Sternal rub was performed to attempt to arouse the patient, and after 10 seconds [the] resident woke up, coughing on food that he had pocketed into his mouth. Resident was awake and responsive at this point, but very confused. He proceeded to make animals noises at staff, growling and barking, and attempting to grope staff inappropriately. VS [vitals] were obtained at this time and were as follows: B/p [blood pressure]: 167/80, 95% on RA [oxygen on room air], HR-71 [heart rate], R-18 [respirations], T-97.6*F. [temperature] On call [physician] contacted and notified of resident's status and orders given to transfer to ED [emergency department] for further evaluation and treatment. Review of R2's Progress Notes and Misc tabs of the EMR revealed no documented evidence a written bed hold notice was provided to the resident and/or the resident representative at the time of the transfer or soon after the transfer to the hospital on 06/14/24. During an interview with the DON and the Administrator on 10/10/24 at 1:50 PM, both confirmed the facility did not provide written bed hold notices to residents or resident representatives. 25232

Based on record review, interview, and facility policy review, the facility failed to ensure three residents (Resident (R) 1, R23, and R24) out of 22 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner. This failure has the potential of non-payment for necessary resident care. Findings include: Review of facility's policy titled, MDS Transmission for Skilled Nursing Facilities (SNF), undated, indicated, .3. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. 1. Review of R1's Admission Record, located under the Profile tab in the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE]. Review of R1's significant change in status MDS with an assessment reference date (ARD) of 03/05/23 and located under the MDS tab in the EMR revealed MDS completed on 03/17/23 and submitted on 04/12/23 which indicated it was transmitted outside the required 14 days. Review of R1's quarterly MDS with an ARD of 06/04/23 and located under the MDS tab in the EMR, revealed MDS completed on 06/16/23 and submitted on 07/07/23 which indicated it was transmitted outside the required 14 days. Review of R1's quarterly MDS with an ARD of 09/03/23 and located under the MDS tab in the EMR, revealed MDS completed on 09/15/23 and submitted on 10/06/23 which indicated it was transmitted outside the required 14 days. Review of R1's quarterly MDS with an ARD of 12/03/23 and located under the MDS tab in the EMR, revealed MDS completed on 12/15/23 and submitted on 01/11/24 which indicated it was transmitted outside the required 14 days. Review of R1's annual MDS with an ARD of 03/03/24 and located under the MDS tab in the EMR, revealed MDS completed on 03/15/24 and submitted on 04/10/24 which indicated it was transmitted outside the required 14 days. Review of R1's quarterly MDS assessment with an ARD of 06/02/24 and located under the MDS tab in the EMR, revealed MDS completed on 06/14/24 and submitted on 07/11/24 which indicated it was transmitted outside the required 14 days. 2. Review of R23's Admission Record, located under the Profile tab in the EMR revealed R23 was admitted to the facility on [DATE]. Review of R23's quarterly MDS with an ARD of 03/12/23 and located under the MDS tab in the EMR, revealed MDS completed on 03/14/23 and submitted on 04/12/23 which indicated it was transmitted outside the required 14 days. Review of R23's annual MDS with an ARD of 06/04/23 and located under the MDS tab in the EMR, revealed MDS completed on 06/16/23 and submitted on 07/07/23 which indicated it was submitted outside the required 14 days. Review of R23's quarterly MDS with an ARD of 09/03/23 and located under the MDS tab in the EMR, revealed MDS completed on 09/15/23 and submitted on 10/06/23 which indicated it was transmitted outside the required 14 days. Review of R23's quarterly MDS with an ARD of 12/03/23 and located under the MDS tab in the EMR, revealed MDS completed on 12/15/23 and submitted on 01/11/24 which indicated it was transmitted outside the required 14 days. Review of R23's quarterly MDS with an ARD of 03/03/24 revealed located under the MDS tab in the EMR, MDS completed on 03/15/24 and submitted on 04/10/24 which indicated it was transmitted outside the required 14 days. Review of R23's annual MDS with an ARD of 06/02/24 located under the MDS tab in the EMR, revealed MDS completed on 06/14/24 submitted on 07/11/24 which indicated it was transmitted outside the required 14 days. 3. Review of R24's Admission Record, located under the Profile tab in the EMR revealed R24 was readmitted to the facility on [DATE]. Review of R24's admission MDS with an ARD of 06/18/23 and located under the MDS tab in the EMR, revealed MDS completed on 06/21/23 and submitted on 07/07/23 which indicated it was transmitted outside the required 14 days. Review of R24's quarterly MDS with an ARD of 12/03/23 located under the MDS tab in the EMR, revealed MDS completed on 12/15/23 and submitted on 01/11/24 which indicated it was transmitted outside the required 14 days. Review of R24's quarterly MDS with an ARD of 03/03/24 and located under the MDS tab in the EMR, revealed MDS completed on 03/15/24 and submitted on 04/10/24 which indicated it was transmitted outside the required 14 days. Review of R24's annual MDS with an ARD of 06/02/24 and located under the MDS tab in the EMR, revealed MDS completed on 06/14/24 and submitted on 07/11/24 which indicated it was transmitted outside the required 14 days. During an interview on 10/10/24 at 8:35 AM, the Director of Nursing (DON) confirmed the assessments were transmitted late and stated they should have been transmitted within 14 days of being completed. Continued interview revealed the DON was unaware of the last time that she reviewed the missing assessment report.

Based on record review, interview, and policy review, the facility failed to ensure three of five Certified Nursing Assistants (CNA)1, CNA6, and CNA7) completed the minimum of 12 hours of in-service training per year. The lack of in-service training could have a negative impact on all 72 residents currently residing at the facility by the staff not knowing how to care for the residents. Findings include: Review of the facility policy titled, In-Service/Employee Education, revised 06/12, indicated, It is the policy of [name of the facility] that all nursing employees receive, at a minimum, 12-hours in-service education yearly .All [name of the facility] employees are required to attend at least one block mandatory in-service yearly, covering state and federal requirement. Procedure: 2. All department directors are responsible for ensuring the continuing competency of the employees within that department .4. The mandatory block in-service will be offered monthly. 5. The mandatory block in-service will cover, at a minimum: Resident rights, abuse and neglect, infection control, body substance precautions, handwashing, fire safety and evacuation procedures, resident safety, emergency preparedness, corporate compliance, and health insurance portability and accountability act (HIPPA). 6. Annual nursing staff in-service will include, at a minimum: bowel and bladder retraining, restorative nursing, proper positioning, transfers, ambulation, range of motion, activities of daily living (ADL) training, care of persons with cognitive impairment or dementia, current special resident needs, and any other needs identified .13. All nursing employees must attend, at a minimum, 12-hours of in-service yearly, including the mandatory block in-services .15. All in-service hours will be tracked from anniversary date to anniversary date.'' Review of CNA1's personnel file indicated CNA1's Date of Hire (DOH) was 08/16/23 and there was no evidence of CNA1 receiving the required 12-hours of in-service training during the past year (August 2023-August 2024). Review of CNA6's personnel file indicated CNA6's DOH was 08/10/23 and there was no evidence of CNA6 receiving the required 12-hours of in-service training during the past year (August 2023-August 2024). Review of CNA7's personnel file indicated CNA7's was hired on 03/15/23 and there was no evidence of CNA7 receiving the required 12-hours of in-service training during the past year (March 2023-March 2024). During an interview on 10/11/24 at 9:30 AM, the Director of Nursing (DON) confirmed that the three CNA's personal files did not include documentation of 12-hours of in-service training for the past year.

Based on observation, interview, record review, and policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medications assessment, a physician's order, and a care plan completed for two of two residents (Resident (R) 4 and R44) reviewed for self-administration of medications out of a total sample of 22 residents. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents. Findings include: Review of the facility's policy titled, Self-Administration of Medications, revised 02/2021, indicated, Resident have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status .8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 1. Review of R4's Face Sheet, located under the Profile tab in the Electronic Medical Record (EMR) indicated that R4 was admitted to the facility with diagnoses which included allergic rhinitis. During observation on 10/08/24 at 10:20 AM of R4's room a white box with a bottle of nasal spray inside was observed on the resident's bedside table. The label read Azelastine Hydrochloride Nasal Spray (this medication is used for seasonal allergies). R4 said that she took one spray each nostril in the morning and at night. R4 said that the facility knew she had them because the facility just re-ordered her a new bottle. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/25/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. Review R4's Physician Orders, dated 09/01/23, provided by the facility indicated Azelastine HCl Nasal Solution 0.1 % (Azelastine HCl) 137 micrograms (mcg) in each nostril two times a day for allergic rhinitis, may keep at bedside. Review of R4's EMR under the Assessments tab revealed no documented evidence that the resident had been assessed for self-administration of medication. Review of R4's Care Plan, located under the Care Plan tab in the EMR indicated no evidence of a self-administration of medication care plan. Observation on 10/10/24 at 8:30 AM and 10:08 AM of R4's room revealed a box with nasal spray on R4's over the bed table. During an observation and interview on 10/10/24 at 10:20 AM, Licensed Practical Nurse (LPN) 3, confirmed that R4 had nasal spray next to her bed. LPN3 stated she was unsure if R4 had been assessed for self-administration of medication. Continued interview revealed that the LPN3 was not sure if residents should be care planned if they self-administered their medications. During an interview on 10/10/24 at 11:25 AM, the Director of Nursing (DON) confirmed for a resident to self-administer medications, the resident required a physician's order, assessment, care plan for self-administration, and a way to lock up the medication. The DON confirmed R4 was not assessed for self-administration of medication and was not care planned for self-administration of medication. 2. Review of R44's Face Sheet, located under the Profile tab of the EMR indicated R44 was admitted to the facility with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD). Observation of medication administration on 10/09/24 at 8:27 AM, Certified Medication Technician (CMT) 6 gathered R44's morning medication and went into R44's room with Advair hydrofluoroalkane (HFA) inhaler (this is an inhaler to help breathing) and a vital sign machine. Once inside R44's room, CMT6 handed the inhaler to R44 and took R44's vital signs. The CMT left the room prior to observing R44 administer the inhaler medication. After two minutes, CMT6 returned to R44's room, handed R44 her other medication, and asked R44 if she administered her inhaler medication. R44 said yes and handed the inhaler back to CMT6. Review of R44's quarterly MDS with an ARD of 07/21/24 and located under the MDS tab in the EMR revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Review of R44's Physician Orders, dated 02/05/24 and located under the Orders tab in the EMR, indicated, Advair HFA Inhalation Aerosol 115-21 MCG/Asthma Control Test (ACT) (Fluticasone-Salmeterol), two puffs inhale orally two times a day related to COPD. Continued review of R44's Physician Orders revealed no documented evidence of an order for R44 to self-administer any medications. Review of R44's EMR under Assessments tab indicated no documented evidence that the resident had been assessed for self-administration of medications. Review of R44's Care Plan, located under the Care Plan tab in the EMR indicated no evidence of self-administration of medication care plan. During an interview on 10/10/24 at 11:15 AM, the Nursing Supervisor (NS) confirmed R44 did not have a physician's order, was not assessed for self-administration of medications, and the resident' care plan did not reflect self-administration of medications. During an interview on 10/10/24 at 11:25 AM, the DON confirmed R44 was not assessed to determine if the resident was able to safely self-administer medications, the resident was not ordered by their physician to self-administer their medications, and the resident's care plan did not reflect self-administration of medication.

Based on observation, interview, and record review, the facility failed to provide the physician follow up information on a skin condition for one resident (Resident (R) 45) delaying treatment and failed to assess the need to crush medications for one resident (R5) out of a total sample of 22 residents. These failures increased the risk that residents would not receive timely and/or effective treatments. Findings include: 1. Review of R45's Admission Record, located under the Profile tab of the electronic medical record (EMR) identified R45 was admitted on [DATE]. Review of R45's quarterly Minimum Data Set (MDS), located under the RAI tab in the Electronic Medical Record (EMR), with an Assessment Reference Date (ARD) of 09/01/24, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated R45 had short and long term memory problems, and the staff could not determine a BIMS score. R45 was identified as being dependent on staff for activities of daily living (ADL's). Review of R45's Nurses Note located under the Progress Notes tab in the EMR read 9/21/2024 16:03 [4:03 PM] Health Status Note: Resident has multiple blood blisters on palm of Rt [right] hand, some have opened & [and] are dried. Resident winces when hand is examined & she stated she doesn't know what happened. The note was completed by Licensed Practical Nurse (LPN) 5. Review of R45's communication form, dated 09/22/24, located under the MISC tab in the EMR, noted Blood blisters palm of right hand, some intact, some open and dried. Resident grimaces when hand examined. The form was signed by LPN5. There was no documented evidence in the EMR that the resident's physician had responded to the faxed communication form. During an interview on 10/10/24 at 2:23 PM, LPN4 confirmed that there was no evidence in the EMR that the resident's physician had responded to the 09/21/24 faxed communication form. Review of R45's Skin Condition Evaluation, located under the Assessments tab, noted the following information: On 09/21/24, R45 was identified to have Multiple blood blisters palm of Rt [right] hand, some have opened & dried. Resident winces when hand is examined. On 09/30/24, R45 was identified to have Palm of rt [right] hand has blisters bruising to bilat [bilateral] arms. On 10/05/24, R45 was identified to have Blisters noted to both palms of hands- RT [right] worse than LT [left]- some are popped and open- others are still blistered over- unknown etiology. During an interview on 10/10/24 at 3:51 PM, R45's primary care physician (PCP) confirmed receipt of the faxed notification of blood blisters on palm of right hand. R45's physician stated, The resident had been transferred to the hospital shortly after the fax was sent for treatment of pneumonia. The physician stated that she had responded to the fax and asked for a report of the condition of the hand upon return to the facility. The physician was informed that her faxed return with the request for an update on the resident's hand upon return from the hospital was not located in the EMR. The physician stated I received a fax on 10/06/24 identifying bilateral palm blisters and on inner thighs. The facility asked for a culture. I received the fax at 9:07 AM on 10/07/24 and responded at 10:41 AM ordering the culture. The facility thought it might be staph [an infection caused by staphylococcus bacteria] possibly contact dermatitis. I instructed the staff to make an appointment with dermatology, if persists. I was told the resident representative declined to have the resident sent to dermatology. R45's physician said she did not believe the blisters started prior to 09/21/24 because she had seen R45 prior to that time without any skin concerns. R45's physician confirmed that she should have received the requested update in order to determine the next course of action. During an interview, on 10/10/24 at 10:42 AM, the Nursing Supervisor (NS), responsible for the facility wound care program, stated, We don't know what caused the blisters. The culture was negative, the physician ordered treatment today. The order read, Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to affected area to both han [hands] topically every day and evening shift for blistered areas on hands. The NS said R45's hands were wrapped in gauze, prior to the 10/10/24 treatment order, to help discourage scratching the blisters. 2. Review of R5's Admission Record, located under the Profile tab, indicated R5 was admitted on [DATE] with diagnoses that included spondylosis and cervicalgia. Review of R5's quarterly MDS, with an ARD of 09/22/24 revealed the facility assessed the resident to have a BIMS score of six out of 15 which indicated R45 was severely cognitively impaired. Observation on 10/08/24 at 3:12 PM revealed R5 seated in her wheelchair at a dining room table. Certified Medication Technician (CMT) 3 was observed to ask R5 her pain level on a scale of one-10. The resident stated six. CMT3 offered R5 Tylenol, which resident said would be good. CMT3 crushed the Tylenol, placed it in applesauce, brought a tissue to R5 and stated, I brought you water and a tissue, I know how much you hate this. R5 stated, I hate it, why they think I can't swallow a Tylenol. It gets under my dentures. R5 was observed to spit pieces of Tylenol into the tissue while stating I hate this. During an interview on 10/08/24 at 3:30 PM, CMT3 was asked had staff questioned if R5 could have the Tylenol administered in a different route. CMT3 stated she was not aware if that had been considered. Review of R5's Physician's Orders, located under the Orders tab in the EMR for the month of October 2024 revealed no order to crush the Tylenol or any of R5's medications. During an interview on 10/11/24 at 11:27 AM, CMT3 stated, We've always crushed all [of] R5's meds [medications] since she moved over from the other unit in April 2024. During an interview on 10/11/24 at 1:15 PM, the Director of Nursing (DON) stated, If you didn't see an order to crush, it's probably not there.

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents' (Resident (R) 4) call light was present and functioning. This failure had the potential to restrict residents from calling for assistance while using the restroom. Findings include: Review of an undated, and untitled document, provided by the facility, indicated, The nurse call policy for [name of the facility] is to ensure resident can effectively communicate with staff for assistance. Here are the key points: 1. Resident Call System Requirements:. Toilet and bathing facilities: The call system must also be accessible from toilet .Functionality: The system must be fully operational at all times .with alternative communication methods in place if necessary.'' Review of R4's Admission Record, located under the Profile tab in the electronic medical record (EMR) indicated R4 was admitted to the facility on [DATE]. During an interview and observation on 10/08/24 at 10:20 AM, R4 stated she fell while in the bathroom over the weekend and could not call for help due to the facility taking the call light out of the bathroom to replace the call light in her bedroom. R4 stated her family was aware and had spoken with the facility about this. During the interview there was no call light observed next to her toilet in the bathroom. Review of R4's quarterly ''Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/25/24 and located under the MDS tab in the EMR revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R4 was cognitively intact. Further review indicated R4 did not have any impairments in her extremities and that the resident was independent for personal hygiene, meaning that she can use the bathroom without assistance. Observations on 10/09/24 at 2:00 PM and 10/10/24 at 8:30 AM revealed no call light was observed next to the toilet. During an interview on 10/10/24 at 10:20 AM, Licensed Practical Nurse (LPN) 3, confirmed R4's bathroom did not contain a call light. During an interview on 10/10/24 at 10:27 AM, the Maintenance Director stated she was aware of the missing call light last week; however, she was unable to repair the call light. The Maintenance Director stated an outside company had been contacted; however, the company had not been to the facility yet. The Maintenance Director stated she did not replace the call light with another one or gave R4 a way to call for assistance.

Based on observation, interview, and record review, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 67. Observations on 01/24/23 between 8:50 A.M. and 9:14 A.M. showed the following: -Dietary Aide prepared food in the kitchen. He/She had a beard and was not wearing a beard restraint; -Dietary Aide Y prepared food in the kitchen. His/Her hair was not completely covered with a hairnet, the sides of his/her hair hung out from under the hairnet; -The dietary manager prepared food in the kitchen. His/Her hair hung out from under his/her hairnet and was not completely covered. Observation on 1/24/23 at 8:58 A.M., showed a heavy brown/black buildup on the inside of the convection oven. Observation on 1/24/23 at 11:30 A.M., showed the front of the deep fryer, both sides of the fryer, and the side of the stove were covered with a thick layer of grease and food debris. During interview on 01/24/23 at 2:25 P.M., the dietary manager said the following: -She expected the dietary staff to follow the cleaning schedule that included cleaning the convection oven, the stove and deep fryer; -She expected staff to completely cover all hair and beards with hairnets and beard nets. During interview on 01/27/23 at 11:33 A.M., the administrator said he expected all hair and beards to be covered with hair and beard nets at all times in the kitchen. He expected the convection oven, the stove, and the deep fryer to be clean.

Based on observation, interview, and record review, the facility failed to update and revise the comprehensive care plans for four residents (Residents #10, #24, #30, and #48) in a review of 21 sampled residents. The facility census was 67. Review of the facility's undated policy, Comprehensive Resident Centered Care Plans, showed the following: -It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident; -The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate; -It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care; -A comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, dated October 2019, showed the following: -The comprehensive care plan is an interdisciplinary communication tool; -The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. 1. Review of Resident #48's face sheet showed the resident was admitted [DATE] and had a diagnosis of dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/27/22, showed the following: -Moderately impaired cognition; -No behaviors, rejection of cares or wandering; -Daily antipsychotic medication taken. Review of the resident's care plan, dated 6/22/20 and last reviewed 12/12/22, showed the following: -The resident uses psychotropic medications for behavior management; -Consult with pharmacy. Physician to consider dosage reduction when clinically appropriate at least quarterly; -Monitor/document/report as needed any adverse reactions of psychotropic medications; -Monitor/record occurrence of target behavior symptoms: multiple falls due to crawling out of bed and crawling around on the floor, not sleeping, abusive towards others verbally and physically, Unable to redirect, no regard for self-safety. Review of the resident's nurses' notes showed the following: -On 1/8/23, the resident was in Resident #24's room, climbed into a peer's bed by the wall and fell asleep. Staff attempted to assist the resident out of the peer's bed and room. The resident became very angry and agitated, hitting at Nurse Assistant (NA)'s and this writer. The resident would not respond to redirection. The peer was also yelling at staff saying, Just leave him/her in here, he/she is fine. Staff left room. The resident and peer visited; -On 1/9/23, the resident lay in bed with Resident #24. He/She was combative and said he/she wanted to stay in his/her room; -On 1/10/23, the resident is confused and agitated this morning. The resident was in Resident #24's bed with him/her. The resident said he/she couldn't get out of the bed when staff tried to get him/her up. Staff attempted to get the resident up again. The resident got up and staff took him/her to the bathroom and took him/her to the table for breakfast. The resident was agitated saying he/she wanted to go to his/her family's room. This nurse attempted to redirect the resident and told him/her that his/her family was at home getting ready for work. The resident said, You don't know my family. Double doors were closed briefly to redirect the resident and the resident turned away as he/she began cursing at staff; -On 1/10/23, this nurse called the resident's family member to let him/her know the resident has had a change in behavior and that the resident believes his/her family is in Resident #24's room. Staff reported to the resident's family member that they have tried to redirect the resident by telling him/her that his/her family was getting ready for work. This nurse asked if he/she could talk to him/her or come visit him/her. The resident's family member talked to the resident. Staff has had to redirect the resident multiple times this morning telling him/her that the other resident was resting. This nurse showed the resident his/her room and showed him/her a family picture. The resident continued to be agitated and left the room, saying he/she didn't know why they wanted to lock him/her in a room, and he/she wanted to go see his/her family. Will continue to monitor; -On 1/10/23, the resident had a shower and is currently wandering in the hall in his/her wheelchair; -On 1/12/23, the resident slept in Resident #24's bed. The resident has been going into Resident #24's bathroom when he/she was in it. The resident is hateful to employees in the dining room. Attempted to hit another employee; -On 1/12/23, spoke with the resident's family today on the phone. Explained to them that the resident is still not sleeping in his/her room, and he/she is still sleeping in another resident's room with them. Family asked if this was an every night thing, and staff explained to them it was not. Just the last few nights staff have had an issue with this. Staff also explained to the resident's family member that when the resident is being redirected, he/she is getting combative towards staff. Family asked that staff test the resident to see if his/her sodium levels were low. Family said the resident has had low sodium levels before and asked that staff keep them updated on this situation; -On 1/14/23, the resident was in Resident #24's room. Resident #24 did not want this resident in his/her room. This nurse asked the resident to leave Resident #24's room. This resident became agitated and said he/she wasn't leaving, this is his/her family. This resident started swinging his/her arms trying to hit this nurse and other staff. The resident also started kicking and cursing at this nurse and other staff. The resident then planted his/her feet on the floor and wouldn't let staff take him/her out. This nurse placed his/her arm around the resident and wheeled the wheelchair backwards through the door. Once staff got the resident to the dining room, staff shut the double doors to give the resident time to calm down. The resident continued cursing and saying he/she wanted to go see his/her family. Staff attempted to redirect the resident and let him/her know that his/her family was not here; -On 1/16/23, a urinalysis (urine test for infection) obtained and lab work ordered. Observation on 1/30/23 showed the resident in his/her wheelchair. He/She propelled himself/herself to Resident #24's doorway then turned around and propelled back to the dining room. Review of the resident's care plan showed no specific care area or goal identified for behaviors, and no specific interventions listed to address the resident's behaviors toward staff and other residents. 44665 2. Review of Resident #10's care plan, initiated on 5/17/21, showed the following: -He/She used a walker for walking; -He/She was independent for locomotion; -He/She had dementia; -Staff were to identify themselves at each interaction, face him/her when speaking and make eye contact; -He/She understood consistent, simple, directive sentences; -Staff were to present just one thought, idea, question or command at a time; -Staff were to ask yes/no questions in order to determine the resident's needs; -Staff were to cue, reorient, and supervise the resident as needed; -Staff were to provide him/her with necessary cues. Stop and return if agitated; -Staff were to keep his/her routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Review of the resident's progress notes, dated 4/5/22 at 1:19 P.M., showed the following: -The resident was very restless/agitated this morning, pacing back and forth from his/her room to the nursing station; -He/She demanded to know why staff was there and who was paying staff to be here in his/her house; -Staff were unable to redirect him/her and he/she wanted to know why all these people were at his/her house and where were his/her parents; -Staff attempted to explain to the resident, and he/she was not able to comprehend explanation. Review of the resident's care plan showed no documentation the resident had confusion related to others being in his/her house which caused agitation and wandering behavior. Review showed no listed interventions to address the resident's agitation and inability for staff to redirect related to his/her cognitive status. Review of the resident's annual MDS, dated [DATE], showed the following: -His/Her cognition was moderately impaired; -He/She had diagnoses of non-traumatic brain dysfunction and dementia; -He/She made himself/herself understood and he/she understood others; -He/She did not exhibit behaviors such as inattention, disorganized thinking, hallucinations, delusions, physical or verbal behaviors, rejection of care, or wandering; -He/She used a walker; -He/She used a wander/elopement alarm daily. Review of the resident's progress notes, dated 5/18/22 at 12:05 A.M., showed the following: -The resident has been confused this evening. He/She was looking for his/her family member and wanted to go home; -After several staff attempted to redirect him/her, he/she went to his/her room; -About 15 minutes later, he/she went out the door; -Staff caught up with him/her on the sidewalk, no injuries noted. Review of the resident's care plan showed no documentation the resident attempted to leave the facility on 5/18/22, and no updated interventions identified on the care plan to prevent this from reoccurring. Review of the resident's progress notes, dated 6/13/22 at 7:54 A.M., showed the following: -The resident became restless in late afternoon, was walking without his/her walker, and was turning off lights in rooms down the hall; -He/She made statements, This is my grandfather's house, and why are all these people here?; -He/She became angry with staff when staff attempted to redirect him/her. The resident did not respond to redirection. Review of the resident's care plan showed no documentation the resident had agitation and wandering behavior. Review showed no listed interventions to address the resident's agitation and inability for staff to redirect related to his/her cognitive status. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was moderately impaired; -He/She made himself/herself understood and he/she understood others; -He/She did not exhibit behaviors such as inattention, disorganized thinking, hallucinations, delusions, physical or verbal behaviors, rejection of care, or wandering; -He/She used a walker; -He/She used a wander/elopement alarm daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was moderately impaired; -He/She made himself/herself understood and he/she understood others; -He/She did not exhibit behaviors such as inattention, disorganized thinking, hallucinations, delusions, physical or verbal behaviors, rejection of care, or wandering; -He/She used a walker and cane/crutch; -He/She used a wander/elopement alarm daily. Review of the resident's progress notes, dated 11/1/22 at 10:57 P.M., showed the following: -The resident was very confused and agitated, and said he/she wanted to go home; -Staff were unable to help him/her understand and called the resident's family member so the resident could speak with the family member; -The resident was rude and cursed at his/her family member, and said the police would take him/her home. Review of the resident's progress notes, dated 11/2/22 at 3:02 P.M., showed the following: -He/She was up for lunch and after eating. He/She attempted to leave out of the dining room door; -He/She said he/she needed to leave and was trying to get staff to mail his/her stuff to his/her house; -Staff were unable to redirect him/her. Review of the resident's care plan showed no documentation the resident had agitation related to wanting to go home and the resident attempted to leave the facility on 11/2/22. Review showed no interventions identified on the care plan to address the resident's desire to go home and interventions to attempt in order to redirect the resident when he/she was agitated. Review of the resident's progress notes, dated 11/6/22 at 6:52 A.M., showed the following: -He/She has been agitated and restless this shift, and was going in and out of peers' rooms; -Staff tried to redirect resident out of a peer's room and resident became upset with staff, slapped the staff in the face and told the staff to mind your own business; -The resident was directed to go to his/her room, and the resident went to his/her room; -The resident was up sitting in the hall chair, asked staff questions of how he/she got there, why is he/she here, and can he/she go home; -Staff redirected him/her and reassured him/her that he/she was safe and that his/her family was aware of where he/she was. Review of the resident's care plan showed no documentation the resident had agitation related to wanting to go home and wandered into other residents' rooms. Review showed no interventions identified on the care plan to address the resident's desire to go home and interventions to attempt in order to redirect the resident when he/she was agitated. Review of the resident's fall investigation report, dated 12/21/22 at 5:20 P.M., showed the following: -The resident went out the west end doors, the main door didn't lock down or alarm; -The alarm finally went off when it was halfway open, and he/she was to the other door; -Staff took off down the hallway, and by then the resident was out the outer door. Review of the resident's care plan showed no documentation the resident attempted to leave the facility on 12/21/22, and no updated interventions identified on the care plan to prevent this from reoccurring. During an interview on 1/30/23 at 12:53 P.M., Certified Medication Technician (CMT) C said the following: -The resident wore a Wanderguard bracelet that would start beeping near exits. (Review of the resident's care plan showed no documentation the resident wore a Wanderguard bracelet.); -The resident displayed confusion at times such as when he/she would look for his/her family members. During interview on 1/30/23 at 3:07 P.M. and 4:46 P.M., the Director of Nurses (DON) said the following: -The resident wore a Wanderguard bracelet on his/her ankle; -In December the resident attempted to leave with his/her family member out the door when the family member had visited the resident; -She expected resident elopement attempts and behaviors to be included in a resident's care plan; -She expected devices, including Wanderguard devices, to be included in a resident's care plan and include information regarding what the device was and how the resident used the device. 46506 3. Review of Resident #30's Discharge Assessment, Return Anticipated Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/20/22, showed the following: -Cognition intact; -No specific identification of concern related to pain or behaviors; Review of the resident's care plan, dated 05/21/22 and revised 12/8/22, showed no specific care area, goal or interventions identified for pain or behaviors. Review of the December 2022 Physician Order Summary (POS) showed no physician order for pain medication, including Tylenol. Review of resident's Pain Level Summary showed on 12/31/22 at 5:07 A.M., the resident's pain value was a 7 (on a scale of 1 to 10). Review of resident's Pain Level Summary showed the following: -On 1/8/23 at 12:26 P.M., the resident's pain value was a 5 (on a scale of 1 to 10). -On 1/18/23 at 5:25 P.M., the resident's pain value was a 3 (on a scale of 1 to 10). -On 1/23/23 at 12:01 P.M., the resident's pain value was a 4 (on a scale of 1 to 10). Observation on 1/24/23 at 9:50 A.M. showed the following: -The resident sat in a recliner with his/her feet elevated, and repeatedly called out, Help me. Please help me; -The resident said, It hurts, my left leg. Oh God, please help me; -Certified Nurse Assistant (CNA) L entered the room, and placed a pillow beneath the resident's left leg; -The resident said this is a new pain. Observation on 1/24/23 at 10:00 A.M. showed the following: -The resident called out, and repeated, Please help me. Oh God, please hurry. Help me; -The resident said, It's hurting worse. It's hurting so bad. Hurry God, hurry. Help me!; -CNA L readjusted the pillow beneath the resident's left leg. Review of resident's Pain Level Summary showed on 1/24/23 at 10:07 A.M., the resident's pain scale was a 9 (on a scale of 1 to 10). Observation on 1/24/23 at 10:15 A.M. showed the following: -The resident yelled repeatedly, Help me, help me!; -CMT B entered the room and asked the resident where his/her pain was located; -The resident said, In my left leg. Please help me; -CMT B asked the resident to rate his/her pain; -The resident said his/her pain was a 9; -CMT B said, Oh God, let's give you some Tylenol; -CMT B gave the resident the medication and left the room. (Review of the resident's POS showed no orders for pain medication.) Observation on 1/24/23 at 10:25 A.M. showed the following: -The resident yelled repeatedly, Help me. Oh God, please hurry; -The resident said his/her leg was hurting 'so bad'; Observation on 1/27/23 showed the following: -At 6:32 A.M., the resident sat in a wheelchair in the dining room. The resident said, Oh God, it really hurts. -At 6:35 A.M., the resident called out, Help me, please help. It hurts. It hurts. It hurts. -At 6:37 A.M., the resident said, Oh God and NA P walked through the dining room to the clean utility room. CMT C told NA P that the resident needed repositioned; -At 6:39 A.M., the resident complained of pain in his/her left hand. The resident's hand was contracted into a fist and his/her hand was swollen. The resident said, Oh it hurts. CMT C offered the resident some Tylenol and the resident was agreeable; -At 6:40 A.M., CNA L sat with the resident and massaged his/her left hand while CMT C administered Tylenol to the resident. The resident stated his/her pain was a nine out of ten. During an interview on 1/27/23 at 11:20 A.M., Certified Nurse Aide (CNA) L said the following: -The resident had been hollering like this since he/she was moved to this wing at the end of December 2022; -Some mornings the resident is just hollering help me, help me; -He/She didn't know if the resident was agitated or in pain; -He/She thought sometimes the resident was in pain; -The resident has had swelling in his/her left hand and leg for some time now. During an interview on 1/30/23 at 10:35 A.M., Licensed Practical Nurse (LPN) A said the following: -He/She has heard the resident calling out, help me, help me; -The resident's physician just started the resident on an anti-anxiety medication on 1/30/23 in response to a nursing fax that the resident was having behaviors and calling out and being disruptive. (Review of the resident's care plan showed no documentation related to anxiety or disruptive behaviors.) -Sometimes when the resident called out, he/she just wanted to be pulled up in his/her chair or his/her left hand was bothering him/her. During an interview on 1/30/23 at 10:15 A.M., the resident said the following: -His/Her left leg was still hurting; -His/Her pain scale was a 3 (on a scale of 1 to 10) right now; -He/She thought Tylenol had helped him/her; -Staff have told him/her that he/she is loud sometimes and disruptive to others; -He/She didn't mean to be that way; it's the only way he/she can get staff's attention sometimes; -Sometimes he/she hollered because he/she was in pain. Review of the resident's care plan showed no specific care area, goals or interventions to address pain or anxiety for the resident. 4. Review of Resident 24's face sheet showed the resident was admitted on [DATE] and had a diagnosis of dementia, anxiety and mood disorder. Review of the resident's care plan, dated 5/8/21, showed the following: -The resident has impaired cognitive function/dementia; -Administer medications as needed; -Ask yes/no questions in order to determine the resident's needs; -Communicate with the resident/family regarding his/her capabilities and needs; -Cue, reorient and supervise as needed; -Engage the resident in simple, structured activities that avoid overly demanding tasks; -Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion; -Monitor/document/report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status; -Provide resident with a homelike environment; -No specific care area, goals or specific interventions related to agitation or verbal or physical aggression. Review of the resident's nurses' notes showed the following: -On 1/29/22, the resident was in dining room with other residents. He/She was getting the other residents worked up and having them all repeatedly say a discriminatory word. When the resident was politely redirected, he/she then proceeded to holler and scream at the staff. Family was notified and came to calm him/her down; -On 2/13/22, unidentified staff reported to the nurse that this resident hit another certified nurse assistant (CNA) multiple times on the aide's arm for no apparent reason. Will continue to monitor resident; -On 2/13/22, another resident was passing by his/her wheelchair and the resident said, You should have been the one to die instead. Staff redirected the resident and said that is not appropriate, then the resident continued to yell and this nurse stepped out of nurses station and attempted to redirect the resident by saying, That is inappropriate. The resident continued to yell and this nurse suggested, let's go back to your room. The resident said, No, I'm going to stay right here with him/her. For other residents' safety, nurse suggested to move other resident away from situation. The resident said, No, you're not, then proceeded to grab other residents' wheelchair and pulled him/her towards him/her, then this nurse said Stop and attempted to remove other resident from the situation. The resident then slapped this nurse's hand and this nurse called for another nurse to help assist with the situation. While other nurse was on his/her way, the resident said, I am contaminated that's why they are moving you away from me, then resident said to this nurse, Oh look he/she called for help, and then looked this nurse up and down and said, I am going to turn you in and rip you a new ass when I'm through. Then two other nurses arrived and assisted with calming the resident down and assisted the resident to his/her room; -On 2/21/22, the resident said, I am going to punch him/her if he/she tries anything. The resident was asked to sit at another table away from the other resident and then the resident continued to tell other resident, I dare you to try me. The resident was then moved to other table; -On 3/13/22, before supper this evening, this nurse witnessed the resident sitting next to another resident, who repeatedly calls out. This resident then proceeded to cover the other resident's mouth with his/her hand and said shhhh. When this nurse intervened and educated the resident in the importance of leaving our hands to ourselves, but that it was okay to speak and comfort another resident without touching, the resident then grabbed this nurse's hand and squeezed while scratching the nurse in the process. Will continue to monitor; -On 3/23/22, the resident sat by two other residents that repeat the same thing over and over. This resident put his/her hand up to their mouths trying to get them to stop, had a cloth and put it to a resident's mouth. When the CNA intervened, this resident told the CNA to leave him/her alone, he/she could do this and slung the cloth at the CNA to hit him/her with it; -On 4/14/22, the resident sat in the dining room with other residents. It was reported to this nurse that the resident became angry and yelling about the temperature in room. When a CMT went to talk to him/her about being loud and angry in dining room, the CMT said the resident slapped him/her in the face twice. The CMT told the resident that he/she is not going to hit him/her and resident replied that he/she would and smacked the aide in the arm. This nurse spoke to resident about not putting his/her hands on other people. Unable to redirect resident at this time, but when spoke to him/her 15 minutes later, the resident was calm and said that sometimes he/she over does things and knows he/she shouldn't have hit the CMT. The resident is currently sitting at the dining room table conversing pleasantly with other residents. Temperature in dining room was adjusted as several other residents were chilly as well; -On 6/19/22, the resident was hateful to staff and residents through most of shift. Most times staff were unable to redirect. Staff had to ask the resident to go to his/her room if he/she was going to continue being hateful to residents. The resident did stop when he/she was asked to go to his/her room. Review of the resident's physician's orders, dated June 2022, showed an order on 6/23/22 for Seroquel (antipsychotic) 12.5 milligrams (mg) by mouth daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Had verbal behaviors one to three days in the seven day look-back period; -Daily antipsychotic and antidepressant medication taken. Review of the resident's care plan showed no specific care area, no goal or specific interventions identified to address the resident's agitation or verbal or physical aggression towards others and use of antipsychotic medications. 5. During an interview on 1/30/23 at 1:20 P.M., the Care Plan/MDS Coordinator said the following: -Care plans should be updated as required; -She is responsible for updating care plans for residents; -Resident behaviors should be included on the care plans. During interview on 1/30/23 at 4:48 P.M., the Director of Nurses (DON) said resident behaviors should be updated/included in the care plan. 47246

Based on observation, interview, and record review, the facility failed to assess residents for the use of bed rails prior to installation, failed to review the risks and benefits with the residents/resident representatives and obtain consent for the use of bed rails prior to installation, and failed to assess the residents risk for entrapment from bed rails for eight residents (Residents #2, #6, #9, #10, #33, #47, #51 and #61), in a review of 21 sampled residents. The facility census was 67. The facility did not have a policy on bed rail use. Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the patient's health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high-risk patients; -Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail; -Reduce the gaps between the mattress and side rails; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #33's face sheet showed diagnoses included history of falling, syncope (fainting) and collapse, anxiety disorder and weakness. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/16/22, showed the following: -Moderately impaired cognition; -Required extensive assistance of two staff for bed mobility and transfers. Review of the resident's care plan, revised 11/4/22, showed the following: -Anticipate the resident's needs; -Fall precautions in place included a bolster mattress (a mattress with raised sides); -Requires extensive assistance of one staff for bed mobility and transfers; Review showed no documentation related to bed rails on the resident's care plan. Observation on 1/26/23 at 9:09 A.M. and 3:52 P.M., showed the resident lay in bed sleeping with 1/4 bed rails raised on both sides of the resident's bed. The resident had a bolster mattress. Observation on 1/27/23 at 6:07 A.M. and 10:46 A.M., showed the resident lay in bed sleeping with 1/4 bed rails raised on both sides of the resident's bed. The resident had a bolster mattress. Observation on 1/30/23 at 10:06 A.M. and 11:23 A.M., showed the resident lay in bed sleeping with 1/4 bed rails raised on both sides of the resident's bed. The resident had a bolster mattress. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 2. Review of Resident #6's care plan, dated 1/1/23, showed the following: -The resident had an activities of daily living (ADL) self-care need; -The resident required limited assistance from one staff to turn and reposition in bed and to move between surfaces. Review showed no documentation related to bed rails on the resident's care plan. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -He/She required supervision with bed mobility; -He/She required limited assistance of one staff member for transfers. Observation on 1/26/23 at 9:50 A.M., showed the resident lay in bed with 1/4 bed rails raised on both sides of the bed. Observation on 1/27/23 at 6:12 A.M., showed the resident lay in bed with 1/4 bed rails raised on both sides of the bed. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 3. Review of Resident #51's face sheet showed the resident's diagnoses included anxiety disorder and mild cognitive impairment. Review of the resident's significant change MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She was independent with bed mobility; -He/She required limited assistance from one staff member for transfers. Review of the resident's care plan, revised on 1/9/23, showed the following: -The resident had ADL self-care needs; -The resident required no staff assistance to turn and reposition in bed; -The resident required limited assistance from one staff to move between surfaces; -The resident was moderate risk for falls related to confusion and gait/balance problems; -Anticipate his/her needs. Review showed no documentation related to bed rails on the resident's care plan. Observation on 1/27/23 at 6:12 A.M., showed the resident lay in bed with 1/4 bed rails raised on both sides of the bed. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 44610 4. Review of Resident #9's face sheet showed the resident's diagnoses included dementia with anxiety, repeated falls, weakness, age-related physical debility and dependence on other enabling machines and devices. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with bed mobility and transfers. Review of the resident's care plan, revised 10/29/22, showed the following: -The resident has impaired cognitive function/dementia or impaired thought process; -The resident is low to moderate risk for falls; -The resident is able to complete bed mobility repositioning and turning in bed without assistance. Review showed no documentation related to bed rails on the resident's care plan. Observation on 1/24/23 at 9:28 A.M., showed the resident lay in bed sleeping, with bilateral upper 1/4 bed rails. The bed rail on the right side of the resident's bed was lowered, and the bed rail on the left side of the resident's bed was raised. During an interview on 1/24/23 at 9:28 A.M., the resident said the bed rail helped him/her reposition. Observation on 1/30/23 at 8:38 A.M., showed the resident lay in bed. The bed rail on the right side of the resident's bed was lowered and the bed rail on the left side of his/her bed was raised. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 5. Review of Resident #2's face sheet showed the resident's diagnoses included muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with bed mobility and transfers. Review of the resident's care plan, revised 11/27/22, showed the following: -The resident is assist of one for ambulation; -The resident is low to moderate risk for falls; -The resident is able to complete bed mobility without assistance; -The resident is able to complete his/her own transfers between surfaces. Review showed no documentation related to bed rails on the resident's care plan. Observation on 1/24/23 at 3:00 P.M., showed the resident lay in bed. The resident had 1/4 bed rails on both sides of the bed. The bed rail on the left side of the bed was raised and the bed rail on the right side was lowered. During an interview on 1/26/23 at 10:30 A.M., the resident said he/she used the bed rail on his/her left side when in bed for repositioning. Observation on 1/30/23 at 8:48 A.M., showed the resident lay in bed. The 1/4 bed rail on the left side of the bed was raised. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 6. Review of Resident #61's face sheet, dated 1/24/23, showed the resident's diagnoses included morbid (severe) obesity, abnormalities of gait and mobility, and weakness. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Independent for bed mobility and transfers. Review of the resident's care plan, revised 12/31/22, showed the following: -The resident required limited assistance from one staff to turn and reposition in bed; -The resident required limited assistance from one staff to move between surfaces. Review showed no documentation related to bed rails on the resident's care plan. Observation on 1/24/23 at 10:15 A.M., showed the resident lay in bed. The resident had 1/4 bed rails on both sides of the bed. The bed rail on the left side of the bed was lowered and the bed rail on the right side was raised. During an interview on 1/24/23 at 10:15 A.M., the resident said he/she used the bed rail on his/her right side when in bed for repositioning. Observation on 1/30/23 at 8:42 A.M., showed the resident lay in bed. The 1/4 bed rail on the right side of the bed was raised. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 44665 7. Review of Resident #10's care plan, revised 11/21/22, showed the following: -He/She was independent for transferring; -The resident was independent for repositioning and turning in bed; -Bed rail as needed or desired for increased mobility and transfers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was moderately impaired; -He/She had diagnoses of non-traumatic brain dysfunction and dementia; -He/She was independent with bed mobility. Review of the resident's physician's order sheet showed no orders for a bed rail. Observation on 1/26/23 at 9:18 A.M. showed the following: -The resident lay in his/her bed with his/her eyes closed; -The resident's bed had 1/4 bed rails on both sides of the bed; -The head of the bed was elevated and the resident's bed rail located closest to the door was in the raised position. During an interview on 1/30/23 at 12:36 P.M., the resident said he/she used the bed rail located on his/her bed to help him/her get out of bed. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 8. Review of Resident #47's face sheet showed his/her diagnoses included seizures, repeated falls, personal history of transient ischemic attack (a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain or eye, sometimes a precursor of a stroke) and cerebral infarction (death of cerebral tissue) without residual deficits, hemiplegia (partial paralysis on one side of the body) and hemiparesis (weakness on one-side of the body) following cerebral infarction affecting right dominant side, aphasia (a language disorder that affects a person's ability to communicate and can occur after a stroke, head injury, disease, or brain tumor), weakness, rheumatoid arthritis (chronic inflammatory disorder affecting many joints including those in the hands and feet), and other vascular syndromes of brain in cerebrovascular diseases (all disorders in which an area of the brain is temporarily or permanently affected). Review of the resident's quarterly MDS, dated [DATE], showed the following: -He/She was independent for bed mobility; -He/She required staff supervision (oversight, encouragement or cueing) for transfers to/from bed, chair, wheelchair, standing position and walking in corridor. Review of the resident's physician's order sheet showed no orders for a bed rail. Review of the resident's care plan, revised 11/27/22, showed the following: -He/She had self-care needs for activities of daily living; -The resident was able to complete his/her own position when in bed; he/she does use the bed rail to assist him/her; -Half bed rail up per physician's order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to bed rail use; -The resident required supervision assisted of one with use of a walker for all transfers; -He/She had impaired cognitive function/dementia or impaired thought processes related to his/her neurological symptoms; -He/She had a seizure disorder; -He/She used bed/chair alarms due to getting up on his/her own and having impaired balance. Observation on 1/26/23 at 9:25 A.M. showed the following: -The resident sat in the recliner in his/her room with his/her eyes closed; -The 1/4 bed rail located on the resident's bed was in the raised position. During an interview on 1/26/23 at 11:46 A.M., the resident said he/she used the bed rail on his/her bed when maneuvering in and out of his/her bed. Review of the resident's medical record showed no documentation the facility assessed the resident for the use of bed rails prior to installation, reviewed the risks and benefits with the resident or his/her representative and obtained consent for the use of bed rails prior to installation, and assessed the resident's risk for entrapment from bed rails. 9. During interviews on 1/30/23 at 4:47 P.M. and 5:08 P.M., the Director of Nursing (DON) said the following: -Residents should be assessed for entrapment with use of bed rails; -The facility has no policy for bed rails; -She would expect staff to review the risks and benefits of bed rails with the resident or resident representative; -She would expect staff to obtain an informed consent prior to installation or use of bed rails; -She would expect staff to ensure correct use of an installed bed rail; -She would expect bed rails be checked regularly for any maintenance issues; -She would expect there to be ongoing monitoring and supervision of bed rails in use; -Bed rail use should be identified in the residents' care plans; -She would expect physician orders to be issued for residents with bed rails. During an interview on 1/30/23 at 5:10 P.M., the administrator said the following: -He would expect staff to review the risks and benefits of bed rails with the resident or resident representative; -He would expect staff to obtain an informed consent prior to installation or use of bed rails; -He would expect bed rails be checked regularly for any maintenance issues; -He would expect there to be ongoing monitoring and supervision of bed rails in use. 46506

Based on observation, interview, and record review, the facility failed to remove expired stock medication from the medication room and medication carts, failed to date an open insulin vial for one resident (Resident #22), and failed to keep medications secured when staff left a medication cart unlocked and unattended in a hallway when passing medications. The facility census was 67. Review of the facility's policy, Destruction/Returning of Discontinued Medications, dated [DATE], showed the following: -Purpose: To assure discontinued medications are either destroyed in a timely manner or returned to the pharmacy; -Resident medications that have been discontinued by the physician shall be either destroyed on the premises or returned to the pharmacy (in accordance with pharmacy policy and state and federal law) within 30 days; -Outdated, contaminated or deteriorated medications or non-returnable medications of a deceased resident shall be destroyed within 30 days; -All medication destruction, including controlled substances, shall involve two licensed nurses or a licensed nurse and a pharmacist and their signatures must be recorded on the Medication Destruction Record, and if applicable, on the Individual Controlled Substance record; -When a medication is discontinued on your shift, it is the charge nurse's responsibility to initiate actions for returning the medication to the pharmacy, or if indicated by state law or pharmacy policy as a medication that cannot be returned, destroying the medication; -The charge nurse/certified medication technician (CMT) on the shift that the medication was discontinued on is responsible for proper documentation on the medication administration record and on the individual controlled record if the medication is a controlled drug. (Two signatures are required on the individual controlled record). Review of the facility policy, Administering Medications, dated 2001 and revised [DATE], showed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in a doorway of the resident's room, with open drawers facing inward and all other sides closed. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 1. Observation on [DATE] at 11:44 A.M., showed Certified Medication Technician (CMT) B prepared medications for Resident #14 and walked into the resident's room. CMT B left the medication cart unlocked and not in his/her line of sight. The medication cart was not in the doorway to the room with the drawers facing the room. Observation on [DATE] at 11:46 A.M., showed CMT B prepared medications for Resident #28. CMT B walked into the resident's room leaving the medication cart unlocked in the hallway where staff and residents walked past. The medication cart was not in the doorway to the room with the drawers facing the room. During interview on [DATE] at 11:34 A.M., CMT B said he/she should not leave the medication cart unlocked and should have kept it in his/her line of sight. 2. Observation of the [NAME] Court and Monterey Terrace medication room on [DATE] at 12:35 P.M., showed the following: -90 capsules of fiber laxative 625 milligrams (mg), expired ,d+[DATE]; -Ferrous sulfate (iron supplement) 325 mg, 100 tablets, expired ,d+[DATE]; -Three bottles Mag Ox (supplement) 400 mg, 120 tablets per bottle, expired ,d+[DATE]; -Two bottles of vitamin E (supplement) 400 international unit (IU) 100 soft gels per bottle, expired ,d+[DATE]; -Six bottles enteric coated aspirin (used for pain, fever or inflammation) 325 mg, 100 tablets per bottle, expired ,d+[DATE]; -Six bottles of Senna S (stool softener with laxative) 60 tablets per bottle, expired ,d+[DATE]; -Four bottles of ProSight (vitamin/mineral supplement) 60 tablets per bottle, expired ,d+[DATE]; -120 tablets calcium 500 + D (supplement), expired ,d+[DATE]; -Three-fourths of a bottle of Nystatin (antifungal) powder for Resident #24, expired ,d+[DATE]; -Five bottles aspirin 325 mg, 100 tablets per bottle, expired ,d+[DATE]; -Two bottles bisacodyl (laxative) 5 mg, 100 tablets per bottle, expired ,d+[DATE]. Observation of the medication cart on Monterey Terrace on [DATE] at 2:23 P.M., showed the following: -116 tablets of Mag Ox 400 mg, expired ,d+[DATE]; -94 tablets of Senna, expired ,d+[DATE]; -39 soft gels of vitamin E, expired ,d+[DATE]; -58 tablets of Senna S, expired ,d+[DATE]; -60 tablets of ProSight, expired ,d+[DATE]. Observation of the medication storage room on Park Place on [DATE] at 2:38 P.M., showed the following: -One box of loperamide HCL (antidiarrheal) 2 mg, expired on ,d+[DATE]; -One bottle of fiber laxative 625 mg, expired on ,d+[DATE]; -Two bottles of acidophilus (a bacterium used as a probiotic), expired on ,d+[DATE]; -One bottle of Senna 8.6 mg, expired on ,d+[DATE]; -Six bottles of enteric coated aspirin 325 mg, expired on ,d+[DATE]; -Five bottles of aspirin 325 mg, expired on ,d+[DATE]; -Two bottles of vitamin E 180 mg, expired on ,d+[DATE]; -Three bottles of Senna S 8XXX,d+[DATE] mg, expired ,d+[DATE]; -Three bottles of ProSight Vitamin and Mineral, expired on ,d+[DATE]; -One bottle of vitamin B complex, expired on ,d+[DATE];. Observation of the medication cart on Park Place on [DATE] at 2:30 P.M., showed the following: -One bottle of simethicone (relieve painful pressure caused by excess gas in the stomach and intestines) 80 mg, expired ,d+[DATE]; -One bottle of fiber laxative 625 mg, expired ,d+[DATE]; -One bottle of ferrous sulfate 325 mg, expired ,d+[DATE]; -One bottle of Senna 8.6 mg, opened [DATE] and expired ,d+[DATE]; -One bottle of enteric coated aspirin 325 mg, expired ,d+[DATE]; -One bottle of aspirin 325 mg, expired ,d+[DATE]; -One bottle of vitamin E 180 mg, expired ,d+[DATE]; -One bottle of Senna S 8XXX,d+[DATE] mg, expired ,d+[DATE]; -One bottle of Pro Sight Vitamin and Mineral, expired ,d+[DATE]; -One bottle of vitamin B complex, expired ,d+[DATE]; -One bottle of bisacodyl (laxative) 5 mg, expired ,d+[DATE]. 3. Observation of the medication storage room refrigerator on Park Place on [DATE] at 2:38 P.M., showed an open bottle of Lantus insulin for Resident #22. The bottle was not labeled with an open date or a discard date. Review of Drugs.com showed to store opened Lantus in a refrigerator or at room temperature and use within 28 days. 4. During an interview on [DATE] at 12:30 P.M., CMT T said all CMTs who used the medication carts were to check for outdated medications. During interview on [DATE] at 11:00 A.M., Licensed Practical Nurse (LPN) E said usually he/she and CMT B checked for outdated medication when restocking the medication carts. If medications could go back to pharmacy, they were sent back. If medications were not able to be sent back to the pharmacy, then staff destroyed them once a month. During interview on [DATE] at 4:50 P.M., the Director of Nursing (DON) said licensed nurses were responsible for checking for outdated medications twice a week when checking supplies in the medication carts. Expired or discontinued medication should be destroyed within 30 days. The medication cart should be locked if not within the staff person's line of sight. 46506 47246

Based on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination when staff failed to place oxygen tubing in a plastic bag while not in use and placed contaminated nasal cannula prongs in one resident's (Resident #51) nares of 21 sampled residents. The facility also failed to ensure staff did not handle medication with their bare hands for one resident (Resident #30). Staff failed to follow appropriate handwashing after peri-care and the removal of a soiled dressing, touching the resident and supplies with soiled gloves for one resident (Resident #29). The facility's census was 67. Review of the facility's Hand Hygiene policy, dated 2019, showed the following: -Hand hygiene consistent with accepted standards of practice such as the use of alcohol-based hand rub (ABHR) instead of soap and water in all clinical situations except when: -Hands are visibly soiled (e.g., blood, body fluids); -Staff must perform hand hygiene even if gloves are utilized. Review of the facility's Infection Prevention and Control Manual Resident Care: Nursing policy, dated 2019, showed items used for resident care will be cleaned, disinfected per facility policy (using designated disinfectant-following manufacturer's recommendations) or discarded and designated for single resident's use only. 1. Review of Resident #51's physician orders, dated January 2023, showed an order for oxygen at 2 liters per nasal cannula (L/NC) to maintain oxygen saturation above 92% (normal range of 92-100%) as needed for congestive heart failure and low oxygen saturation. Review of the resident's care plan, dated 1/9/23, showed the following: -The resident had altered respiratory status/difficulty breathing; -Oxygen at 2 L/NC to maintain oxygen saturation above 92%. Observation on 1/24/23 at 1:05 P.M., showed the following: -An oxygen tank hung on the back of the resident's wheelchair and was set at 2 L/NC; -The resident's oxygen cannula hung over the arm of the wheelchair, and the prongs of the cannula touched the wheel of the wheelchair; -The resident propelled himself/herself from the sink to the recliner with the nasal cannula dragging on the floor; -After the pressure alarm activated, Certified Nurse Aide (CNA) M came into the room and picked up the oxygen cannula from the oxygen concentrator off the floor, where the nares of the nasal cannula had been touching the floor, and assisted the resident with placing the nasal cannula in his/her nose and around the ears. During interview on 1/26/23 at 10:30 A.M., CNA M said he/she didn't realize the resident's nasal cannula was on the floor or he/she would have changed it. During interview on 1/30/23 at 4:47 P.M., the Director of Nursing (DON) said the following: -Staff were expected to store oxygen cannulas in plastic bags when not in use; -The staff were expected to change dirty oxygen cannulas when needed between weekly changes. 2. Observation on 1/27/23 at 7:22 A.M., showed Certified Medication Technician (CMT) C prepared medications for Resident #30. CMT C popped ten medications out of the pharmacy bubble packs into his/her bare hand and then dumped the medications into the medication cup. One pill landed on top of the medication cart where there was no barrier, and CMT C picked it up with his/her bare hands and placed it in the medication cup. CMT C administered the medications to Resident #30. CMT C did not wash his/her hands with soap and water or use sanitizer before preparing the medications. During interview on 1/27/23 at 11:23 A.M., CMT C said he/she shouldn't pop pills into his/her bare hand and if a pill falls on the medication cart then it should be destroyed and a new one given. During interview on 1/30/23 at 4:47 P.M., the DON said the following: -Staff should pop the medications from the bubble pack directly into the medication cups and not into bare hands; -If a medication falls on to the medication cart then it should be discarded and another pill obtained. 3. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/2/22, showed the following: -Cognition moderately impaired; -Required extensive assistance for bed mobility; -Totally dependent on staff for toileting; -Always incontinent. Observation on 1/16/23 at 11:55 A.M. showed the following: -Nurse Aide (NA) O and CNA L entered the resident's room; -Both applied gloves from the glove box on the resident's bedside table; neither staff washed their hands with soap and water before applying gloves; -NA O removed the covers from the resident and unfastened the resident's disposable brief; -CNA L used a disposable cloth to wipe the resident's groin area from top to bottom, then disposed of the wipe into a small trash; -CNA L did not change gloves or wash his/her hands after providing peri-care; -CNA L and NA O assisted the resident to roll over onto his/her right side; CNA L provided the care and touched the resident's upper back with his/her soiled gloves; -CNA L removed the resident's disposable brief and wiped the resident's buttocks from top to bottom with a new disposable wipe, then he/she threw the used wipe into the trash can; -The resident's brief appeared soiled with a light yellow fluid; -CNA L removed a dressing from the resident's coccyx (the tailbone) and threw it into the trash can at the resident's bedside; -The dressing was soiled with a dried, green exudate (dried fluid that leaks out of blood vessels into nearby tissues); -With the same gloves, CNA L opened a new disposable brief and slid it under the resident's buttocks; -NA O and CNA L helped the resident to roll back onto his/her back and then left side. CNA L provided care and touched the resident's upper left shoulder, buttocks and left thigh with soiled gloves; -Both staff fastened a new brief on the resident and then pulled the covers back up on him/her; -Both staff assisted the resident up to the side of the bed; -NA O applied a gait belt to the resident while CNA L touched the resident's wheelchair with his/her soiled gloves and both staff assisted the resident into the wheelchair at bedside; -Both staff removed their gloves and threw them away into the trash can at the resident's bedside; -Both staff used a hand sanitizer on the resident's bedside table after removing their gloves; they did not use soap and water; -NA O removed the trash can liner from the trash can at the resident's bedside, tied it and then carried it to the dirty utility room and placed in into a large black receptacle labeled trash; NA O was not wearing gloves; -NA O started to wash his/her hands in the dirty utility room and then said there was no soap; he/she went out to the commons area and washed his/her hands with soap and water there. During interview on 1/30/23 at 4:47 P.M., the DON said staff were expected to follow hand hygiene standards: before procedures, after procedures, going from dirty to clean, and from one resident to the next.

Based on interview and record review, the facility failed to follow professional standard of practice by failure to follow the facility's policy for Hypoglycemic (low blood sugar) Protocol for one resident (Resident #65), who presented with a low blood sugar, during a closed record review in a review of 21 sampled residents. The facility census was 67. Review of the facility policy Hypoglycemic Protocol, dated 1/27/09 and reviewed/revised 2/8/10, showed the following: -Policy: The facility provides the necessary care and services to ensure that each resident attains or maintains the highest practicable physical, mental and psychosocial well-being in accordance with the resident's comprehensive assessment and plan of care; -Procedure: Initial Evaluation: If blood sugar is found to be less than 60, assess resident's cognitive function and level of consciousness. If found to be at baseline, then proceed with Management of Mild Hypoglycemia pathway. If cognitive function or level of consciousness is impaired from baseline, then proceed with Management of Severe Hypoglycemia pathway; -Management of Mild Hypoglycemia: -Resident is to ingest 15 to 30 grams of a fast-acting carbohydrate, either by mouth or by feeding tube. Options for fast-acting carbohydrates may include, but are not limited to: glucose tablets (according to package label), one tube of glucose paste, 4-8 oz. sweetened fruit juice or one can of regular soda; -Fingerstick will be performed every 15 minutes until the blood sugar is found to be above 60. At this point, the resident should eat a snack with a complex carbohydrate, such as crackers or a sandwich; -If blood glucose does not go above 60 after one hour of consumption of the fast-acting carbohydrate, then the physician will be notified; -If the resident's cognition or level of consciousness deteriorates during this treatment period, then the Management for Severe Hypoglycemia will be initiated. 1. Review of Resident #65's face sheet, dated 8/19/22, showed his/her diagnoses included type II diabetes mellitus (too much sugar in the blood). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/24/22, showed the following: -Cognition intact; -Required extensive assistance with transfers, toileting, and locomotion off the unit; -Limited assistance of one staff member with personal hygiene, dressing, and locomotion on the unit; -Independent for eating, set-up help only. Review of the resident's care plan, dated 11/28/22, showed the following: -The resident has potential nutritional problem related to diabetes; -Monitor blood glucose as ordered. Notify physician if indicated by facility parameters; -Monitor for signs of hypoglycemia - pale skin, sudden mood changes, sudden nervousness, and rapid heartbeat. Review of the resident's Clinical Physician Orders for December 2022 showed the following: -Metformin (a medication that lowers the blood sugar levels by improving the way the body handles insulin) 500 milligrams (mg) by mouth two times daily with meals; -Accuchecks (a method to take a sample of blood to determine the blood glucose level) daily at 6:30 A.M. Review of a copy of the Vital Signs-Daily, Every shift, Every 4 hours, etc. Sheet for the resident, dated 12/3/22, showed at 8:22 P.M., the resident's blood sugar was 42 mg/dl. Staff gave gluco (glucose gel) to the resident. Review of the resident's nursing progress notes, dated 12/3/22 at 8:32 P.M., showed during assessment, the resident appeared very lethargic and tired. The resident was able to answer questions during the assessment. The resident's blood sugar reading at 42 mg/deciliter (dl) (normal value 80 mg/dl to 130 mg/dl). Because the resident was able to still swallow, this nurse administered glucagon gel. Will recheck in 15 minutes. Physician on-call for the resident's physician notified of the situation, and instructed to monitor and try to get the resident to eat when blood sugar stabilizes and to call if any further issues. Review of the resident's Weights and Vitals/Blood Sugar Summary showed on 12/3/22 at 9:48 P.M., the resident's blood sugar was 44.0 mg/dl. Review of the resident's medical record showed no documentation staff checked the resident's blood sugar between 8:32 P.M. and 9:28 P.M. (over one hour). Review of a copy of the Vital Signs-Daily, Every shift, Every 4 hours, etc. Sheet for the resident, dated 12/3/22, showed at 10:03 P.M., the resident's blood sugar was 55 mg/dl. Review of the resident's nursing progress notes, dated 12/3/22 at 10:09 P.M., showed unable to stabilize blood sugar. The resident was sent to the emergency room (ER) for evaluation per on-call physician. During interview on 1/30/23 at 1:51 P.M., Licensed Practical Nurse (LPN) B said the following: -He/She went into the resident's room between 8:00 P.M. and 9:00 P.M. (on 12/3/22) to do his/her evening assessment; -The resident seemed a little off and a little tired; -The resident was not confused and could answer his/her questions; -The resident's blood sugar was 42 mg/dl; -He/She gave the resident one tube of glucose gel from the E-kit (emergency medication kit); -He/She called the on-call physician for the resident and told him/her what was going on; -He/She rechecked the resident about 15-30 minutes later and his/her blood sugar was 55 mg/dl. (Review of documentation showed no evidence LPN B checked the resident's blood sugar at this time.); -He/She gave the resident a Glucerna Shake to drink (a diabetic-specific liquid nutrition drink used to provide protein and a lower amount of added sugar); -The resident didn't really like the Glucerna Shake and only drank about 20%; -He/She rechecked the resident's blood sugar 15 minutes later and it was 44 mg/dl. (Review of documentation showed no evidence LPN B checked the resident's blood sugar at this time.); -He/She called the on-call physician and he said to send the resident to the emergency room (ER); -He/She was familiar with the facility policy for low blood sugars. If the resident cannot take oral food or fluids, then give them glucagon gel and call the family and the physician. They are usually sent to the emergency room to make sure their blood sugars are stabilized. During interview on 1/30/23 at 12:39 P.M., the on-call physician said the following: -He/She received a call about the resident's low blood sugar that evening (12/3/22) and was told staff had given the resident some glucose gel and some juice; -He/She told staff to send the resident to the emergency room when his/her blood sugar did not come up; -If the resident is still stable and talking, can give oral supplements like juice, check the blood sugar every 15 minutes until it is normal (around 60 at least); -Nursing should expect that the oral glucose gel should have brought the resident's blood sugar up relatively quickly, by at least 10 points or more; -He would not expect the staff to wait over an hour for them to recheck the blood sugar after giving the glucose gel; -If it's one hour later and the blood sugar is only up by a few points, he would have told the staff to send the resident to the emergency room ; -Nursing staff should have been more aggressive in treating the low blood sugar. During an interview on 1/30/23 at 4:47 P.M., the Director of Nurses (DON) said she would expect staff to follow the facility policy for Hypoglycemia Protocol.

Based on interview and record review, the facility failed to consistently implement and modify interventions as necessary, in accordance with current standards of practice to prevent falls for two residents (Residents #1 and #3) in a review of ten sampled residents, and failed to ensure safety interventions in use, including bed alarms, functioned appropriately. Resident #3's cause of death was determined to be complications from an unwitnessed fall from the bed. Resident #1 sustained a concussion as a result of his/her fall. The facility's census was 51. The administrator was notified on [DATE] at 10:52 A.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite. Record review of the facility's Falls and Fall Risk Managing Policy dated 2017 showed the following: -Based on previous evaluations and current data, the staff will notify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize serious injuries and/or complications from falling; -The nursing staff in conjunction with the therapy department will identify appropriate interventions to reduce the risks of falls. If a systemic evaluation of a resident's fall risk identifies several interventions, the staff may choose to prioritize the interventions; -Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture, bed height adjustment, alarms, bolsters etc.; -If falling continues despite initial interventions, staff will implement additional or different interventions, or indicate why the approach remains relevant; -If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of the falls, until the falls are reduced or stopped, or until the reason for the continuation of the fall is identified as unavoidable; -Staff will monitor and document each resident's response to interventions intended to reduce falls and risk of falls; -If interventions have been successful in preventing falls, staff will continue the interventions or reconsider whether these measures are still needed if the problem that required the intervention has resolved; -If the resident continues to fall, staff (primarily the Care Plan Coordinator) will re-evaluate the care plan, and whether it is appropriate, to continue or change current interventions. 1. Record review of Resident #3's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's fall risk assessment dated [DATE] at 12:15 (P.M.) showed the following: -The resident had diminished safety awareness; -Moderate to severe restlessness/anxiety; -Needs assist and assistive device or help of two persons; -fell in the last four weeks; -Score of 11. During an interview on [DATE] at 1:45 P.M., the Director of Nursing (DON) said a score of 11 meant the resident was at high risk for falls. Record review of the resident's Fall Investigation dated, [DATE] at 4:00 P.M., showed the following: -A certified nurse assistant told the nurse the resident was on the floor and there was blood; -The resident was on the floor of the shower with splattered blood on the shower floor; -The aide left to get equipment and while he/she was gone the resident said he/she felt like throwing up; -The resident vomited twice; -The resident had a laceration on the back of his/her head behind the right ear; -The resident transferred to the hospital via an ambulance. Record review of the resident's nurse's notes dated, [DATE] at 6:15 P.M., showed the following: -The local hospital called; -The resident transferred to a different hospital for further evaluation. Record review of the resident's re-entry MDS (Minimum Data Set), a federally mandated assessment completed by facility staff, dated [DATE], showed the resident returned to the facility. Record review of the resident's significant change MDS, dated [DATE] showed the following: -The resident admitted to the facility on [DATE]; -He/She readmitted to the facility on [DATE]; -The resident had one fall since re-entry/admission with an injury; -The resident's diagnoses included dementia, stroke without residual deficits, and depression; -The resident required limited assistance of one staff member for bed mobility, transfers, dressing, toileting, hygiene and ambulating; -He/She required supervision and meal set up to eat; -The resident ambulated with a walker; -The resident had one fall with no injury and one fall with an injury since admission/re-entry. Record review of the resident's Fall Investigation dated [DATE] at 9:21 P.M., showed the following: -The resident in bed; -Appropriate height of bed and alarms on; -He/She tried to ambulate on his/her own and fell ; -He/She complained of head pain; -He/She had a medium hematoma (a collection of blood outside of blood vessels); -By 9:17 P.M., the resident had emesis (vomiting); -Staff notified the resident's physician; -Instructed to call the resident's family and sent to the Emergency Department. Record review of the resident's care plan dated [DATE] showed the following: -Fall on [DATE]; -Initiated low bed intervention; -Fall on [DATE]; -Care plan reviewed, no interventions initiated; -The resident is a moderate risk for falls related to confusion; -Fall intervention/prevention: low bed, bed/chair alarm; -Needs floors even, free from spills and clutter; -Adequate glare free light; -Ensure the resident's call light is within reach and encourage him/her to use it; -Ensure resident is wearing appropriate non-skid socks and shoes when ambulating or mobilizing in his/her wheelchair; -Personal items within reach. Record review of the resident's care plan showed no new interventions following the resident's [DATE] fall. Record review of the resident's quarterly MDS, dated [DATE] showed the following: -The resident's diagnoses including dementia, depression, [CONDITION(S)] (stroke) and palliative care (comfort care); -He/She had no behaviors or refusal of care. -He/She requires limited assistance of one staff member to transfer, toilet, dress, and bed mobility; -He/she had one fall with an injury since admission/re-entry to the facility. Record review of the resident's progress notes dated, [DATE] at 4:27 A.M., showed the following: -The resident's alarm was alarming; -The nurse went to the resident's room; -The resident had his/her knees on the fall mat; -The resident's buttocks were partially on the bed, but not on the floor; -The resident's head remained on the pillow; -The resident had been incontinent of urine. Record review of the resident's care plan showed no new intervention/prevention planned to address the resident coming/sliding off the bed. Record review of the resident's Fall Investigation dated [DATE] at 2:35 A.M., showed the following: -Certified Nurse Aide (CNA) informed charge nurse of resident falling out of bed; -RN (Registered Nurse) E entered the resident's room to find the resident out of the bed with his/her head on the floor mat and his/her legs in the bed; -As RN E walked closer, the rest of the resident's body fell on to the floor mat and the resident landed face down on the floor mat; -The bed alarm sounded when the resident was completely on the floor; -With assistance, RN E and the CNA picked up the resident and placed him/her into the bed. Record review of an updated care plan dated [DATE] showed the following: -Fall; -Care plan reviewed, no intervention initiated. Record review of the resident's care plan showed no new intervention to address the the resident coming/sliding off the bed or intervention to address the bed alarm not sounding until the resident was on the floor. Record review of the resident's progress notes dated, [DATE] at 1:07 A.M. (progress note pertains to CNA F finding the resident laying on the floor on [DATE] after 11:00 PM.), showed the following: -CNA called RN E to the resident's room; -RN E found the resident on the fall mat next to his/her bed face down on the mat with blood next to his/her head; -Urine was on the fall mat; -The bed was in the high position, with the head of the bed and the foot of the bed both raised (care plan directed the resident's bed be in the low position); -The bed alarm and the linens where on the floor next to the resident; -The bed alarm did not sound; -The resident did not appear to be breathing upon initial examination; -Staff picked up the resident and placed him/her in the bed; -No respirations, but faint heart beat noted on auscultation (listening to the heart with a stethoscope); -Blood noted on the top of the resident's right side of his/her head; -A hematoma noted on the left forehead; -Called for another nurse to verify resident not breathing and heart beat ceased at 11:55 P.M. Record review of electronic charting documentation dated [DATE] (no time) showed the following: -Staff interviewed (regarding the resident's [DATE] fall); -Maintenance supervisor tested the bed for malfunction; -Could not determine how the bed position was changed. Record review showed no documentation staff had been retrained regarding resident supervision. During an interview on [DATE] at 3:45 P.M., the DON said following the resident's fall on [DATE], the facility checked to make sure the bed was functioning properly. She said staff was inserviced on resident safety and directed to ensure resident call lights are within reach. During an interview on [DATE] at 3:46 P.M., CNA F said the following: -On [DATE] after 11:00 P.M., he/she went to the resident's room first and found the resident lying on the floor face down on the fall mat; -He/She called for help; -The resident's bed controller was hanging off the bed, like the resident had a hold of it; -The bed was raised waist high, the head of the bed was slightly raised, and the foot of the bed was flat. During an interview on [DATE] at 7:21 A.M., RN E said the following: -He/She worked both [DATE] and [DATE]; -The resident had a history of falling out of bed; -A CNA called for him/her to come to the resident's room; -He/She found the resident on the fall mat; -There was fresh blood was on the mat; -The resident was not breathing and had a faint pulse; -They put the resident on the bed; -The resident's bed was raised as high as it could go; -The head of the bed and the foot of the bed were raised completely and the side rail was raised; -The pad and the alarm were on the floor with the resident; -The alarm did not go off until they moved the resident; -The resident had an air mattress with bolsters on the sides; -The resident landed on a pad (no base sheet on the bed) with the alarm under it; -He/She did not recall where the bed controller was located, but he/she generally kept it away from the resident's reach for safety; -The resident had the strength to adjust the bed, but he/she did not know if the resident manipulated the bed controls. During an interview on [DATE] at 7:37 A.M., RN E said the following: -He/She could have been wrong about the head and foot of the bed completely raised; -The bed was raised as high as it could go. During an interview on [DATE] at 1:01 P.M., RN D said the following: -Care plans should be reviewed and updated after falls; -He/She felt every fall precaution for the Resident #3 was in place; -The resident had a bed alarm, the bed was lowered and a fall mat next to the bed; -Resident #3's room was close to the nurse's station so more frequent monitoring was not included in the care plan; -He/She was not aware the resident ever tried to manipulate the bed controls. During an interview on [DATE] at 10:14 A.M., the DON said the following: -Resident's care plans should be personalized toward the resident's needs and care including fall intervention and prevention; -Care plan fall interventions should reflect the cause of the fall; -Resident #3's positioning bar had a holder which held the bed controls; -She felt Resident #3 either got a hold of his/her bed controls or the control was close to him/her and he/she rolled onto it or pushed the buttons; -She felt Resident #3's fall interventions were exhausted, and could not think of any other interventions for the resident; -She was not aware the resident manipulated the bed controls. Record review of the resident's Death Certificate dated [DATE] showed the following: -Manner of death: accident; -Place of death: Nursing Home, Long Term Care facility; -Time of death 11:55 P.M., on [DATE]; -Cause of death: Complications from an unwitnessed fall in an adult care center; -History of falls; -History of Cerebral Infarct (stroke); -Dementia. During an interview on [DATE] at 5:11 P.M., the Coroner said the following: -He completed the death certificate; -He investigated the death and determined the resident's diagnoses included a history of falls, dementia and stroke; -He spoke with physicians, family and staff, and reviewed medical records; -He determined the night the resident died , the resident fell out of bed; -The resident's bed was not lowered to the floor; -The resident's cause of death was complications following an unwitnessed fall from bed in an long term care nursing facility. During an interview on [DATE] at 11:08 A.M., Resident #3's physician said the following: -The resident's care plan should be updated after a resident falls; -He expected staff to try new interventions; -The facility staff told him they felt having the bed lowered and a fall mat on the floor was enough. 2. Record review of Resident #1's admission MDS dated [DATE], showed the following: -His/Her diagnoses included adult failure to thrive, cardiomegaly (enlarged heart), repeated falls, stenosis (narrowing of spine); -The resident requires supervision of one staff member to provide set up help to transfer, toilet, ambulate; -He/She required limited assistance of one staff member with limited assistance to dress; -He/she required extensive assistance of one staff member to bathe. Record review of the resident's care plan dated [DATE] showed the following: -The resident was a moderate risk for falls related to gait and balance problems; -The resident needs a safe environment with even floors free of spills and/or clutter; -Adequate glare free lighting; -A working and reachable call light, encourage the resident to use the call light; -Ensure the resident is using appropriate footwear shoes or nonskid socks when ambulating or mobilizing in wheel chair; -Physical Therapy to evaluate and treat as needed. Record review of the resident's Fall Investigation dated, [DATE] at 3:55 P.M., showed the following: -Staff said the resident was in the bathroom and said he/she was going to fall; -Before staff could get to him/her, the resident went back against the wall, slid down and bumped the right side of his/her head on the door frame; -Staff called to the resident's room; -Resident was sitting on the bathroom floor and leaned against the wall; -The resident ambulated unsteady at times, to the dining room; -Fall witnessed. Record review of the resident's care plan dated [DATE] (clarified date of [DATE]) showed the following: -Fall; Care plan reviewed; -No intervention initiated. Record review of the resident's care plan showed no new interventions in place following the resident's fall on [DATE]. Record review of the resident's Fall Investigation dated,[DATE] at 5:15 P.M., showed the following -The resident walked back to his/her room after dinner; -He/She said he/she tried to open the door, but fell backwards and hit his/her head; -The resident had a large goose egg on the back of his/her head with a trickle of dried blood, no active bleeding; -The resident complained of pain where he/she hit his/her head; -Fall unwitnessed; -The resident transferred to the Emergency Department; -Interventions: Sent to acute care. Record review of electronic charting documentation dated [DATE] at 5:15 P.M. showed: -The resident had been in the dining room; -He/She gotten up and taken his/herself back toward his/her room; -Resident found on the floor outside his/her room. Record review of the resident's nurse's notes dated, [DATE] at 9:23 P.M., showed the following: -Staff contacted the hospital for status check; -The resident was admitted for a concussion. Record review of the resident's care plan dated [DATE] showed the following: -Receiving Part B Physical Therapy; -Use of bed alarm when he/she returns. Record review showed no documentation staff had been retrained on resident supervision. Record review of the resident's nurse's notes dated, [DATE] at 5:07 P.M., showed the resident returned to the facility. During an interview on [DATE] at 1:01 P.M., RN D said the following: -Care plans should be reviewed and updated after falls; -Resident #1's care plan should have had interventions related to the cause of the fall. During an interview on [DATE] at 1:09 P.M., Resident #1's physician said the following: -After a resident had a fall the resident should have implemented new interventions; -If current interventions are repetitive after several falls, new interventions should be implemented; -The resident's care plan should be personalized and the interventions should reflect the cause of the latest fall. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 7, MO 4, MO 4

Based on interview and record review, the facility failed to identify a Stage II pressure ulcer on admission for one resident (Resident #4) of ten sampled residents and failed to notify the resident's physician to obtain orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ulcer further declined and was classified as a Stage III pressure ulcer. The facility census was 51. Record 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). May 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. May 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; Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Record review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Assess the pressure ulcer initially and re-assess it at least weekly for four weeks; -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. Record review of the facility's Protocol for Pressure ulcers dated 2017 showed the following: -A program of prevention, care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -It is the responsibility of all caregivers to prevent, care for and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -A licensed nurse will complete a skin evaluation on the Skilled Nursing Assessment on admission and weekly for four weeks for pre-exiting signs such as purple or very dark area surrounded by profound redness, [CONDITION(S)] or induration with suggests deep tissue damage; -Notify the physician if treatment order is needed if did not come with hospital orders, -Protocol for Stage I: an area of redness in lightly pigmented skin or persistent red, blue purple hues in darker skin tones over a bony prominence without a break in the skin. Clean and dry the area. Treatment may include but not limited to skin prep, Remedy Skin care products (antifungals, skin repair cream, [MEDICATION(S)], barriers and Duoderm ([MEDICATION(S)] dressing); -Protocol for Stage II: a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater. Cleanse and dry. Licensed staff to request treatment order type and frequency of treatment from the resident's physician. If no improvement noted within two to four weeks or deterioration occurs, staff will notify the physician and treatment plan will be re-evaluated and changed as needed; -Stage III: full thickness of skin loss, exposing subcutaneous tissues and Stage IV: a full thickness: licensed staff to notify the physician for treatment. 1. Record review of Resident #4's Skilled Nursing Admission Assessment/Skin Condition Evaluation dated 1/7/21 showed the following: -Scabbed wound on right shin; -Red circular mark on right shin; -Right outer knee red wound bed secured with steri-strips, cleansed and applied [MEDICATION(S)] (silicone foam dressing); -Stage I pressure ulcer to coccyx (tailbone), deep purple in color, superficially open (any superficial opened pressure area is considered a Stage II pressure ulcer, not a Stage I), [MEDICATION(S)] (a zinc based cream) and [MEDICATION(S)] (a foam dressing) applied. Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Braden Scale (tool used to assess the resident's level of risk for development of pressure ulcers) dated 1/7/21, showed the resident scored 10 and therefore at high risk for pressure ulcers. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 1/12/21, showed the following: -The resident admitted to the facility on [DATE]; -The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She required extensive assistance of two staff members to toilet, transfer and for bed mobility; -He/She had a Stage II pressure ulcer present on admission. Review of the resident's admission (Baseline) Care Plan dated 1/19/21 for Pressure Ulcers/Skin Care showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Keep incision clean and dry, follow skin care protocol as needed; -Turn every two hours and as needed; -May use pillows for repositioning; -Report to charge nurse any redness or skin breakdown immediately. Record review showed no documentation the resident's care plan addressed the resident's existing pressure ulcer. Record review of the resident's progress notes showed no evidence staff contacted the resident's physician regarding the resident's Stage II pressure ulcer from 1/7/21 to 1/21/21 (13 days). Record review of the resident's POS dated 1/22/21 showed an order to cleanse the coccyx area and pat dry. Apply Therahoney (wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Do daily and as needed with soilage. Record review showed no documentation the resident's care plan was updated with the pressure ulcer treatment. Review of the resident progress notes dated 1/22/21 at 1:00 P.M. showed the following: -The resident had an open area at his/her coccyx/sacral area; -The wound bed was yellow, no odor, no drainage; -Peri wound (surrounding area) slightly red; -Wound measured 2.5 cm (centimeters) L (length) x 3.0 cm W (width) x 0.1 cm D (depth); -Staff notified the resident's physician, received orders for treatment, protein supplements/[MEDICATION(S)] (protein supplement requested. Review of the resident's EZ Graft Wound Assessment System (facility's wound assessment form used for assessments and measurements) dated 1/22/21, no time specified, showed the following: -Stage II pressure ulcer to the coccyx/sacral area; -The wound measured 2.8cm L x 3.5cm W x 0.1cm D; -Eschar and slough present; -Wound bed yellow; -Scant amount of drainage; -Periwound slightly red. Review of the resident's EZ Graft Wound Assessment System dated 1/27/21, no time specified, showed the following: -Unstageable pressure ulcer to the coccyx/sacral area; -The wound measured 3.5cm L x 2.5cm W x 0 cm D; -The wound base 10% pink, 90% yellow/tan; -Eschar and slough present; -Wound bed yellow; -Scant amount of drainage; -Periwound erythematous (red); -No tunneling or undermining. Record review showed no documentation a skin assessment was completed or a wound measurement completed for 12 days (between 1/28/21 to 2/8/21). Record review showed no documentation staff notified the resident's physician of the decline (pressure ulcer progressed to unstageable) of the resident's pressure ulcer. Record review showed no documentation the resident's care plan was updated with the decline in the resident's pressure ulcer. Record review of the resident's EZ Graft Wound Assessment System dated 2/9/21, no time specified, showed the following: -A Stage III pressure ulcer to the coccyx/sacral area; -The wound measured 3.cm L x 2.cm W x 1.0cm D; -Undermining 0.8cm at 9:00 o'clock to 12:00 o'clock; -The wound base pink, yellow; -Eschar and slough present; -Wound bed yellow; -Small amount of serosanguinous (blood and clear yellow) drainage; -Periwound clear. Record review of the resident's POS dated 2/9/21 showed the following: -Discontinue previous dressing order; -An order to clean the open area at coccyx/sacrum area and pat dry, lightly pack with one inch width strip of [MEDICATION(S)] (an absorbent fiber wound filler), cover with [MEDICATION(S)]. Do daily on day shift and as needed with soilage. Record review showed no documentation the resident's care plan was updated with the new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's EZ Graft Wound Assessment System dated 2/16/21, no time specified, showed the following: -A stage III pressure ulcer to the coccyx/sacral area; -The wound measured 2.5.cm L x 2.cm W x 1.0cm D; -Undermining 1.6cm at 9:00 o'clock to 12:00 o'clock -The wound base pink, yellow; -Eschar and slough present; -Wound bed pink; -Small amount of serosanguinous drainage; -Periwound clear. Record review showed no documentation the resident's care plan was updated with the new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/25/21 at 1:02 P.M., Registered Nurse (RN) D said the following: -He/She did not know why staff did not notify Resident #4's physician of the Stage II pressure ulcer on admission; -Staff should have reported this to the physician to receive orders for treatment; -He/She was not aware of a pressure ulcer until 1/22/21; -Staff did not notify him/her of the pressure ulcer; -Skin assessments should be done weekly, he/she did not know why staff skipped a weekly skin assessment. During an interview on 3/26/21 at 10:14 A.M., the Director of Nursing said the following: -All staff are to notify the charge nurse when there is a change in the resident's skin; -The charge nurse is responsible to notify the resident's physician of any skin issues; -Any pressure ulcer greater than a Stage II should be reported to the resident's physician to receive orders for treatment; -Pressure ulcers are to be measured weekly; -Pressure ulcer prevention, and interventions should be addressed on care plans; -Staff should update the resident care plans when there has been a change in their condition. During an interview on 3/29/21 at 1:09 P.M., the resident's physician said the following: -He expected staff to notify him when a resident first develops a pressure ulcer; -Staff should have notified him of the resident's pressure ulcer on admission; -Staff should have notified him when the pressure ulcer progressed to an unstageable pressure ulcer; -He expected weekly skin assessments; -He expected pressure ulcer care to be individualized toward the resident on the resident's care plan. MO 3, MO 9

Based on interview and record review, the facility failed to provide personal attention and nursing care in accordance with one resident's (Resident #1's) condition, a resident with chronic pai[DIAGNOSES REDACTED] with orders for [MEDICATION NAME] 30 milligrams every 12 hours routinely, (initial order dated 5/9/11), of six sampled residents. The facility ran out of the resident's scheduled [MEDICATION NAME], and did not follow up with the physician to ensure a prescription for the medication was obtained to ensure the resident received the ordered medication. The resident missed four doses of the narcotic over a period of three days. On the third day the resident presented with symptoms of hypertension, nausea and vomiting, and was sent to a local hospital for evaluation. The resident was subsequently admitted and treated at a regional hospital for narcotic withdrawal and an [MEDICAL CONDITION] mucosal tear due to the nausea and retching caused by withdrawal. The physician reported a mucosal tear could be life threatening if the tear bled out. The census was 85. 1. Review of Resident #1's care plan dated 5/9/11, showed the facility identified the resident at risk for pain due to a history of pain, directed staff to monitor for signs and symptoms of pain, address pain promptly with medications as ordered, and teach the resident the early intervention to pain. Review of the resident's Annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 4/21/12, showed the following: -Resident with a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact; -Resident presented with no [MEDICAL CONDITION] or behaviors; -Resident did have presence of pain and was on a scheduled regimen for pain control and received prn (as needed) pain medications; -The facility identified the resident with no problem conditions including fever, vomiting or internal bleeding. Review of the resident's history and physical dated 5/9/12, showed [DIAGNOSES REDACTED]. Review of the resident's telephone order dated 5/9/12, showed the resident was readmitted back to the facility following hospitalization . The order directed staff give [MEDICATION NAME] ([MEDICATION NAME]) 30 milligrams every twelve hours, hold for somnolence (sleepiness). Orders also directed staff to give [MEDICATION NAME] sulfate 15 mg every four hours as needed for pain. Review of the resident's nurses notes dated 5/12/12, showed staff documented staff attempted notifying the physician to get a prescription for [MEDICATION NAME] mg. No complaints of any discomfort at this time, will continue to monitor for pain. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Entry for [MEDICATION NAME] 30 mg one tab po (by mouth) every 12 hours, do not crush; -Staff initialed and circled the 8:00 P.M. dose on 5/12/12, initialed and circled the 8:00 A.M. and 8:00 P.M. on 5/13/12, and 8:00 A.M. dose on 8/14/12; -Staff noted on the back of the MAR indicated [REDACTED].M. [MEDICATION NAME] 30 mg unavailable, call to physician for script and call to pharmacy. There was no notation as to why the doses on 5/12 and 5/13 were circled as not given; -No [MEDICATION NAME] 15 mg was given during the time when the [MEDICATION NAME] was unavailable. Review of the resident's daily skilled nurses notes dated 5/14/12 showed the following: -At 3:30 P.M. the resident had nausea, vomiting, and diarrhea; -At 3:42 P.M. the resident's blood pressure was 208/102 (normal range:100-140/60-90), notified the physician and the nurse said she would get back with the facility as soon as possible; -At 4:35 P.M. the resident's blood pressure was 190/98; the nurse re-called the physician and received an order for [REDACTED]. -At 5:00 P.M. the resident was given the antihypertensive; -At 5:50 P.M. the resident had multiple episodes of emesis; -At 6:10 P.M. the resident's blood pressure was 236/152; -At 6:15 P.M. the nurse called the resident's physician and received an order to send to the emergency room for evaluation; -At 6:30 P.M. notified the ambulance of the transfer and called report to the emergency room ; -At 6:40 P.M. ambulance arrived and transported the resident to the emergency room . Review of the resident's local hospital emergency room note dated 5/14/12, showed the following: -The resident stated he/she had been sick to his/her stomach with vomiting and diarrhea since 5/13/12, he/she apparently had not had any of his/her scheduled [MEDICATION NAME] since the AM of 5/12/12; -The resident's blood pressure upon admission to the emergency room was 199/82. Review of the resident's regional hospital history and physical report dated 5/15/12, showed the following: -When the resident was questioned as to what happened on 5/14/12 he/she informed them he/she thought he/she was going through withdrawal from [MEDICATION NAME]; -When asked more specifically, he/she said that he/she had been on [MEDICATION NAME] for some time for diffuse intractable general body pains from [MEDICAL CONDITION] including his/her back, hips, legs, head, and neck, arms, and said the nursing home ran out of [MEDICATION NAME] and he/she did not receive any on the 13 th or 14 th; -He/she was having severe intractable diarrhea with shakes and general pain and was taken to the local emergency room and later on transferred to the regional hospital. Review of the resident's regional hospital progress notes dated 5/20/12 and 5/21/12, showed the following: -On 5/20/12 the resident noted with a medical history significant for chronic pai[DIAGNOSES REDACTED] and chronic narcotic use and narcotic dependence, who presented to the hospital as a transfer from an outside institution secondary to elevated troponins (a cardiac protein). The resident's major issues were nausea and vomiting, likely related to opiate withdrawal as he/she had stopped receiving his/her normal narcotic pain medication at the nursing home. The resident's hospital stay was complicated by an upper [MEDICAL CONDITION], likely related to his/her repeated retching and mucosal tear. Upper endoscopy did not reveal any signs of active bleeding; -On 5/21/12 the resident noted as very frail and came in with marginal troponin and some chest discomfort. His/Her issue was probably noncardiac at this time. He/She has a very large hiatal hernia which was complicated by bleeding and nausea with vomiting. The trigger for his/her acute nausea episode may have been withholding of narcotics which he/she has been on chronically. Review of the resident's regional discharge note dated 5/21/12, showed the following: -Discharge [DIAGNOSES REDACTED]. -During the hospital course the resident was having symptoms of diarrhea, severe pain, elevated blood pressure, which were all consistent with opiate withdrawal. During an interview on 5/30/12 at 11:30 A.M., the resident said the following: -He/she had been informed by the facility that he/she would never have to go without medication ([MEDICATION NAME]) again; -He/she was feeling better and did not want to experience going without his/her medication ever again. During a telephone interview on 5/31/12 at 2:20 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she circled the resident's MAR indicated [REDACTED] -He/she had been informed by Registered Nurse (RN) C the facility was awaiting a return call from the resident's physician; -He/she did not attempt to call the resident's physician, the physician on call, or the medical director of the facility; -The resident had no more nausea than he/she usually does and did not have any vomiting. During a telephone interview on 5/31/12 at 2:45 P.M., Registered Nurse (RN) C said the following: -He/she was on duty 05/12/12 and 05/13/12 and attempted only one time to get a hold of the resident's physician. He/She had left a message at the resident's physician's office on 5/9/12 informing the physician the facility need a script for the [MEDICATION NAME] 30 mg; -He/she did not attempt to call the physician on call or the medical director to try an obtain a prescription for the resident; -The resident did not have any nausea or vomiting on the day shift on 5/12/12 and 5/13/12; -It is facility policy to reorder medications when running low, when there were about two to three days left; -Symptoms of opiate withdrawal included shakiness and nausea, kind of like going through detox and the resident did not exhibit any of those symptoms while he/she was on duty. During an interview on 5/30/12 at 3:25 P.M., the Director of Nurses (DON) said the following: -About 48-72 hours before a controlled medication is due to run out, she expected staff to make sure the facility had a prescription to replace the controlled medication; -If the last dose was given, she expected the staff to contact the resident's physician or on call physician and make arrangements to either get a prescription or see about giving something in place of the medication until the prescription was available; -She had not been called in regards to the resident's medication being unavailable, and found out on 5/14/12 during morning meeting; -When she found out the medication was unavailable, she was informed by staff that a prescription had since been sent; -She would have expected staff to continue to call the resident's physician until staff got a response. During a telephone interview on 6/1/12 at 10:00 A.M., the administrator said she was not called in regards to the unavailability of the resident's medication. She found out during morning meeting on 5/14/12. She said the DON was the one overseeing the prescription was being taken care of. During a telephone interview on 5/31/12 at 2:25 P.M., Physician B from the regional hospital said the following: -The resident had a mucosal tear from the retching he/she had been experiencing and that was caused by the resident going through opiate withdrawal; -Opiate withdrawal was not fatal or life threatening, it was symptomatic, however if the mucosal tear continued to bleed and went untreated the tear could have been life threatening; -He would not expect narcotics be stopped abruptly, especially on someone with long term use. Record review of drugs.com showed the following information in regards to [MEDICATION NAME]: -Medication was a prescription narcotic pain medication; -One may experience withdrawal symptoms if stopped abruptly; -Withdrawal symptoms could vary and may include: Anxiety, nausea, loss of appetite, vomiting, diarrhea, and high blood pressure. Review of the facility's change in condition policy dated 1/13/2009, showed the following: -Physician notification procedures for non-emergency situations: The charge nurse will contact the attending physician, nurse practitioner, or covering physician's office during normal business hours by phone and fax. If no response is received after two attempts, the charge nurse will page the attending physician, nurse practitioner or covering physician through the hospital switchboard or personal pager; -The charge nurse will page attending physician, nurse practitioner or covering physician during non-business hours. If no response, continue paging until 10:00 PM. If no response is received within 24 hours, notify the medical director. If resident becomes unstable or condition worsens, proceed with emergent protocol. -Physician notification procedures for emergent situations: The charge nurse will page the attending physician, nurse practitioner or covering physician and activate EMS if supported by the resident's advance directive. Review of the facility's pharmacy orders policy dated 9/97, showed the following: -For reorders (refills), the resident name and prescription number are written on a sheet to be faxed. Refills are reordered at least three days before needed to prevent avoidable delays in getting the medication to the resident; -Responsibility for routine faxing is assigned to one nurse on each unit, on the 7-3 shift, Monday through Friday; -Routine orders that are needed at the next scheduled medication delivery time are faxed as needed. Emergency orders obtained outside of the provider pharmacy's regular hours are called in to the provider pharmacy's emergency number. Complaint #MO 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 complete during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began interviewing licensed nursing staff regarding the facility's new schedule II medication policy and the physician notification policy. Resident #1 was receiving his/her medication as ordered and the facility maintained a supply of his/her medications. The facility began assessment of all current residents' medications to ensure the facility maintained an adequate supply of the medications and began reordering if not. The facility still had to complete staff education or assessment of all residents' medications. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).